# Football Heading Risk and Safety - Expert Conclusions over 20 Years

Scientific and Technical Writer
May. 12, 2023
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### Football Heading Risk and Safety - Expert Conclusions over 20 Years

• 1. Football Heading Risk and Safety Expert Conclusions over Twenty Years Safia Fatima Mohiuddin, Researcher and Scientific Writer Based on Global Studies of Child and Adolescent Play
• 2. The Physics of Heading a Football High kicks Collisions Head Ball Contact Section 1 An Early Answer to the Question: Why do football and soccer players have deficits in concentration, memory, planning, and alertness overtime? Charles Babbs’ Model to Assess Brain Injury Risk from Heading (2001) Babbs’ Experiment Falling
• 3. Head-ball contact may be a possible cause of head injury. Babbs’ study to understand whether heading in football was safe or harmful: 🔻 Heading is an essential aspect of competition, a controversial research topic. Yet, it is important to analyze the risk of cumulative injury related to brain acceleration A small percentage of permanent brain injury implies serious public health consequences A Mathematical Model Newton’s Second law of Motion A meter stick A stopwatch A balance ➔ The Player ➔ The Ball ➔ Flight of the ball prior to impact ➔ Eﬀects of variables on intensity and duration of head acceleration The Variables Measured Two Masses
• 4. Horizontal Head Acceleration (Dependencies) Player’s Eﬀective Body Mass Horizontal speed of ball Size of ball Inflation Pressure of the ball Speed of Player Force = Mass * Acceleration Estimation of Acceleration for many game scenarios - The Data Corner kicks Goal Kicks Crosses Clearances Shots Large and small players Poor or good technique Mass of Ball The Forces
• 5. Trajectories of Lofted Balls (The Data) Estimating the Horizontal Speed of the Ball (The Variables) Air Resistance Drag of Motion Spring Constant (Function of Inflation Pressure of the ball) Damping Coeﬃcient (Height to which ball bounces initially when dropped from a height) Players between the ages 10 and 14 Amateur and professional levels Adult men and women Equations of motion for spherical projectiles slowed by air resistance The Variables
• 6. Ratio of horizontal force to horizontal acceleration (depending on angle of inclination of player to the ground) Eﬀective Body Mass The Ideal Heading Technique ➔ Strong, stiﬀ neck muscles ➔ Head does not wobble backwards ➔ Entire body mass connected to the ball ➔ Eﬀective body mass is one half body mass for grounded and jumping player Player Unaware of the Ball ➔ Mass of the head alone is used ➔ Head is susceptible to acceleration during head - ball contact Mediocre Technique ➔ Head wobbles slightly ➔ Eﬀective body mass is intermediate between head and one half of total body mass Higher Eﬀective Body Mass Results in Smaller Head Acceleration When the Ball Collides with the Forehead The Biomechanics of Heading
• 8. Dr. Babbs lauded Ronaldo for “both eﬀectiveness and safety” “It was perfect in more ways than one” -- Physicist and scientist, Dr. Charles Babbs on Cristiano Ronaldo diving bullet header in 2018 FIFA pantheon between Portugal and Morocco News Reference: Won, A.S., Perone, B., Friend, M., & Bailenson, J.N. (2016). Identifying Anxiety Through Tracked Head Movements in a Virtual Classroom. Cyberpsychology, behavior and social networking, 19 6, 380-7 . Ronaldo became the second-highest goal scorer in men’s international soccer Babbs’ Recent Observation
• 9. A Nurse Explains Concussions Information for Young Football Players Section 2 The Value of Safety from a Nurse’s Perspective: What children, adolescents, caregivers, and coaches need to know about Chronic Traumatic Encephalopathy (CTE) Perspective of Linda Hepler, BSN, RN (2016)
• 10. What is a Concussion and How is it Treated Whiplash along the Sagittal Plane Whiplash along the Axial Plane Whiplash along the Coronal Plane Image Reference: Won, A.S., Perone, B., Friend, M., & Bailenson, J.N. (2016). Identifying Anxiety Through Tracked Head Movements in a Virtual Classroom. Cyberpsychology, behavior and social networking, 19 6, 380-7 . The Brain Shifts Rapidly within the Skull A Force is Transmitted to the Brain ⚽ Concussions in children under 19 are on the rise ⚽ Helmet-to-helmet concussions may go undetected
• 11. CTE was first recorded by forensic pathologist, Bennet Omalu in 2002 from the autopsy of the deceased football player, Mike Webster Advanced neurocognitive and radiological studies in children can provide evidence of brain damage at cellular level even without any symptoms or reported concussions Advocates advice exposure to non-impact football, accompanied by strengthening exercises (core and neck strengthening) during practice. Concussion: 2015 Book and Film Omalu’s Discovery of Chronic Traumatic Encephalopathy (CTE)
• 12. Nurse Recommendations for Young Football Players Identifying Common Symptoms ➔ Sleep disturbances ➔ Problems with Concentration ➔ Headache, dizziness ➔ Irritability, Nausea Diagnosis and Care ➔ Diagnosed using Neurocognitive Testing and Imaging ➔ Treated with Physical and Cognitive Rest ➔ Break from Screen Time and Homework for 7-10 days ➔ Concomitant migraine or ADHD may require longer recovery times Nurse Recommendations for Youth ➔ Mandatory education for coaches on concussion symptoms ➔ Implementing age-appropriate laws ➔ Sports medicine professionals recommend head up tackling to reduce risk ➔ Pre-season neurocognitive testing ➔ Following physician recommendations for concussions for prompt recovery
• 13. Stanford Team Studies Head Impact Kinematics MiG2.0 Mouthguards to Measure Brain Strain Measuring Sub-Concussive Brain Strain: How well did instrumented mouthguards (mouthguards with accelerometers) measure sub-concussive brain strain and concussions in head impact? Section 3 Finite Element (FE) Analysis of Liu’s team (2021).
• 14. ⚽ The link between head kinematics and deformation of the brain is used as a predictor of risk of brain injury. ⚽ Finite element head models were used to calculate brain strain and ascertain the risk of mild traumatic brain injury (mTBI) - a type of brain injury that causes cognitive deficits and changes in neurological function. ⚽ 118 head impacts were recorded by video and compared to those collected by Stanford Instrumented Mouthguard (MiG2.0 devices). ⚽ All 118 impacts were found to be subconcussive (neither recorded nor diagnosed) Experimental Setup Results ⚽ A wearable device (instrumented mouthguards) to collect data related to head impact kinematics measurements during a specific period of time ⚽ Finite element (FE) analysis was used to calculate peak brain strains (rotation) MiG2.0 Mouthguards Successfully Detect Subclinical Concussions
• 15. Safety Equipment may not Reduce Risk of CTE Camarillo’s Padded Helmet Test Section 4 Protective Equipment Ineﬀective in Preventing CTE: How Dr. David Camarillo’s team experimented in their lab, and discovered that padded helmets failed to soften blows. Dr. David Camarillo’s Experiment on Helmets (2023)
• 16. ⚽ Researchers pounded the head at diﬀerent speeds and angles using a battering device to measure the force of blows ⚽ Experts fitted mouthguards with the same motion sensor technology on the field (real scenario) on five players during a practice season, with and without soft caps. ⚽ The soft cap that shifted like a loose wig over the helmet provided 15% to 20% more protection (probably due to redirection in some of the impact energy when the impact was received at the right angle). ⚽ Researchers identified 97 head-to-head collisions, which they matched to the sensor data from the mouthguards. The cap did not seem to provide protection against the blows. Experimental Setup Results ⚽ Camarillo tested a padded helmet using a crash test with a dummy head using motion sensors on the head ⚽ Head impact in the absence of a concussion contributed to CTE. Dr. David Camarillo’s Enquiry into the Eﬀectiveness of Padded Helmets
• 17. Dealing with Pediatric Concussions RTS Clearance Guidelines + Evidence-Based Prevention Section 5 Protecting Children with and without a History of Concussion: What factors increase risk of recurrent concussion? How can Evidence-Based prevention and RTS Guidelines help?
• 18. Incidence of Concussions in Children ➔ Collision sports have the highest risk of concussion ➔ Incidence of concussion per 1000 exposures is 0.5 to 4.2 concussions. ➔ Recurrent concussion among youth happen due to ⚽ lack of knowledge of concussion signs and symptoms ⚽ fear of being removed from the game ⚽ not thinking the concussion was serious enough to seek medical attention ⚽ not wanting to let down teammates. 1-2 million children under 18 sustain sports-related concussions per year Increased Risk of Concussion in Children and Adolescents
• 19. Risks of Concussions in Children and Adolescents ➔ Prior history of concussion increased risk of concussion and injury, as well as lower extremity musculoskeletal injury. ➔ Factors contributing to greater vulnerability and delayed recovery were ⚽ thinner cortical skull bones ⚽ neurological immaturity ⚽ weaker supportive neck musculature. ➔ Adolescents are more susceptible to second impact syndrome, with catastrophic consequences, on returning to high-risk activity while still symptomatic from previous concussion ➔ Increased cerebral vulnerability may be due to exacerbated symptoms of index injury or a reinjury. Overall risk of sustaining a concussion with a prior history was four times greater. Increased Risk of Concussion in Children and Adolescents
• 20. Reducing Risk of Concussion Recurrence (For Clinicians) ➔ Preventing concussion through neuromuscular training ➔ Individualized vestibular and cervical physiotherapy to decrease return-to-sport clearance ➔ Educate youth and parents about increased risk ➔ Understand biomarkers of recovery to predict recurrence of concussion ➔ Learn about functional disturbances and microstructural injury ➔ Follow a conservative approach in treating children and adolescents, considering increased vulnerability, recovery times, and adverse long-term consequences, given the sensitive neurodevelopment growth period. Ensure that consensus guidelines for RTS following concussion are evidence-based, sex-specific, and age-specific Increased Risk of Concussion in Children and Adolescents
• 21. Examining, Diagnosing, and Managing Concussions ➔ Injuries in football can go undetected, cause transient functional impairment, or lead to life-threatening structural lesions. Most physicians find it challenging to assess injury severity on-field and oﬀ-field. ➔ The clinical symptoms of brain injury may develop after minutes, hours, or days after the injury, and a standardized approach for physician decision-making is required with regard to player removal from play. ➔ Current international guidelines consist of examination and management procedure within 72 hours after the injury accompanied by a “graduated return-to-football” program. ➔ Seven stages are required to be completed from on-pitch examination to return-to-play. These stages cover several criteria for removal of play, emergency management, and specialist referral. Ensure consensus guidelines for RTS following concussion are evidence-based, sex-specific, and age-specific Sports Medicine Guidelines
• 22. Sports Medicine Guidelines Seven Stages from On-Pitch Examination to Return-to-Football TBI care is administered in line with European Federation of Neurological Societies (EFNS) guidelines for mTBI, National Institute of Health and Care Excellence (NICE) guidelines Stage 1 - On-pitch exam of head injury: checking acute signs, Glasgow Coma Scale, Maddocks questionnaire for memory and orientation Stage 2 - Oﬀ-field assessment: Ocular motor function test, treating minor injuries Stage 3 - Treatment in a quiet area using latest concussion assessment tool with detailed neurological examination. Players return to play when they have no symptoms after Phase 2 and 3. Players with TBI symptoms complete graduated return-to-football program. Stage 4 - Team physician continues to observe player until end of play, directing player to emergency management for worsening symptoms. Players are re-examined before leaving facility and may require driving clearance. Stage 5 - Player is observed for 24 hours by team physician, directing to emergency when required. Stage 6 - Re-evaluation: Physician performs physical and cognitive tests; players advised to avoid electronic devices; return-to-play in case of absence of symptoms; reevaluation after 18-72 hours Stage 7 - Return-to-football graduated program based on McCrory’s Protocol: Medical exam for abnormal diagnostic signs on day of injury, persisting symptoms, and developing symptoms under increasing cognitive and physical training load
• 23. More on the Graduated Program Based on McCrory’s Protocol Sports Medicine Guidelines ➔ The graduated program requires a multidisciplinary approach ➔ The program consists of six stages including graduated increase in physical demand, risk of contact, football-specific exercises, and head impact, spread over training sessions ➔ Younger players with risk factors and history of concussive injuries require a conservative approach ➔ Specific guidelines exist on the initiation of the graduated return-to-football program ➔ Physicians must perform a diﬀerential diagnosis using available guidelines for all domains (consciousness, sleep, vision, etc.) following head injury Future guidelines must include impact severity (threshold), time course of metabolic and pathophysiological changes, as these signs may cause energy crisis & delayed symptoms
• 24. Important Information Brain Injury Blog: https://tbisequelae.wordpress.com/ Edited by: Safia Fatima Mohiuddin Researcher and Scientific Writer Email: safia_fatima@yahoo.com Disclaimer: The enclosed content is for information and discussion only. It is not a substitute for medical or professional advice. It is not an oﬀer to buy or sell any product or service. Facts and opinions are summarized and available as per date of writing indicated. The editor does not accept any responsibility or liability for any damage caused by following advice mentioned in the document. The editor holds no responsibility for the content summarized or linked in the document. The inclusion of authors and links does not imply any sort of endorsement.
• 25. References Babbs, C. F. (2001). Biomechanics of Heading a Soccer Ball: Implications for Player Safety. The Scientific World JOURNAL, 1, 281–322. https://doi.org/10.1100/tsw.2001.56 Cook, N. E., Gaudet III, C. E., Van Patten, R., Kissinger-Knox, A. M., & Iverson, G. (2022). Clinical Outcome Following Sport-Related Concussion Among Children and Adolescents with a History of Prior Concussion: A Systematic Review. Journal of Neurotrauma. https://doi.org/10.1089/neu.2022.0078 Erickson, M. (2023). Padded helmet cover shows little protection for football players. Scope. https://scopeblog.stanford.edu/2023/03/28/padded-helmet-cover-shows-little-protection-for-football-player s/ Feddermann‐Demont, N., Chiampas, G., Cowie, C. M., Meyer, T., Nordström, A., Putukian, M., Straumann, D., & Kramer, E. (2020). Recommendations for initial examination, diﬀerential diagnosis, and management of concussion and other head injuries in high‐level football. Scandinavian Journal of Medicine & Science in Sports, 30(10), 1846–1858. https://doi.org/10.1111/sms.13750 Hepler, L. (2016). Football & Concussion: Worth the Risk?. CHOC Children’s. https://www.choc.org/news/football-concussion-worth-risk/ Liu, Y., Domel, A. G., Cecchi, N. J., Rice, E., Callan, A. A., Raymond, S. J., Zhou, Z., Zhan, X., Zeineh, M., Grant, G., & Camarillo, D. B. (2021). Time Window of Head Impact Kinematics Measurement for Calculation of Brain Strain and Strain Rate in American Football. Annals of Biomedical Engineering, 49, 2791–2804. https://doi.org/10.1007/s10439-021-02821-z Van Ierssel, J., Osmond, M., Hamid, J., Sampson, M., & Zemek, R. (2020). What is the risk of recurrent concussion in children and adolescents aged 5–18 years? A systematic review and meta-analysis. British Journal of Sports Medicine, bjsports-2020-102967. https://doi.org/10.1136/bjsports-2020-102967