12/6/2017. Evidence-Based Practice: Head Impacts in Lacrosse: Should We Be Concerned? Disclaimer. Concussions in Lacrosse

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1 Evidence-Based Practice: Head Impacts in Lacrosse: Should We Be Concerned? Fredericksburg Regional Sports Medicine Symposium Michael Higgins PhD, ATC, PT, CSCS University of Virginia Objectives: Following this presentation, attendees will be able to: Compare the frequency and magnitude of impacts sustained during lacrosse to other sports. Summarize the effects of these impacts on athletes function. Give examples of different ways that subconcussive forces can be minimized during practice and competitions. Explain the Head Impact Frequency and Magnitude in Men s and Women s Lacrosse (High School and Collegiate) Describe head impact characteristics in Men s and Women s Lacrosse Describe possible effects of impacts during a season Explain the new guidelines for helmet use in women s lacrosse Disclaimer Concussions in Lacrosse The presenter has no conflicts or bias for the equipment or measurement techniques in this presentation. Change Concussion Rates in NCAA Sports Change Football % W Ice Hockey % M Ice Hockey % W Lacrosse % M Lacrosse % W Soccer % M Soccer % Wrestling % W Basketball % M Basketball % Men's Lacrosse Data 1

2 Number of Impacts 12/6/2017 Men s Collegiate lacrosse Linear Accelerations Instrumented Players players instrumented for all three seasons % 12%.04%.03%.012%.01%.01%.003%.002% Mean/Median G by Positions Position Mean impact g Median impact g Mean Rotational Velocity Median Rotatioinal deg/s Velocity deg/s Game Practice Game Practice Game Practice Game Practice Defense 23.6 ± ± ± ± [ ] [ ] [ ] [ ] Attacker 20.7 ± ± ± ± [ ] [ ] [ ] [ ] Midfielder 23.8 ± ± ± ± [ ] [ ] [ ] [ ] Goalie 25.7± ± ± ± [ ] [ ] [ ] [ ] Face off 22.1± ± ± ± Season 2015 Season [ ] [ ] [ ] [ ] Overall 21.4 ± [ ] ± [ ] Impact IR 2016 Season Three Year Impact IR by Position 2

3 Impact Characteristics (> 70g) Impact Characteristics (> 70g) Activity during impact Frequency n (%) No ball Possession Loose ball situation 35 (28.7) Defending/delivering a check 39 (32.0) Hit by shot or deflection 4 (3.3) Setting a pick 4 (3.3) Face off 2 (1.6) With ball Possession Attacking 35 (28.7) Preparing to pass/clear the ball 3 (2.5) Kindschi K, Higgins M, Hillman A, et al. Video analysis of highmagnitude head impacts in men s collegiate lacrosse.bmj Open Sport Exerc Med 2017;0:e doi: /bmjsem Kindschi K, Higgins M, Hillman A, et al. Video analysis of highmagnitude head impacts in men s collegiate lacrosse.bmj Open Sport Exerc Med 2017;0:e doi: /bmjsem Impact Characteristics (> 70g) 164 G Impact Defense Practice Shot to head Cold weather (Feb.) NO Concussion Kindschi K, Higgins M, Hillman A, et al. Video analysis of highmagnitude head impacts in men s collegiate lacrosse.bmj Open Sport Exerc Med 2017;0:e doi: /bmjsem Cumulative impacts and Visuomotor Testing Findings Visuomotor tracking performance correlated with repeated head impacts Individuals approached clinically diagnosed mtbi-like performance as the cumulative rotational velocity increased Brokaw E, et al Journal of Neurotrauma in review 2017 Brokaw E, et al Journal of Neurotrauma in review

4 Concussed Athlete Testing Concussions in Women s Lacrosse Rate of female concussions 1.2 per 1,000 athlete exposures. Seventh highest rate among NCAA sports Caused by stick contact (incidentdal) Similar rate at the High School level Brokaw E, et al Journal of Neurotrauma in review 2017 Sensor Location for Women s Lacrosse Collegiate Women's Lacrosse Gforce Tracker Attached to the goggles Place on the base of the skull 9 subjects Defense (3) Attacker (2) Midfielder (3) Goalie (1) Women's Lacrosse impacts Women s Lacrosse IR and Mean G (games) Impacts Exposures IR (95%CI) Mean G Game ( ) ± Practice ( ) Overall ( ) Total Hits >20 Defense (3) 175 Attacker (2) 92 Midfielder (3) 153 Goalie (1) 48 Overall (9) 486 Exposures Mean IR (95% CI) ± ( ) ± ( ) 36.7 ± ( ) 34.3 ± ( ) ± ( ) 4

5 12/6/2017 Practice Impact: IR and Mean (G) Percentage of Impacts by Location IR (95% CI) 542 Exposures 175 Mean Defense (3) ± ( ) Attacker (2) ± ( ) Midfielder (3) ± ( ) Goalie (1) ± ( ) Overall (9) ± ( ) Total Hits >20 Postions Right Defense 16 Attack 28 Midfield 14 Goalie 11 Left Front Back Top Bottom High School Girls Lacrosse Linear and Rotational Acceleration High School Girls Lacrosse 35 participants Two seasons 180 game acceleration events (58 verified) 469 game exposures 2.1 verified impacts 20g occurring per game 1.7 impacts 20g per player-season Year N Impact Rate Rotational Acceleration (rad/s2) Linear Acceleration (g) Mean ± SD Median [25th - 75] IR (95% CI) ± 16.5 Mean ± SD Median [25th - 75] 30.6 [ ] ± [ ] (96.2, 195.8)a ± [ ] ± [ ] (62.6, 143.2)b Total ± [ ] ± [ ] (91.8, 155.5)c Note: Impact incidence rates presented per 1000 athletic exposures with 226 a, 243b and 469c total player games as respective denominators. Caswell S et al. Characterizing Impact Exposure in High School Girl s Lacrosse, AJSM, 2017 Girls High School Lacrosse Game Impacts by Position. Caswell S et al. Characterizing Impact Exposure in High School Girl s Lacrosse, AJSM, 2017 High School Girls Lacrosse Impacts 30 5 Linear Acceleration (g) Rotational Acceleration (rad/s2) Impact Rate 20 Position N Mean ± SD Median [25th - 75] Mean ± SD Median [25th - 75] IR (95% CI) Attack ± [ ] ± [ ] 84.0 (34.4, 133.6)a Midfield ± [ ] ± [ ] (100.2, 218.0)b Defense ± [ ] ± [ ] 93.0 (40.4, 145.7)c Goalie ± [ ] ± [ ] (58.5, 393.1)d Note: Impact incidence rates presented per 1000 athletic exposures with 131 a, 176b, 129c, and 31d total player games as respective denominators. Caswell S et al. Characterizing Impact Exposure in High School Girl s Lacrosse, AJSM, Goalie Attack Ball Stick Midfield Player Ground Defense Unknown Caswell S et al. Characterizing Impact Exposure in High School Girl s Lacrosse, AJSM,

6 Impact Characteristics Impact mechanisms (contact with) stick (n=25, 43.1%) player (n=17, 29.3%) ball (n =7, 12.1%) ground (n =7, 12.1%) Most impacts occurred to the head (n=28, 48.3%) torso (n=12, 17.2%) shoulder (n=10, 20.7%). Men s and women s collegiate lacrosse No significant difference in the number of game or practice head impacts 11.5 for men vs 9.2 for women 3.1 vs 3.1 both practice Reynolds et al. Quantifying Head Impacts in Collegiate Lacrosse. Am J Sports Med published online June 8, 2016, DOI: / Men s and women s collegiate lacrosse Men s lacrosse players had significantly higher average head acceleration per impact during games compared with women (21.1g vs 14.7g) game (21.3g vs 18.1g) practice Comparison of Research Bowman Miyashita Cortez Reynolds Higgins Level DIII DI HS DI DI Sensor X2 Gforce X2/Gforce Tracker X2 Gforce Tracker Tracker Sex Mens Mens Both Both Both Length 2 season 2 seasons 2 seasons 1 season 3/2 seasons Impacts/exposure Video Verified Video Verified Video verified Game (W) 2.8 (M) 9.2(W) 11.5 (M) 3.9 (W) 7.5 (M) Practice (W) 3.1 (M) 2.3 (W) 2.7 (M) Mean G game (W) 46 (M) 18.2 (W) Practice (W) 21.2 (M) 32.3 (W) 38.3 (M) 21.3 (M) 27.4 (W) 24.2 (M) Reynolds et al. Quantifying Head Impacts in Collegiate Lacrosse. Am J Sports Med published online June 8, 2016, DOI: / Comparison of Sports Age Group Frequency (season) Mean Acceleration Football Collegiate G High School G Hockey Collegiate 287 (m) 170 (f) G Youth G Lacrosse Collegiate 230 (m) 225 (f) G High School 55 (m) 22 (f) Sensors HIT System G-Force Tracker X-2 Sensor Triax Mouthgurard 6

7 Sensor Accuracy The current data indicate that existing wearable sensor technologies may substantially overestimate head impact events. Sensors always estimated a head impact location, But only 48% of the impacts were a result of direct contact to the head as characterized on video. Head Acceleration Event Boys High School Game Impacts Cortes, N et al. Am J Sp Med May 25, / Girls High School Game Impacts Are All Helmets Created Equal Cortes, N et al. Am J Sp Med May 25, / Are all Lacrosse Helmets made Equal? Protective? 7

8 Lacrosse Helmet Design: Cascade Lacrosse Helmet Design: Schutt Lacrosse Helmet Design: Warrior Helmet Testing: Standards for Laboratory Testing Standards Testing Procedure :Laboratory NOCSAE Drop System 8

9 Impactor Testing Helmet testing Helmet and Facemask Removal Guide Are Helmets the Answer? /safety/facemask-and-helmet-removal-2017.pdf Soft Helmet Testing Higher velocity ball impacts, No statistically-significant difference in the measured linear and rotational response of the head for the no headgear and soft headgear test conditions. Lower velocity ball impacts, A small, reduction in head linear acceleration for one of the soft headgears compared to no headgear No statistically-significant difference in rotational impact response between headgear. Results indicate that the soft headgear would not be effective in reducing head injury potential during higher velocity ball impacts, such as ball speeds associated with shooting in women's lacrosse. Stick Impacts No statistically-significant differences in lateral impacts to the head for helmeted and soft headgear test conditions compared to no headgear test condition Falls produced the highest linear and angular acceleration, followed by ball and high-velocity stick impacts. Low-velocity stick impacts were found to produce the lowest linear and angular accelerations. Men s lacrosse helmets significantly decreased linear and angular accelerations in all conditions Unhelmeted impacts = high accelerations Rodowicz, K.A., Olberding, J.E. & Rau, A.C. Ann Biomed Eng (2015) 43: 949. doi: /s x Rodowicz, K.A., Olberding, J.E. & Rau, A.C. Ann Biomed Eng (2015) 43: 949. doi: /s x 9

10 ASTM standard F3137 (Women s helmet) The ASTM standard is the first-ever performance standard for women s lacrosse headgear Developed to help reduce impact forces associated with stick and ball contact in women s lacrosse. Is not a soft headgear standard and the standard itself makes no mention of the word "soft." Testing protocol requires that the product meets a certain flexibility to insure that players who are wearing the product do not injure those who are not. Womens Lacrosse Helmet Standards The 2 standards available for women s lacrosse F3077 for women s lacrosse goggles F3137 for headgear (3 main test requirements) a drop impact test that simulates a 45 mph stick swing a 60 mph ball impact test deformation test to ensure a level of softness that complies with the rules of women s lacrosse. Points of Emphasis The use of headgear is optional in girls' and women's lacrosse. Any headgear used after January 1, 2017 must meet the ASTM standard, F3137. The ASTM standard, F3137, is a performance standard, not a design standard. Product designs will likely vary from one manufacturer to another. Products must provide full coverage of the head. Products must be worn with required ASTM women s lacrosse eyewear. There must be marking on both the packaging and product that states that the headgear conforms to ASTM standard F3137. Lacrosse Rules Enforcing Rules or Wearing Helmets 108 head impacts in games that should have drawn a penalty, only two were called Bowman et al, 2015 Most impacts occurred to field players within the attack area (n=32, 55.2%) or the midfield (n=18, 31.0%) regions of the field. Caswell et al (3.4%) impacts resulted in a penalty. Caswell et al 2017 If women s field lacrosse is played within the rules, only falls were found to produce high linear and angular acceleration. Clark J and Hoshizaki, The American Journal of Sports Medicine, Vol. 44, No.12 New Florida High School Mandate NEW FHSAA REGULATION MAKES HEADGEAR MANDATORY FOR ALL SCHOLASTIC GIRLS LACROSSE PLAYERS Rodowicz, K.A., Olberding, J.E. & Rau, A.C. Ann Biomed Eng (2015) 43: 949. doi: /s x 10

11 Risk compensation Opposition to the Mandate A theory which suggests that people typically adjust their behavior in response to the perceived level of risk, becoming more careful where they sense greater risk and less careful if they feel more protected Ann Carpenetti, vice president of lacrosse operations at US Lacrosse, the sport s national governing body, called Florida s decision irresponsible and said the headgear decision could make the game more hazardous because it might embolden players to be more aggressive. Helmets in the Women s Game? THANK YOU Shane Caswell PhD, ATC Nelson Cortes PhD, ATC Tom Bowman PHD, ATC MITRE Kari Kindschi MD, MPH Towson University Lacrosse Teams Towson University Athletic Training Staff Towson University AT Students 11