How to Prevent Concussions in High-Impact Sports

by Dr Nate Dau

Most parents want their children to participate in sports for all the physical, social, and psychological benefits it provides. However, parents also want to protect their children, and sports can pose a risk of injury. One of the biggest concerns for parents is sports concussions, and they ask, “How can concussions be prevented?”. Unfortunately, there is no perfect solution to prevent concussions. The good news is there are simple things parents and coaches can do to reduce the risk of concussion.

As a scientist, I know that I cannot prevent every injury, I can only reduce the risk of an injury. When we apply the following preventative measures to sports, we can reduce the risk of concussion, which should lower the number of concussions, and prevent some concussions from occurring. Rather than addressing the reduction in risk of concussion, I will discuss these as possible concussion prevention methods, understanding that they can prevent some but not all concussions.

Before we get into how to prevent concussions in sports or how to prevent some concussions in sports, I’d like to define a concussion. According to the CDC, a concussion is a type of traumatic brain injury that is caused by excessive motion of the head that can be caused by direct contact or a blow to the body that results in excessive head motion.1 Concussions are not life-threatening but are considered a serious injury. Research has shown that the head motion resulting from an impact is the best predictor of a concussion. How much your head accelerates, how fast it spins, and in which direction all contribute to the risk of concussion. We have demonstrated this by measuring head impacts in player participating in sports, by recreating concussive impacts with crash test dummies, and by running computer simulations of human models. All these experiments have provided a better understanding of how concussions occur. All this research has led to improvements in protective equipment, new equipment tests, rule changes, and guidelines for coaching. As our knowledge of what causes concussions has increased, our techniques for prevention of concussion in sports have increased.

The risk of concussion differs by sport. As you might expect, there are more concussions in football compared to golf. Researchers have quantified the risk of concussion in sports to evaluate the risk in each sport. Because some sports are more common than others, we cannot simply compare the number of concussions each year. The term scientist use is concussion rate per athlete exposure. An athlete’s exposure is defined as a game or a practice. Since concussions are relatively rare, the rate is defined as concussions per 1000 athlete exposures. This reduces the amount of fractions and small numbers, to create an easily relatable number. As we move forward, when we talk about concussion risk, we will be using the number of concussions per 1000 athlete exposures. Below is a table of concussion rates for different sports. One strategy parents could employ is choosing a sport with a lower concussion rate for their child. This strategy will only work if the parents can choose or even influence their child’s choice of sport. If your child cannot be persuaded to play a sport with a lower concussion rate, there are still strategies to reduce the risk of concussion in any sport.

Table 1 - Concussion rate by sport reported as concussions per 1000 athlete exposures [AE] (practice, game, competition).2

There are three main techniques to concussion prevention in sports: equipment, coaching, and limiting exposure. No matter which sport your child plays, they should wear properly fitting and high performing protective equipment. The coaches should ensure that safety is a top priority and that proper techniques to prevent injuries are reinforced early and often during the season. Finally, limiting exposure means that the team and league should have a strategy for intentionally reducing the number of head impacts players experience while participating in the sport. Although these apply to every sport, I’ll address them here individually for the 2 most popular sports with high concussion rates: Football and Soccer.

Concussions in Football

Football continues to be the most popular professional sport in the United States. However, parents are concerned about letting their children play football due to the concussion risk. There has been significant focus on the risk of concussions in football in the media as well. The NFL has spent 100 million dollars over the last 6 years to address concussions in football. These resources have pushed the development of better helmets, research that identifies risky behaviors, and rule changes to reduce exposure. This is great news for professional athletes, and these improvements provide benefits for all levels of football participation.

Football Equipment

People are very familiar with the football helmet which is required equipment for participation. All helmets worn need to be certified by NOCSAE (National Operating Committee on Standards for Athletic Equipment). This certification standard was created in 1973 and is the minimum standard for a helmet to be worn in the sport.3 The NOCSAE standard includes how a helmet can be reconditioned after use and when it should be retired. This standard led to an increase in head protection in football but it should be considered the minimum requirement as it is a simple pass/fail test. The NOCSAE standard does not evaluate a helmet’s ability to prevent concussions in football, it evaluates a helmet’s ability to prevent more serious brain injuries. So this test and certification are important, but is the minimum threshold for football helmets.

Researchers have developed additional standard tests for football helmets to evaluate their effectiveness in preventing concussions. These new tests are more complex, incorporate concussion risk, are based on real-world data, and provide more detailed results. The new tests use data collected on the field to define the test conditions. These new standards provide more meaningful tests and guidance on how to prevent a concussion in football.

Researchers at Virginia Tech have created a helmet STAR ranking test methodology.4 The STAR ranking utilizes on-field data to define the test conditions. It then uses the knowledge of concussion risk associated with head measurements to evaluate the effectiveness of a helmet. Finally, the Virginia Tech test provides a STAR ranking 1-5 to the helmet. This test and the STAR ranking provide additional information about helmet performance. Virginia Tech has also created this STAR ranking for two types of Football helmets: Youth and Varsity.

The NFL has also developed their own test methodology. Like the Virginia Tech STAR ranking test, on-field data was used to develop the test conditions for the NFL helmet test. The NFL tests every helmet their players can wear, and ranks the helmets based on how well they perform in the lab.5 These rankings are posted in every NFL locker room and on the NFL’s website. The NFL helmet rankings poster is another reference to evaluate football helmets. However, it should be noted that these tests are specifically focused on impacts measured in professional athletes. They may not directly relate to youth helmets, concussion risk and prevention at other levels of participation.

So how do you choose a football helmet for your child. Here are the steps:

1. Select ONLY NOCSAE certified helmets
2. Look for VT 5-STAR rated helmet for the appropriate age (Youth or Varsity)
3. Check the NFL helmet ranking poster to ensure it is a green helmet

Once you have a list of 2-3 helmets that fit these criteria, go to a store and try them out. Make sure the helmet fits and is comfortable. This might seem a bit much, but think of it this way: how much time and energy do you spend picking the right cleats for your child? Should you spend more or less time selecting a helmet?

Football Coaching

Since the majority of football concussions occur during tackling and being tackled, proper technique is critical. The team should have a Heads-Up Football program, which emphasizes the importance of proper tackling technique. Each season begins with coaching proper tackling techniques at walking speed without pads. Young players need to be reminded each year about keeping their head up when tackling, starting at walking speed and moving to full speed with pads. This should be a given at all youth levels. Additionally, youth teams should have a player safety coach, whose sole focus is safety. This has proven to lower concussions in practice and in games.6

Football Limiting Exposure

Although the coaching staff will have the most influence on limiting exposure, the league the team participates in can also limit exposure. Rules have been implemented in the NCAA that should be consistent in youth sports.7 These include limiting the number of contact practices in training camp to 3 per week and 12 total and eliminating 2 contact practices in a day. Anytime a team has 2 practices in a day, one of those practices should be non-contact. During the season, contact practices should be limited as well with only 2 contact practices per week.

There is also a meaningful push to increase the minimum age for contact football. Kids interested in football at a younger age are being steered towards flag football rather than contact football. Research has shown that kids playing full contact football experience more than 17 times the number of head impacts of kids playing flag football.8 However, there is still a risk of head impacts in flag football. These head impacts are typically accidental resulting from contact with another player or the ground. The good news is that there is equipment designed for flag football and the limited head impacts that occur in the sport. Virginia Tech has created a 5-STAR rating system for flag football head protection. There are two options for head protection in flag football: soft shell helmets and head bands. The soft shell helmets and the headbands are tested, evaluated, and ranked in the VT 5-STAR system together. Soft shell helmets provide more coverage than headbands, especially on the top of the head. However, some kids have hair that just doesn’t work with a helmet and chose a headband. At SYZMIK, we designed the X7 Soft Shell Helmet that has a ponytail port in the back to allow athletes with longer hair to wear a full helmet. The X7 headgear was designed to have the highest score in the VT 5-STAR flag football testing while still being something athletes want to wear. This includes design considerations like the ponytail port, a full range of vision, unobstructed ears, and ample ventilation. All of these features are provided in a helmet weighing about 9oz. Despite the ponytail port, there are some players who still want to wear a headband. SYZMIK created the X7c Non Tackle Protective Headband specifically for these athletes. The X7c Soft Shell Headband also received a 5-STAR rating in the Virginia Tech flag football testing. The two products together (X7 and X7C) allow teams to outfit all their athletes with 5-STAR rated headgear that the athletes will want to wear.

Concussions in Soccer

Soccer Equipment

Soccer has not historically included protective headgear. As our knowledge of concussions and the risks of head impacts has increased over the years, the sport has been changing to address the head impact risks in the sport. The most common source of concussions in soccer are head impacts with other players, the ground, or goal posts. There is also a growing concern about sub-concussive impacts from heading the ball. Although our knowledge about sub-concussive impacts is limited, we know that softening the blow of these impacts should reduce the risk of concussions from a cumulative load.

There are soccer headbands that are designed to soften the blow of headers and accidental head impacts with other players. Again, Virginia Tech has developed a 5-STAR rating for soccer headbands. Choose a 5-STAR rated headband that your child is willing to wear. SYZMIK has created the lowest profile VT 5-STAR soccer headband on the market, the X11 Soccer Performance Headband. It is similar to the X7c, with thinner padding and a grippy front pad to improve control when heading the ball. This is to create the best opportunity for athletes to wear a headband in soccer. Since headbands are not required in soccer, having a low-profile comfortable headband is critical to getting young athletes to adopt headbands. The grippy front pad provides protection in the front without sacrificing control when heading the ball. These headbands can be worn in practice and games.

Limiting Exposure

According to the US Youth Soccer association, children should not begin heading the ball until they are 11 years old.9 This is for a couple reasons. The first reason is that children have heads that are proportionally larger than adults. The neck muscles are not sufficiently developed at 10 years of age to prevent the head from moving involuntarily when impacting a soccer ball. The second reason is that heading pushes players to jump for headers. Children under 11 years old are not typically coordinated for aerial maneuvering in a crowded space. For these reasons, children under 11 years old should not head the ball in soccer.

Once heading is introduced at age 11, it should still be limited through the age of 13. This allows a measured introduction into this aspect of the game. At age 14, or high school, children can head the ball using proper techniques.

Soccer Coaching

Once children are old enough to begin heading the ball, coaching proper techniques are critical. Coaches need to introduce the proper heading technique to kids at a slow pace with sufficient space for them to avoid contact with other athletes. These drills will slowly build up to full speed, as each athlete develops the skill.

What Can I do as a Parent?

How can you help prevent concussions in sports? The simple answer is to address the 3 items listed above: equipment, coaching, and limiting exposure.

• Ensure your child’s protective equipment is in good condition
• Ensure your child wears their protective equipment
• Review league rules and policies for limiting head impact exposure
• Talk to coaches about their strategies for training proper technique and limiting exposure

All of these should be completed prior to the season starting. Then you and your child can make a confident and informed decision about their participation in sports.

Concussion Treatment

Although we’ve described how to prevent concussions in sports, it is important to know what to do if your child does suffer a concussion. The first and most important step is to remove the child from participation immediately.10 There is a risk of second concussion syndrome, which happens when a player receives two concussions in a short amount of time. If an athlete is concussed, they should not return to play in that game/practice that day no matter what. The athlete should be examined by a medical professional to determine the severity of their concussion and provide a multi-step return to participation schedule. These steps begin with complete rest from activity, including school in some cases. The next step is light activity without any contact. The next steps are increasing activity until the last step, returning to full participation. Each concussion is different, and each athlete is different, so the timeline on the return to participate schedule will be individualized. Each step should have a minimum time and a symptom checklist.

References

1. https://www.cdc.gov/headsup/basics/concussion_whatis.html
2. Pfister T, et al. Br J Sports Med 2016;50:292–297. doi:10.1136/bjsports-2015-094978
3. https://nocsae.org/
4. https://helmet.beam.vt.edu/
5. https://www.nfl.com/playerhealthandsafety/equipment-and-innovation/equipment-testing/helmet-laboratory-testing-performance-results
6. Kerr ZY, et al. Orthopaedic Journal of Sports Medicine. 2016;4(5). doi: 10.1177/2325967116648441
7. https://ncaaorg.s3.amazonaws.com/ssi/concussion/SSI_YearRoundFootballPracticeContactBriefingDocument.pdf
8. Sarmiento K, et al. Am J Sports Med. 2021 Jul;49(8):2218-2226. doi: 10.1177/03635465211011754.
9. http://www.usyouthsoccer.org/assets/56/6/us_youth_soccer_policy_on_players_and_playing_rules.pdf
10. https://ncaaorg.s3.amazonaws.com/ssi/concussion/2020_Concussion_Safety_Protocol_Checklist.pdf