The biomechanical signature of loss of consciousness: computational modelling of elite athlete head injuries.

Sports related head injuries can cause transient neurological events including loss of consciousness and dystonic posturing. However, it is unknown why head impacts that appear similar produce distinct neurological effects. The biomechanical effect of impacts can be estimated using computational models of strain within the brain. Here, we investigate the strain and strain rates produced by professional American football impacts that led to loss of consciousness, posturing or no neurological signs. We reviewed 1280 National Football League American football games and selected cases where the team's medical personnel made a diagnosis of concussion. Videos were then analysed for signs of neurological events. We identified 20 head impacts that showed clear video signs of loss of consciousness and 21 showing clear abnormal posturing. Forty-one control impacts were selected where there was no observable evidence of neurological signs, resulting in 82 videos of impacts for analysis. Video analysis was used to guide physical reconstructions of these impacts, allowing us to estimate the impact kinematics. These were then used as input to a detailed 3D high-fidelity finite element model of brain injury biomechanics to estimate strain and strain rate within the brain. We tested the hypotheses that impacts producing loss of consciousness would be associated with the highest biomechanical forces, that loss of consciousness would be associated with high forces in brainstem nuclei involved in arousal and that dystonic posturing would be associated with high forces in motor regions. Impacts leading to loss of consciousness compared to controls produced higher head acceleration (linear acceleration; 81.5 g ± 39.8 versus 47.9 ± 21.4; P = 0.004, rotational acceleration; 5.9 krad/s2 ± 2.4 versus 3.5 ± 1.6; P < 0.001) and in voxel-wise analysis produced larger brain deformation in many brain regions, including parts of the brainstem and cerebellum. Dystonic posturing was also associated with higher deformation compared to controls, with brain deformation observed in cortical regions that included the motor cortex. Loss of consciousness was specifically associated with higher strain rates in brainstem regions implicated in maintenance of consciousness, including following correction for the overall severity of impact. These included brainstem nuclei including the locus coeruleus, dorsal raphé and parabrachial complex. The results show that in head impacts producing loss of consciousness, brain deformation is disproportionately seen in brainstem regions containing nuclei involved in arousal, suggesting that head impacts produce loss of consciousness through a biomechanical effect on key brainstem nuclei involved in the maintenance of consciousness.

Comparison of head impact frequency and magnitude in youth tackle football and ice hockey.

Repetitive head impacts are a growing concern for youth and adolescent contact sport athletes as they have been linked to long term negative brain health outcomes. Of all contact sports, tackle football and ice hockey have been reported to have the highest incidence of head or brain injury however, each sporting environment is unique with distinct rules and regulations regarding contact and collisions. The purpose of this research was to measure and compare the head impact frequency and estimated magnitude of brain tissue strain, amongst youth tackle football and ice hockey players during game play. Head impact frequency was documented by video analysis of youth tackle football and ice hockey game play. Impact magnitude was determined through physical laboratory reconstructions and finite element modelling to estimate brain tissue strains. Tackle football demonstrated significantly higher impact frequency (P < 0.01) and magnitude of estimated brain tissue strains (P < 0.01) compared to ice hockey. A significantly higher number of higher strain head impacts were documented in tackle football when compared to ice hockey (P < 0.01). These differences suggest that youth football players may experience increased frequency and magnitude of estimated brain tissue strains in comparison to youth hockey.

Influence of play type on the magnitude and number of head impacts sustained in youth American football.

The magnitude and number of head impacts experienced by young American football players are associated with negative brain health outcomes and may be affected by play-type strategies. The purpose of this research was to examine how play type affects the magnitude and number of head impacts in youth American tackle football. Head impacts were recorded for 30 games in the 5-9 age category and 30 games in the 9-14 age category. Impacts using physical and finite element models were conducted to determine the brain strain. Run plays had a higher head impact frequency in both age groups (p < 0.05). This increase in head impacts was consistent for all positions (p < 0.05), except wide receiver, and offensive line and defensive back in the 9-14 age group (p > 0.05). Both age groups experienced significantly different magnitude proportions with higher numbers of very low and low strain magnitude impacts during run plays (p < 0.05), and a higher proportion of moderate magnitude impacts in the 5-9 age category (p < 0.05). This data can be used to inform and educate teams and coaches and influence decisions around the use of runs and passing plays that may lead to a decrease in head impacts.

The Influence of Neck Stiffness on Head Kinematics and Maximum Principal Strain Associated With Youth American Football Collisions.

Understanding the relationship between head mass and neck stiffness during direct head impacts is especially concerning in youth sports where athletes have higher proportional head mass to neck strength. This study compared 2 neck stiffness conditions for peak linear and rotational acceleration and brain tissue deformations across 3 impact velocities, 3 impact locations, and 2 striking masses. A pendulum fitted with a nylon cap was used to impact a fifth percentile hybrid III headform equipped with 9 accelerometers and fitted with a youth American football helmet. The 2 neck stiffness conditions consisted of a neckform with and without resistance in 3 planes, representing the upper trapezius, the splenius capitis, and the sternocleidomastoid muscles. Increased neck stiffness resulted in significant changes in head kinematics and maximum principal strain specific to impact velocity, impact location, and striking mass.

Exposure to brain trauma in six age divisions of minor ice hockey.

Acute and chronic neurological risks associated with brain trauma sustained in professional ice hockey has generated concern for youth participants. Minor hockey is a different game when compared to elite players presenting distinctive risk factors for each age division. Objective measures of brain trauma exposure were documented for six divisions in minor ice hockey; U7, U9, U11, U13, U15, U18. Game video analysis, physical reconstruction and computational modelling was employed to capture the event conditions, frequency of impacts, frequency of high strain magnitude (>0.17) impacts, and cumulative trauma. The results showed proportional differences in the event conditions; event type, closing velocity, and head impact location, informing the improvement of age appropriate protection, testing protocols, and safety standards. Frequency of events were highest for U7 when players were learning to skate, and again in U18 as game physicality increases. No significant difference was observed in frequency of high magnitude impacts across age divisions. A peak in high magnitude impacts was empirically observed at both U7 and U15 where skill development in skating and body checking, respectively, were most prominent. Finally, a cumulative trauma metric incorporating frequency and magnitude of impacts provided a detailed analysis of trauma exposure provides for a targeted approach to managing injury risk specific to age division. Objective measures of brain trauma exposure identified in the current study are important to inform strategy, guide legislation and initiate policy for safe play in minor ice hockey.

Biomechanical comparison of concussions with and without a loss of consciousness in elite American football: implications for prevention.

Loss of consciousness (LOC) associated with concussion is no longer considered an indicator of severity of injury in concussion management protocols. Studies investigating the association between LOC and recovery time or neurophysiological performance have reported ambiguous findings and resulted in a limited understanding of the severity of LOC-inducing head impacts. Concussive injuries with and without LOC from helmet-to-helmet and shoulder collisions and falls in elite American football were reconstructed in laboratory using a hybrid III headform and finite element model to obtain peak linear and rotational acceleration and brain tissue deformation metrics in the cerebral cortex, the cerebral white matter, the corpus callosum, the thalamus and the brainstem. Impact velocity, peak linear and rotational acceleration were significantly greater in the LOC group than the no LOC group. The brain tissue deformation metrics were greater in the LOC group than the no LOC group. The best overall predictor for LOC was impact velocity. Concussions with LOC are characterised by greater magnitudes of brain tissue deformation. This was mainly the result of higher impact velocities in the LOC group providing league decision-makers with an understanding of the importance of managing impact velocity through athlete education and rule enforcement or change.

Abnormal Motor Response Associated With Concussive Injuries: Biomechanical Comparison Between Impact Seizures and Loss of Consciousness.

CONTEXT: Loss of consciousness (LOC) and impact seizures associated with concussion represent different clinical presentations of concussion; however, they are often investigated and treated similarly. The biomechanical parameters differentiating these 2 distinct signs of injury are poorly described. OBJECTIVE: To differentiate between cases of concussions with LOC and those with impact seizures by comparing the impact velocity, peak linear and peak rotational acceleration, as well as brain tissue deformation in the cerebral cortex, white matter, brainstem, cerebellum, thalamus, and corpus callosum. DESIGN: Descriptive laboratory study. PATIENTS OR OTHER PARTICIPANTS: Elite American football players who sustained an LOC (n = 20) or impact seizures (n = 21). MAIN OUTCOME MEASURE(S): Impact velocity, peak linear and peak rotational acceleration, maximum principal strain, cumulative strain damage measure at 10%, and strain rate (SR). RESULTS: The SR in the cerebral white matter was greater in the LOC group than in the impact-seizure group. Similar trends were observed for SRs in the cerebral cortex, brainstem, and corpus callosum. No differences were present between groups for the other variables in this study. CONCLUSIONS: A lower SR in certain brain regions helps to explain why motor function is preserved and can be observed in patients with impact seizures versus LOC from concussive injuries.

Head dynamic response and brain tissue deformation for boxing punches with and without loss of consciousness.

BACKGROUND: Loss of consciousness is a poorly understood indicator of concussion severity. Conflicting results have been published supporting loss of consciousness as a severe concussion as well as having no relationship with severity. Understanding how loss of consciousness relates to brain trauma severity will provide useful insights to guide rule changes and return to sport protocols. The purpose of this study was to compare magnitudes of head acceleration and brain tissue deformation for punches resulting in a loss of consciousness and punches that do not. METHODS: Physical representations of boxing punches presenting with and without loss of consciousness were performed using an anthropometric headform and finite element model. The variables measured were peak linear and rotational acceleration, maximum principal strain, cumulative strain damage 10%, and strain rate in five regions of the brain. FINDINGS: Loss of consciousness in boxing resulted from hooks to the side of the mandible creating high levels of rotational acceleration and increased magnitudes of brain trauma in all regions of the brain. Differences between punches resulting in loss of consciousness and no loss of consciousness were distinguished by maximum principal strain for each of the brain region analyzed. INTERPRETATION: This research supports the notion that loss of consciousness in boxing is caused by higher levels of brain trauma and may require a longer recovery time.

The biomechanics of concussion for ice hockey head impact events.

The purpose of this research was to conduct reconstructions of concussive and non-concussive impacts in ice hockey to determine the biomechanics and thresholds of concussive injury in ice hockey. Videos of concussive and non-concussive impacts in an elite professional ice hockey league in North America were reconstructed using physical and finite element model methods. Eighty concussive and 45 non-concussive events were studied. Logistic regressions indicate significant thresholds for concussion for linear/rotational acceleration and CSDM10%. Impacts in ice hockey were mostly long duration events, longer than 15 ms. These results have significant implications for helmet standards and development to prevent concussion.

Brain tissue analysis of impacts to American football helmets.

Concussion in American football is a prevalent concern. Research has been conducted examining frequencies, location, and thresholds for concussion from impacts. Little work has been done examining how impact location may affect risk of concussive injury. The purpose of this research was to examine how impact site on the helmet and type of impact, affects the risk of concussive injury as quantified using finite element modelling of the human head and brain. A linear impactor was used to impact a helmeted Hybrid III headform in several locations and using centric and non-centric impact vectors. The resulting dynamic response was used as input for the Wayne State Brain Injury Model to determine the risk of concussive injury by utilizing maximum principal strain as the predictive variable. The results demonstrated that impacts that occur primarily to the side of the head resulted in higher magnitudes of strain in the grey and white matter, as well as the brain stem. Finally, commonly worn American football helmets were used in this research and significant risk of injury was incurred for all impacts. These results suggest that improvements in American football helmets are warranted, in particular for impacts to the side of the helmet.

The Ability of American Football Helmets to Manage Linear Acceleration With Repeated High-Energy Impacts.

CONTEXT: Football players can receive up to 1400 head impacts per season, averaging 6.3 impacts per practice and 14.3 impacts per game. A decrease in the capacity of a helmet to manage linear acceleration with multiple impacts could increase the risk of traumatic brain injury. OBJECTIVE: To investigate the ability of football helmets to manage linear acceleration with multiple high-energy impacts. DESIGN: Descriptive laboratory study. SETTING: Laboratory. MAIN OUTCOME MEASURE(S): We collected linear-acceleration data for 100 impacts at 6 locations on 4 helmets of different models currently used in football. Impacts 11 to 20 were compared with impacts 91 to 100 for each of the 6 locations. RESULTS: Linear acceleration was greater after multiple impacts (91-100) than after the first few impacts (11-20) for the front, front-boss, rear, and top locations. However, these differences are not clinically relevant as they do not affect the risk for head injury. CONCLUSIONS: American football helmet performance deteriorated with multiple impacts, but this is unlikely to be a factor in head-injury causation during a game or over a season.

Characterization of persistent concussive syndrome using injury reconstruction and finite element modelling.

Concussions occur 1.7 million times a year in North America, and account for approximately 75% of all traumatic brain injuries (TBI). Concussions usually cause transient symptoms but 10 to 20% of patients can have symptoms that persist longer than a month. The purpose of this research was to use reconstructions and finite element modeling to determine the brain tissue stresses and strains that occur in impacts that led to persistent post concussive symptoms (PCS) in hospitalized patients. A total of 21 PCS patients had their head impacts reconstructed using computational, physical and finite element methods. The dependent variables measured were maximum principal strain, von Mises stress (VMS), strain rate, and product of strain and strain rate. For maximum principal strain alone there were large regions of brain tissue incurring 30 to 40% strain. This large field of strain was also evident when using strain rate, product of strain and strain rate. In addition, VMS also showed large magnitudes of stress throughout the cerebrum tissues. The distribution of strains throughout the brain tissues indicated peak responses were always present in the grey matter (0.481), with the white matter showing significantly lower strains (0.380) (p<0.05). The impact conditions of the PCS cases were severe in nature, with impacts against non-compliant surfaces (concrete, steel, ice) resulting in higher brain deformation. PCS biomechanical parameters were shown to fit between those that have been shown to cause transient post concussive symptoms and those that lead to actual pathologic damage like contusion, however, values of all metrics were characterized by large variance and high average responses. This data supports the theory that there exists a progressive continuum of impacts that lead to a progressive continuum of related severity of injury from transient symptoms to pathological damage.

Concussion knowledge in high school football players.

CONTEXT: Participating in sports while experiencing symptoms of a concussion can be dangerous. An athlete's lack of knowledge may be one factor influencing his or her decision to report symptoms. In an effort to enhance concussion education among high school athletes, legislation in Florida has attempted to address the issue through parental consent forms. OBJECTIVE: To survey high school varsity football players to determine their level of knowledge about concussions after the initiation of new concussion-education legislation. DESIGN: Cross-sectional study. SETTING: Descriptive survey administered in person during a team meeting. PATIENTS OR OTHER PARTICIPANTS: A total of 334 varsity football players from 11 high schools in Florida. MAIN OUTCOME MEASURE(S): Participants completed a survey and identified the symptoms and consequences of a concussion among distractors. They also indicated whether they had received education about concussions from a parent, formal education, neither, or both. RESULTS: The most correctly identified symptoms were headache (97%), dizziness (93%), and confusion (90%), and the most correctly identified consequence was persistent headache (93%). Participants reported receiving education from their parents (54%) or from a formal source (60%). Twenty-five percent reported never receiving any education regarding concussions. No correlations were found between the method of education and the knowledge of symptoms or consequences of concussion. CONCLUSIONS: The high school football players we surveyed did not have appropriate knowledge of the symptoms and consequences of concussions. Nausea or vomiting, neck pain, grogginess, difficulty concentrating, and personality or behavioral changes were often missed by participants, and only a small proportion correctly identified brain hemorrhage, coma, and death as possible consequences of inappropriate care after a concussion. Even with parents or guardians signing a consent form indicating they discussed concussion awareness with their child, 46% of athletes suggested they had not.