Head injuries and concussions in soccer

Head trauma analysis of laboratory reconstructed headers using 1966 Slazenger Challenge and 2018 Telstar 18 soccer balls

Retired soccer players are presenting with early onset neurodegenerative diseases, potentially from heading the ball. It has been proposed that the older composition of soccer balls places higher strains on brain tissues. The purpose of this research was to compare the dynamic head response and brain tissue strain of laboratory reconstructed headers using replicas of the 1966 Slazenger Challenge and 2018 Telstar 18 World Cup soccer balls. Head-to-ball impacts were physically conducted in the laboratory by impacting a Hybrid III head form at three locations and four velocities using dry and wet soccer ball conditions, and computational simulation was used to measure the resulting brain tissue strain. This research showed that few significant differences were found in head dynamic response and maximum principal strain between the dry 1966 and 2018 balls during reconstructed soccer headers. Headers using the wet 1966 soccer ball resulted in higher head form responses at low-velocity headers and lower head responses as velocities increased. This study demonstrates that under dry conditions, soccer ball construction does not have a significant effect on head and brain response during headers reconstructed in the laboratory. Although ball construction didn't show a notable effect, this study revealed that heading the ball, comparable to goalkeeper kicks and punts at 22 m/s, led to maximum principal strains exceeding the 50% likelihood of injury risk threshold. This has implications for the potential risks associated with repetitive heading in soccer for current athletes.

A New In-Skates Balance Error Scoring System for Ice Hockey Players

OBJECTIVE

Evaluate a new in-skates balance error scoring system (SBESS) for ice hockey players wearing their equipment.

DESIGN

Prospective, randomized, single blinded study.

SETTING

Sport Medicine Clinic.

PARTICIPANTS

Eighty university hockey players.

INTERVENTION

A control group performed the SBESS assessment at rest on 2 separate occasions and an experimental group performed the assessment at rest and after exertion. The SBESS consists of maintaining different stances on ice skates for 20 seconds each, while wearing full equipment (no stick, gloves and helmet) and standing on a hard rubber surface. Three independent reviewers scored the video recorded assessments.

MAIN OUTCOMES MEASURES

Primary outcome was the number of balance errors and the secondary outcome was the number of falls.

RESULTS

The control group's median SBESS scores were 2 and 3 on the first and second attempts at rest, respectively. The experimental group's median SBESS scores were 2 at rest and 2 after exertion. There was no fatigue effect and no athletes fell while performing the test. Of the 4 stances tested, the tandem stance had the highest variability in error scores between athletes and when repeated by the same athlete. The intraclass correlation coefficient (ICC) for interrater reliability was above 0.82, and the intrarater reliability ICC was above 0.86 for all SBESS scores. There was no concordance between the SBESS and the modified BESS.

CONCLUSIONS

The SBESS, omitting the tandem stance, is a safe and reproducible sideline balance assessment of ice hockey players wearing full equipment.

Soccer, concussions, and safety: Perceptions of parents of youth soccer participants

INTRODUCTION

The rate of concussions in youth soccer is among the highest of all youth sports. Parents play an important role in caring for their children and making decisions regarding whether they should participate in a sport, such as soccer, where concussions are well known. This study examined parental perceptions regarding: (a) coaches' role in concussion management, (b) heading restriction policies, and (c) overall concussion risk and participation issues.

METHOD

Online surveys were completed by 419 parents of youth soccer players who participated in the largest U.S. youth soccer programs nationwide.

RESULTS

Findings indicated 44.5% of the respondents had considered keeping their children from playing organized soccer and 47.2% were concerned about a potential decline in youth soccer participation due to concussions. Nearly 69% of responding parents agreed that heading should be banned for participants 10 years old or younger, while 56.5% thought heading should not be limited for participants 13 or older. Only 35% of parents were very confident about their child's coach's ability to properly identify concussions and remove those suspected of a concussion from play. Parents' socioeconomic status (SES), soccer coaching and playing experience, and previous history of concussion(s) were key predictors of greater perceived risk about concussions.

CONCLUSIONS

Findings from this study shed light on parents' perceptions about concussions and related safety issues in youth soccer. Understanding what parents believe about concussions is vital to preserve youth soccer participation and can be used to strengthen education and policies that promote a safer environment for youth sport participants. Practical Applications: Youth soccer coaches can benefit from stronger, comprehensive educational efforts at the league/club level. Additionally, parents of youth athletes who are in the lower SES communities should be targeted to receive concussion safety information and/or interventions that would improve their knowledge, attitude, and practices regarding concussion safety.

Should you let your child play football? What about soccer or hockey?

College students (n = 120) answered 18 yes-no questions that varied the child's gender (male, female), grade (grade school, high school, college), and sport (football, soccer, hockey). The format of the 18 yes or no questions was "If you had a child in (grade school, high school, college) would you let (him, her) play (football, soccer, hockey)"? Similar to a previous study, a large percentage (78.8%) of the respondents answered yes to the questions about football, indicating that they would permit their children to play football despite the risk of concussion (96% yes for male children, 67% yes for female children). Although the number of respondents who would allow their male child to play soccer (98% for male children, 99% for female children) or hockey (92% for male children, 89% for female children) was similar to the percentage of respondents that would allow their male child to play football, significantly more respondents would allow their female child to play soccer or hockey than football. This result is potentially problematic because soccer and hockey have high rates of concussion, especially for females, which suggests that the respondents may have been unaware of this fact.

Reducing risk of head injury in youth soccer: An extension of behavioral skills training for heading

Recently, concerns regarding sport-related concussions have increased within the research literature, the media, and popular culture. One potential source of soccer-related concussions involves the purposeful striking of the ball with one's head (i.e., heading). There is currently limited research on an effective teaching method to improve safe heading technique. In the current study, Behavior Skills Training (BST) was evaluated as a method to teach correct heading techniques to youth soccer players. BST increased the percentage of correct steps for each player based on a task analysis of heading. Based on social validity questionnaires administered to players and the coach, BST was rated as an acceptable form of training. After the final training session, experienced coaches rated each player as having improved from baseline to training.

May Heading in Soccer Result in Traumatic Brain Injury? A Review of Literature

Background:

Globally, soccer is the most popular team sport, unifying many fans all around the world. The epidemiological studies so far have confirmed that head playing and hitting the ball with head may cause minor head injuries, which exert their effects in a cumulative way.

Methods:

Literature search for this review was conducted and data about traumatic brain injury collected from various sources.

Results:

The consequences of head injury are evident as chronic changes in cognition, including disturbances in concentration and slowing of mental and physical agility.

Conclusion:

Various recommendations have been issued for the prevention of chronic negative cumulative effects of soccer ball head playing. In addition, the professional soccer players are also exposed to more intense craniocerebral trauma, such as concussions and contusions. These patients require treatment of skilled sports physicians, neurologists and neurosurgeons and some may need long to return to the sport scene again.

Characteristics of sports and recreation-related emergency department visits among school-age children and youth in North Carolina, 2010-2014

BACKGROUND

Sports and recreational activities are an important cause of injury among children and youth, with sports-related traumatic brain injuries (TBIs) being of particular concern given the developing brain. This paper reports the characteristics of sport and recreation-related (SR) emergency department (ED) visits among school-age children and youth in a statewide population.

METHODS

This study included all injury-related visits made to all North Carolina 24/7 acute-care civilian hospital-affiliated EDs by school-age youth, 5-18 years of age, during 2010-2014 (N = 918,662). Population estimates were based on US decennial census data. Poisson regression methods were used to estimate incidence rates and rate ratios.

RESULTS

During the five-year period, there were 767,075 unintentional injury-related ED visits among school-age youth, of which 213,518 (27.8%) were identified as SR injuries. The average annual absolute number and incidence rate (IR) of SR ED visits among school-age youth was 42,704 and 2374.5 ED visits per 100,000 person-years (95% confidence interval [CI], 2364.4-2384.6), respectively. In comparison to other unintentional injuries among school-age youth, SR ED visits were more likely to be diagnosed with an injury to the upper extremity (Injury Proportion Ratio [IPR] = 1.28; 95% CI, 1.27-1.29), the lower extremity (IPR = 1.14; 95% CI, 1.13-1.15), and a TBI or other head/neck/facial injury (IPR = 1.12; 95% CI, 1.11-1.13). Among ED visits made by school-age youth, the leading cause of SR injury was sports/athletics played as a group or team. The leading cause of team sports/athletics injury was American tackle football among boys and soccer among girls. The proportion of ED visits diagnosed with a TBI varied by age and sex, with 15-18 year-olds and boys having the highest population-based rates.

CONCLUSIONS

Sports and recreational activities are an important component of a healthy lifestyle, but they are also a major source of injury morbidity among school-age youth. Physical activity interventions should take into account sex and age differences in SR injury risk.

Frequency of Self-Reported Concussion Amongst Professional and Semi-Professional Footballers in Ireland During the 2014 Season: a Cross-Sectional Study

BACKGROUND

This paper examines the occupational risk of concussion amongst professional and semi-professional footballers in Ireland during the 2014 League of Ireland season. As part of a broader nationally representative study examining occupational safety and health (OSH) awareness amongst professional footballers, this empirical quantitative study, utilising a convenience sample is the first and largest investigation of the frequency of, and attitudes towards, concussion and concussion reporting amongst Irish senior professional and semi-professional footballers.

METHODS

A census survey using an anonymous questionnaire was provided to available League of Ireland clubs between March and May 2015. Permission to access players was provided by the Professional Footballers Association of Ireland. This convenience sample was determined by club availability in relation to match fixtures. Participation by the footballers was voluntary. At the time, there were 250 professional and semi-professional players within the League available to participate.

RESULTS

A total of 149 footballers participated in the study. Sixty percent of the participants were employed on a semi-professional basis and the majority of all participants were aged between 18 and 30. 15.7% of the participants reported having received a concussion in the 2014 season with semi-professional players having a noticeably higher (though not significant) reporting rate. Analysis indicated that there was a significant association between playing position and concussion reporting with defenders having the greater odds of reporting a concussion than other playing positions. Professional and semi-professional footballers have a relatively equal risk of receiving a concussion.

CONCLUSION

This research is the first major investigation of the self-reported frequency of, and attitudes towards, concussion amongst Irish senior professional and semi-professional footballers. The results have important implications for coaches, clinicians, parents, players and national governing bodies. Further research is needed to ascertain whether professional footballers perceive concussion as an occupational risk, and whether they appreciate that accepting such risks can have long-term implications for health.

Head and neck injuries in football (soccer)

The incidence for concussions in football (soccer) is equivalent to other contact sports such as American football and ice hockey. The risk of concussion is increased in goalkeepers, females and perhaps young players. Head to head contact between athletes is the most common mechanism for concussion, while heading does not appear to be a frequent cause. Research is providing evidence that neck muscle development and protective headgear may play a role in the prevention of concussions. The presence and pathophysiology of a chronic encephalopathy secondary to a cumulative subconcussive blows obtained in football is still controversial. Neck injuries are not as common as head injuries and are not frequently reported in the literature. The biomechanics of neck injuries are different between children and adults which may account for the different types of injuries in these populations. Spinal cord injuries are rarely seen in football and are usually associated with major fractures/dislocations.

Modified Balance Error Scoring System (M-BESS) test scores in athletes wearing protective equipment and cleats

Background

Balance testing is an important part of the initial concussion assessment. There is no research on the differences in Modified Balance Error Scoring System (M-BESS) scores when tested in real world as compared to control conditions.

Objective

To assess the difference in M-BESS scores in athletes wearing their protective equipment and cleats on different surfaces as compared to control conditions.

Methods

This cross-sectional study examined university North American football and soccer athletes. Three observers independently rated athletes performing the M-BESS test in three different conditions: (1) wearing shorts and T-shirt in bare feet on firm surface (control); (2) wearing athletic equipment with cleats on FieldTurf; and (3) wearing athletic equipment with cleats on firm surface. Mean M-BESS scores were compared between conditions.

Results

60 participants were recruited: 39 from football (all males) and 21 from soccer (11 males and 10 females). Average age was 21.1 years (SD=1.8). Mean M-BESS scores were significantly lower (p<0.001) for cleats on FieldTurf (mean=26.3; SD=2.0) and for cleats on firm surface (mean=26.6; SD=2.1) as compared to the control condition (mean=28.4; SD=1.5). Females had lower scores than males for cleats on FieldTurf condition (24.9 (SD=1.9) vs 27.3 (SD=1.6), p=0.005). Players who had taping or bracing on their ankles/feet had lower scores when tested with cleats on firm surface condition (24.6 (SD=1.7) vs 26.9 (SD=2.0), p=0.002).

Conclusions

Total M-BESS scores for athletes wearing protective equipment and cleats standing on FieldTurf or a firm surface are around two points lower than M-BESS scores performed on the same athletes under control conditions.

Pediatricians' knowledge of current sports concussion legislation and guidelines and comfort with sports concussion management: a cross-sectional study

BACKGROUND

Sports-related concussions disproportionately affect young athletes. The primary objective of our study was to determine Illinois pediatricians' level of familiarity with state concussion legislation and with published consensus guidelines for sports concussion diagnosis and treatment. We also sought to determine pediatricians' knowledge regarding concussion management and comfort treating sports concussion patients.

METHODS

This was a cross-sectional survey of pediatrician members of the Illinois Chapter of the American Academy of Pediatrics.

RESULTS

Few general pediatricians (26.6%, n = 42) were "very familiar" or "somewhat familiar" with the recently passed Illinois state concussion legislation. Only 14.6% (n = 23) of general pediatrician respondents use concussion consensus guidelines in their practice. Pediatricians were generally very knowledgeable about concussions; only 5 out of 19 knowledge-based items were answered incorrectly by more than 25% of the study participants.

CONCLUSIONS

General pediatricians are knowledgeable about concussions but most are not well aware of state concussion legislation and concussion consensus guidelines.

Mechanisms of injury for concussions in university football, ice hockey, and soccer

OBJECTIVE

To examine the mechanisms of injury for concussions in university football, ice hockey, and soccer.

DESIGN

Prospective cohort design.

SETTING

McGill University Sport Medicine Clinic.

PARTICIPANTS

Male and female athletes participating in varsity football, ice hockey, and soccer.

MAIN OUTCOME MEASURES

Athletes were followed prospectively over a 10-year period to determine the mechanisms of injury for concussions and whether contact with certain areas of the body or individual variables predisposed to longer recovery from concussions. For soccer, data were collected on whether concussions occurred while attempting to head the ball.

RESULTS

There were 226 concussions in 170 athletes over the study period. The side/temporal area of the head or helmet was the most common area to be struck resulting in concussion in all 3 sports. Contact from another player's head or helmet was the most probable mechanism in football and soccer. In hockey, concussion impacts were more likely to occur from contact with another body part or object rather than another head/helmet. Differences in mechanisms of injuries were found between males and females in soccer and ice hockey. Athletes with multiple concussions took longer to return to play with each subsequent concussion. Half of the concussions in soccer were related to attempting to head the soccer ball.

CONCLUSIONS

The side of the head or helmet was the most common area to be struck resulting in concussion in all 3 sports. In ice hockey and soccer, there are differences in the mechanisms of injury for males and females within the same sport.

Concussions and heading in soccer: a review of the evidence of incidence, mechanisms, biomarkers and neurocognitive outcomes

BACKGROUND

Soccer is currently the most popular and fastest-growing sport worldwide. Similar to many sports, soccer carries an inherent risk of injury, including concussion. Soccer is also unique in the use of 'heading'. The present paper provides a comprehensive review of the research examining the incidence, mechanisms, biomarkers of injury and neurocognitive outcomes of concussions and heading in soccer.

METHODS

Seven databases were searched for articles from 1806 to 24 May 2013. Articles obtained by the electronic search were reviewed for relevance, with 229 selected for review. Ultimately, 49 articles met criteria for inclusion in the present review.

RESULTS

Female soccer players have a higher incidence of concussions than males. The most frequent injury mechanism is player-to-player contact for both genders. Few studies examined the effects of concussion in soccer players; however, neurocognitive outcomes were similar to those reported in the larger sport concussion literature, while the effect of heading is less clear.

CONCLUSION

Despite variation in research designs and study characteristics, the outcomes of concussions in soccer align with the greater concussion literature. This review makes recommendations for future research to increase standardization of research for improved understanding of concussions in soccer as well as the effects of heading.

Concussions in soccer: a current understanding

OBJECTIVE

Traumatic brain injury (TBI) is a significant public health problem in the United States, with approximately 1.5-2 million TBIs occurring each year. However, it is believed that these figures underestimate the true toll of TBI. Soccer is the most popular sport in the world and has a following of millions in the United States. Soccer is a sport not traditionally identified as high-risk for concussions, yet several studies have shown that concussion rates in soccer are comparable to, and often exceed those of, other contact sports. As many as 22% of all soccer injuries are concussions.

METHODS

Soccer is a sport not traditionally identified as high risk for concussions, yet several studies have shown that concussion rates in soccer are comparable to, and often exceed those of, other contact sports. As many as 22% of all soccer injuries are concussions. Head injury during soccer is usually the result of either "direct contact" or contact with the ball while "heading" the ball. Relationships between the number of headers sustained in a single season and the degree of cognitive impairment (attention and visual/verbal memory) have been demonstrated. It is also likely that multiple concussions may cause cumulative neuropsychologic impairment in soccer players.

RESULTS

Although our understanding of risk factors for sports-related concussions is far from complete, there is great potential for prevention in sports-related concussions. Several measures must be taken to avert the development of concussions in soccer and, when they take place, reduce their effects. These include the development and testing of effective equipment during play, the maintenance of regulatory standards for all such equipment, educating young athletes on the safe and appropriate techniques used during play, and strict adherence to the rules of competition.

CONCLUSIONS

In spite of such preventive measures, concussions in soccer will continue to occur. Considering the frequency of concussions in soccer, the serious sequelae of these concussions, and because almost half of concussed soccer players were noncompliant with recommended American Academy of Neurology return-to-play guidelines, further measures must be taken to protect players, in addition to understanding those criteria that result in removing an injured player from competition and the steps by which to safely return an athlete to competition after injury.

The relationship between subconcussive impacts and concussion history on clinical measures of neurologic function in collegiate football players

Concussions sustained during college and professional football careers have been associated with both acute and chronic neurologic impairment. The contribution of subconcussive impacts to this impairment has not been adequately studied. Therefore, we investigated the relationship between subconcussive impacts and concussion history on clinical measures of neurologic function. Forty-six collegiate football players completed five clinical measures of neurologic function commonly employed in the evaluation of concussion before and after a single season. These tests included the Automated Neuropsychological Assessment Metrics, Sensory Organization Test, Standardized Assessment of Concussion, Balance Error Scoring System, and Graded Symptom Checklist. The Head Impact Telemetry (HIT) System recorded head impact data including the frequency, magnitude, and location of impacts. College football players sustain approximately 1,000 subconcussive impacts to the head over the course of a season, but for the most part, do not demonstrate any clinically meaningful changes from preseason to postseason on measures of neurologic function. Changes in performance were mostly independent of prior concussion history, and the total number, magnitude and location of sustained impacts over one season as observed R(2) values ranged between 0.30 and 0.35. Repetitive subconcussive head impacts over a single season do not appear to result in short-term neurologic impairment, but these relationships should be further investigated for a potential dose-response over a player's career.

Football (soccer) safety equipment use and parental attitudes toward safety equipment in a community youth sports program

While a growing number of children are playing football (soccer), there are limited data on prevalence of injuries, actual use of football safety equipment (SE), and parental attitudes about football SE. We distributed a self-administered survey by mail to parents of all players enrolled in a community recreation youth football program. Parents of 865 children responded. Overall, 32 (3.7%) children were reported as having injuries requiring medical/dental evaluation. Upper/lower extremities were the most commonly injured sites. Shinguards (SGs) were the only equipment commonly used. While there was high parental support for SG use (97.4%) and moderate support for mouthguards (MGs; 53.8%), there was less support for other SE. Many parents were unfamiliar with available SE, but they were mostly willing to pay for it. In a community youth sports program, reports of football injuries were low as was the use of football SE other than SGs.

Injuries in youth soccer

Injury rates in youth soccer, known as football outside the United States, are higher than in many other contact/collision sports and have greater relative numbers in younger, preadolescent players. With regard to musculoskeletal injuries, young females tend to suffer more knee injuries, and young males suffer more ankle injuries. Concussions are fairly prevalent in soccer as a result of contact/collision rather than purposeful attempts at heading the ball. Appropriate rule enforcement and emphasis on safe play can reduce the risk of soccer-related injuries. This report serves as a basis for encouraging safe participation in soccer for children and adolescents.

Soccer injuries in children

Soccer is the most popular sport in the world, with FIFA recognising more than 265 million amateur players. Despite the fact that soccer is a contact sport, it is perceived to be relatively safe to play, a factor that has contributed to its status as the fastest growing team sport in the USA. Acute and minor injuries predominate in the statistics, with contusions and abrasions being the most commonly recorded. As would be expected, the majority of soccer injuries are to the lower limbs, with serious truncal and spinal trauma being rare. This article examines the type and anatomic location of injuries sustained by children and adolescents who play soccer, and the main mechanisms whereby such injuries occur. The risk factors underpinning injury occurrence are considered, along with injury avoidance tactics.

Sport-related concussion

Sport-related concussion is a common injury in children and adolescents. Athletes seldom report concussive symptoms, which makes the diagnosis a challenge. The management of sport-related concussion has changed significantly over the last several years. The previously used grading systems and return-to-play guidelines have been abandoned in favor of more individualized assessment and management. Neuropsychological testing is being used more frequently to assist in management. After recovery, it is recommended that an athlete's return-to-play progress in a gradual, stepwise fashion while being monitored by a health care provider. Proper assessment and management of a sport-related concussion is crucial, because repeat concussions can result in decreased neurocognitive functioning, increased symptomatology, and, at times, catastrophic outcomes.

Safe and healthy school environments

Children spend much of their waking time at school. Many of the factors in the school environment can be improved with careful planning and allocation of resources. The pediatrician, as a child advocate, is in an excellent position to influence the allocation of school resources to improve the educational outcome. This article summarizes some of the current understanding gathered from applying an environmental health approach to the school setting and provides a basis for the interested physician and other child advocate to learn more and get involved.