On-field Head Acceleration Exposure Measurements Using Instrumented Mouthguards: Multi-stage Screening to Optimize Data Quality.

Instrumented mouthguards (iMGs) are widely applied to measure head acceleration event (HAE) exposure in sports. Despite laboratory validation, on-field factors including potential sensor skull-decoupling and spurious recordings limit data accuracy. Video analysis can provide complementary information to verify sensor data but lacks quantitative kinematics reference information and suffers from subjectivity. The purpose of this study was to develop a rigorous multi-stage screening procedure, combining iMG and video as independent measurements, aimed at improving the quality of on-field HAE exposure measurements. We deployed iMGs and gathered video recordings in a complete university men's ice hockey varsity season. We developed a four-stage process that involves independent video and sensor data collection (Stage I), general screening (Stage II), cross verification (Stage III), and coupling verification (Stage IV). Stage I yielded 24,596 iMG acceleration events (AEs) and 17,098 potential video HAEs from all games. Approximately 2.5% of iMG AEs were categorized as cross-verified and coupled iMG HAEs after Stage IV, and less than 1/5 of confirmed or probable video HAEs were cross-verified with iMG data during stage III. From Stage I to IV, we observed lower peak kinematics (median peak linear acceleration from 36.0 to 10.9 g; median peak angular acceleration from 3922 to 942 rad/s2) and reduced high-frequency signals, indicative of potential reduction in kinematic noise. Our study proposes a rigorous process for on-field data screening and provides quantitative evidence of data quality improvements using this process. Ensuring data quality is critical in further investigation of potential brain injury risk using HAE exposure data.

Resting State EEG Variability and Implications for Interpreting Clinical Effect Sizes.

Resting state electroencephalography (rsEEG) is widely used to investigate intrinsic brain activity, with the potential for detecting neurophysiological abnormalities in clinical conditions from neurodegenerative disease to developmental disorders. When interpreting quantitative rsEEG changes, a key question is: how much deviation from a healthy normal brain state indicates a clinically significant change? Here, we build on the existing rsEEG variability literature by quantifying how this baseline rsEEG range can be attributed to common but underinvestigated sources of variability: experiment day, time of day, and pre-recording exercise level. We found that even within individuals, frequency band powers and entropy measures can vary by 7% (sample entropy and relative alpha power) to 28% (absolute delta power). Absolute and relative delta power increased significantly after running, while relative theta power decreased significantly. Relative beta and gamma power were significantly higher in the afternoon compared to morning trials. Sample entropy and alpha power were relatively consistent. The coefficients of variability we found are similar to some clinical rsEEG effect sizes identified in prior literature, bringing into question the clinical significance of these effect sizes. Furthermore, time of day and activity level accounted for more rsEEG variability than experiment day, indicating the potential to reduce variability by controlling for these factors in repeated-measures studies.

Individualized monitoring of longitudinal heading exposure in soccer.

There is growing concern that repetitive soccer headers may have negative long-term consequences on brain health. However, inconsistent and low-quality heading exposure measurements limit past investigations of this effect. Here we conducted a comprehensive heading exposure analysis across all players on a university women's soccer team for over two calendar years (36 unique athletes), quantifying both game and practice exposure during all in-season and off-season periods, with over ten thousand video-confirmed headers. Despite an average of approximately 2 headers per day, players' daily exposures ranged from 0 to 45 headers, accumulating to highly variable total exposure of 2-223 headers over each in-season/off-season period. Overall, practices and off-season periods accounted for 70% and 45% of headers, respectively. Impact sensor data showed that heading kinematics fell within a tight distribution, but sensors could not capture full heading exposure due to factors such as compliance. With first-of-its-kind complete heading exposure data, we recommend exposure assessments be made on an individual level and include practice/off-season collection in addition to games and competitive seasons. Commonly used group statistics do not capture highly variable exposures, and individualized complete heading exposure tracking needs to be incorporated in future study designs for confirming the potential brain injury risk associated with soccer heading.

On-field instrumented mouthguard coupling.

Instrumented mouthguard (iMG) sensors have been developed to measure sports head acceleration events (HAE) in brain injury research. Laboratory validation studies show that effective coupling of iMGs with the human skull is crucial for accurate head kinematics measurements. However, iMG-skull coupling has not been investigated in on-field sports settings. The objective of this study was to assess on-field iMG coupling using infrared proximity sensing and to investigate coupling effects on kinematics signal characteristics. Forty-two university-level men's ice hockey (n = 21) and women's rugby (n = 21) athletes participated in the study, wearing iMGs during 6-7 month in-season periods. Proximity data classified video-verified HAE recordings into four main iMG coupling categories: coupled (on-teeth), decoupling (on-teeth to off-teeth), recoupling (off-teeth to on-teeth) and decoupled (off-teeth). Poorly-coupled HAEs showed significantly higher peak angular acceleration amplitudes and greater signal power in medium-high frequency bands compared with well-coupled HAEs, indicating potential iMG movements independent of the skull. Further, even video-verified true positives included poorly-coupled HAEs, and iMG coupling patterns varied between the men's hockey and women's rugby teams. Our findings show the potential of using proximity sensing in iMGs to identify poorly-coupled HAEs. Utilizing this data screening process in conjunction with video review may mitigate a key source of sensor noise and enhance the overall quality of on-field sports HAE datasets.

Automated soccer head impact exposure tracking using video and deep learning.

Head impacts are highly prevalent in sports and there is a pressing need to investigate the potential link between head impact exposure and brain injury risk. Wearable impact sensors and manual video analysis have been utilized to collect impact exposure data. However, wearable sensors suffer from high deployment cost and limited accuracy, while manual video analysis is a long and resource-intensive task. Here we develop and apply DeepImpact, a computer vision algorithm to automatically detect soccer headers using soccer game videos. Our data-driven pipeline uses two deep learning networks including an object detection algorithm and temporal shift module to extract visual and temporal features of video segments and classify the segments as header or nonheader events. The networks were trained and validated using a large-scale professional-level soccer video dataset, with labeled ground truth header events. The algorithm achieved 95.3% sensitivity and 96.0% precision in cross-validation, and 92.9% sensitivity and 21.1% precision in an independent test that included videos of five professional soccer games. Video segments identified as headers in the test data set correspond to 3.5 min of total film time, which can be reviewed through additional manual video verification to eliminate false positives. DeepImpact streamlines the process of manual video analysis and can help to collect large-scale soccer head impact exposure datasets for brain injury research. The fully video-based solution is a low-cost alternative for head impact exposure monitoring and may also be expanded to other sports in future work.

Head Impact Exposure and Biomechanics in University Varsity Women's Soccer.

Soccer is a unique sport where players purposefully and voluntarily use their unprotected heads to manipulate the direction of the ball. There are limited soccer head impact exposure data to further study brain injury risks. The objective of the current study was to combine validated mouthpiece sensors with comprehensive video analysis methods to characterize head impact exposure and biomechanics in university varsity women's soccer. Thirteen female soccer athletes were instrumented with mouthpiece sensors to record on-field head impacts during practices, scrimmages, and games. Multi-angle video was obtained and reviewed for all on-field activity to verify mouthpiece impacts and identify contact scenarios. We recorded 1307 video-identified intentional heading impacts and 1011 video-verified sensor impacts. On average, athletes experienced 1.83 impacts per athlete-exposure, with higher exposure in practices than games/scrimmages. Median and 95th percentile peak linear and peak angular accelerations were 10.0, 22.2 g, and 765, 2296 rad/s2, respectively. Long kicks, top of the head impacts and jumping headers resulted in the highest impact kinematics. Our results demonstrate the importance of investigating and monitoring head impact exposure during soccer practices, as well as the opportunity to limit high-kinematics impact exposure through heading technique training and reducing certain contact scenarios.

Head Impact Sensor Triggering Bias Introduced by Linear Acceleration Thresholding.

Contact sports players frequently sustain head impacts, most of which are mild impacts exhibiting 10-30 g peak head center-of-gravity (CG) linear acceleration. Wearable head impact sensors are commonly used to measure exposure and typically detect impacts using a linear acceleration threshold. However, linear acceleration across the head can substantially vary during 6-degree-of-freedom motion, leading to triggering biases that depend on sensor location and impact condition. We conducted an analytical investigation with impact characteristics extracted from on-field American football and soccer data. We assumed typical mouthguard sensor locations and evaluated whether simulated multi-directional impacts would trigger recording based on per-axis or resultant acceleration thresholding. Across 1387 impact directions, a 10g peak CG linear acceleration impact would trigger at only 24.7% and 31.8% of directions based on a 10 g per-axis and resultant acceleration threshold, respectively. Anterior impact locations had lower trigger rates and even a 30 g impact would not trigger recording in some directions. Such triggering biases also varied by sensor location and linear-rotational head kinematics coupling. Our results show that linear acceleration-based impact triggering could lead to considerable bias in head impact exposure measurements. We propose a set of recommendations to consider for sensor manufacturers and researchers to mitigate this potential exposure measurement bias.

Potential Mechanisms of Acute Standing Balance Deficits After Concussions and Subconcussive Head Impacts: A Review.

Standing balance deficits are prevalent after concussions and have also been reported after subconcussive head impacts. However, the mechanisms underlying such deficits are not fully understood. The objective of this review is to consolidate evidence linking head impact biomechanics to standing balance deficits. Mechanical energy transferred to the head during impacts may deform neural and sensory components involved in the control of standing balance. From our review of acute balance-related changes, concussions frequently resulted in increased magnitude but reduced complexity of postural sway, while subconcussive studies showed inconsistent outcomes. Although vestibular and visual symptoms are common, potential injury to these sensors and their neural pathways are often neglected in biomechanics analyses. While current evidence implies a link between tissue deformations in deep brain regions including the brainstem and common post-concussion balance-related deficits, this link has not been adequately investigated. Key limitations in current studies include inadequate balance sampling duration, varying test time points, and lack of head impact biomechanics measurements. Future investigations should also employ targeted quantitative methods to probe the sensorimotor and neural components underlying balance control. A deeper understanding of the specific injury mechanisms will inform diagnosis and management of balance deficits after concussions and subconcussive head impact exposure.

Development of A Learning-Based Terrain Classification Framework for Pushrim-Activated Power-Assisted Wheelchairs.

Pushrim-activated power-assisted wheels (PAPAWs) are assistive technologies that provide on-demand torque assistance to wheelchair users. Although the available power can reduce the physical load of wheelchair propulsion, it may also cause maneuverability and controllability issues. Commercially-available PAPAW controllers are insensitive to environmental changes, leading to inefficient and/or unsafe wheelchair movements. In this regard, adaptive velocity/torque control strategies could be employed to improve safety and stability. To investigate this objective, we propose a context-aware sensory framework to recognize terrain conditions. In this paper, we present a learning-based terrain classification framework for PAPAWs. Study participants performed various maneuvers consisting of common daily-life wheelchair propulsion routines on different indoor and outdoor terrains. Relevant features from wheelchair frame-mounted gyroscope and accelerometer measurements were extracted and used to train and test the proposed classifiers. Our findings revealed that a one-stage multi-label classification framework has a higher accuracy performance compared to a two-stage classification pipeline with an indoor-outdoor classification in the first stage. We also found that, on average, outdoor terrains can be classified with higher accuracy (90%) compared to indoor terrains (65%). This framework can be used for real-time terrain classification applications and provide the required information for an adaptive velocity/torque controller design.

Characterizing head impact exposure in youth female soccer with a custom-instrumented mouthpiece.

While many research efforts have focused on head impact exposure in professional soccer, there have been few studies characterizing exposure at the youth level. The aim of this study is to evaluate a new instrumentation approach and collect some of the first head impact exposure data for youth female soccer players. Athletes were instrumented with custom-fit mouthpieces that measure head impacts. Detailed video analysis was conducted to identify characteristics describing impact source (e.g., kick, header, throw). A total of 763 verified head impacts were collected over 23 practices and 8 games from 7 athletes. The median peak linear accelerations, rotational velocities, and rotational accelerations of all impacts were 9.4 g, 4.1 rad/s, and 689 rad/s2, respectively. Pairwise comparisons resulted in statistically significant differences in kinematics by impact source. Headers following a kicked ball had the highest accelerations and velocity when compared to headers from thrown or another header.

Multi-Directional Dynamic Model for Traumatic Brain Injury Detection.

Given the worldwide adverse impact of traumatic brain injury (TBI) on the human population, its diagnosis and prediction are of utmost importance. Historically, many studies have focused on associating head kinematics to brain injury risk. Recently, there has been a push toward using computationally expensive finite element (FE) models of the brain to create tissue deformation metrics of brain injury. Here, we develop a new brain injury metric, the brain angle metric (BAM), based on the dynamics of a 3 degree-of-freedom lumped parameter brain model. The brain model is built based on the measured natural frequencies of an FE brain model simulated with live human impact data. We show that it can be used to rapidly estimate peak brain strains experienced during head rotational accelerations that cause mild TBI. In our data set, the simplified model correlates with peak principal FE strain (R2 = 0.82). Further, coronal and axial brain model displacement correlated with fiber-oriented peak strain in the corpus callosum (R2 = 0.77). Our proposed injury metric BAM uses the maximum angle predicted by our brain model and is compared against a number of existing rotational and translational kinematic injury metrics on a data set of head kinematics from 27 clinically diagnosed injuries and 887 non-injuries. We found that BAM performed comparably to peak angular acceleration, translational acceleration, and angular velocity in classifying injury and non-injury events. Metrics that separated time traces into their directional components had improved model deviance compare with those that combined components into a single time trace magnitude. Our brain model can be used in future work to rapidly approximate the peak strain resulting from mild to moderate head impacts and to quickly assess brain injury risk.

Validation of a Custom Instrumented Retainer Form Factor for Measuring Linear and Angular Head Impact Kinematics.

Head impact exposure in popular contact sports is not well understood, especially in the youth population, despite recent advances in impact-sensing technology which has allowed widespread collection of real-time head impact data. Previous studies indicate that a custom-instrumented mouthpiece is a superior method for collecting accurate head acceleration data. The objective of this study was to evaluate the efficacy of mounting a sensor device inside an acrylic retainer form factor to measure six-degrees-of-freedom (6DOF) head kinematic response. This study compares 6DOF mouthpiece kinematics at the head center of gravity (CG) to kinematics measured by an anthropomorphic test device (ATD). This study found that when instrumentation is mounted in the rigid retainer form factor, there is good coupling with the upper dentition and highly accurate kinematic results compared to the ATD. Peak head kinematics were correlated with r2 > 0.98 for both rotational velocity and linear acceleration and r2 = 0.93 for rotational acceleration. These results indicate that a rigid retainer-based form factor is an accurate and promising method of collecting head impact data. This device can be used to study head impacts in helmeted contact sports such as football, hockey, and lacrosse as well as nonhelmeted sports such as soccer and basketball. Understanding the magnitude and frequency of impacts sustained in various sports using an accurate head impact sensor, such as the one presented in this study, will improve our understanding of head impact exposure and sports-related concussion.

Pilot Findings of Brain Displacements and Deformations during Roller Coaster Rides.

With 300,000,000 riders annually, roller coasters are a popular recreational activity. Although the number of roller coaster injuries is relatively low, the precise effect of roller coaster rides on our brains remains unknown. Here we present the quantitative characterization of brain displacements and deformations during roller coaster rides. For two healthy adult male subjects, we recorded head accelerations during three representative rides, and, for comparison, during running and soccer headers. From the recordings, we simulated brain displacements and deformations using rigid body dynamics and finite element analyses. Our findings show that despite having lower linear accelerations than sports head impacts, roller coasters may lead to brain displacements and strains comparable to mild soccer headers. The peak change in angular velocity on the rides was 9.9 rad/sec, which was higher than the 5.6 rad/sec in soccer headers with ball velocities reaching 7 m/sec. Maximum brain surface displacements of 4.0 mm and maximum principal strains of 7.6% were higher than in running and similar to soccer headers, but below the reported average concussion strain. Brain strain rates during roller coaster rides were similar to those in running, and lower than those in soccer headers. Strikingly, on the same ride and at a similar position, the two subjects experienced significantly different head kinematics and brain deformation. These results indicate that head motion and brain deformation during roller coaster rides are highly sensitive to individual subjects. Although our study suggests that roller coaster rides do not present an immediate risk of acute brain injury, their long-term effects require further longitudinal study.

Detection of American Football Head Impacts Using Biomechanical Features and Support Vector Machine Classification.

Accumulation of head impacts may contribute to acute and long-term brain trauma. Wearable sensors can measure impact exposure, yet current sensors do not have validated impact detection methods for accurate exposure monitoring. Here we demonstrate a head impact detection method that can be implemented on a wearable sensor for detecting field football head impacts. Our method incorporates a support vector machine classifier that uses biomechanical features from the time domain and frequency domain, as well as model predictions of head-neck motions. The classifier was trained and validated using instrumented mouthguard data from collegiate football games and practices, with ground truth data labels established from video review. We found that low frequency power spectral density and wavelet transform features (10~30 Hz) were the best performing features. From forward feature selection, fewer than ten features optimized classifier performance, achieving 87.2% sensitivity and 93.2% precision in cross-validation on the collegiate dataset (n = 387), and over 90% sensitivity and precision on an independent youth dataset (n = 32). Accurate head impact detection is essential for studying and monitoring head impact exposure on the field, and the approach in the current paper may help to improve impact detection performance on wearable sensors.

Bandwidth and sample rate requirements for wearable head impact sensors.

Wearable inertial sensors measure human head impact kinematics important to the on-going development and validation of head injury criteria. However, sensor specifications have not been scientifically justified in the context of the anticipated field impact dynamics. The objective of our study is to determine the minimum bandwidth and sample rate required to capture the impact frequency response relevant to injury. We used high-bandwidth head impact data as ground-truth measurements, and investigated the attenuation of various injury criteria at lower bandwidths. Given a 10% attenuation threshold, we determined the minimum bandwidths required to study injury criteria based on skull kinematics and brain deformation in three different model systems: helmeted cadaver (no neck), unhelmeted cadaver (no neck), and helmeted dummy impacts (with neck). We found that higher bandwidths are required for unhelmeted impacts in general and for studying strain rate injury criteria. Minimum gyroscope bandwidths of 300Hz in helmeted sports and 500Hz in unhelmeted sports are necessary to study strain rate based injury criteria. A minimum accelerometer bandwidth of 500Hz in unhelmeted sports is necessary to study most injury criteria. Current devices typically sample at 1000Hz, with gyroscope bandwidths below 200Hz, which are not always sufficient according to these requirements. With hard contact test conditions, the identified requirements may be higher than most soft contacts on the field, but should be satisfied to capture the worst contact, and often higher risk, scenarios relative to the specific sport or activity. Our findings will help establish standard guidelines for sensor choice and design in traumatic brain injury research.

Effect of the mandible on mouthguard measurements of head kinematics.

Wearable sensors are becoming increasingly popular for measuring head motions and detecting head impacts. Many sensors are worn on the skin or in headgear and can suffer from motion artifacts introduced by the compliance of soft tissue or decoupling of headgear from the skull. The instrumented mouthguard is designed to couple directly to the upper dentition, which is made of hard enamel and anchored in a bony socket by stiff ligaments. This gives the mouthguard superior coupling to the skull compared with other systems. However, multiple validation studies have yielded conflicting results with respect to the mouthguard׳s head kinematics measurement accuracy. Here, we demonstrate that imposing different constraints on the mandible (lower jaw) can alter mouthguard kinematic accuracy in dummy headform testing. In addition, post mortem human surrogate tests utilizing the worst-case unconstrained mandible condition yield 40% and 80% normalized root mean square error in angular velocity and angular acceleration respectively. These errors can be modeled using a simple spring-mass system in which the soft mouthguard material near the sensors acts as a spring and the mandible as a mass. However, the mouthguard can be designed to mitigate these disturbances by isolating sensors from mandible loads, improving accuracy to below 15% normalized root mean square error in all kinematic measures. Thus, while current mouthguards would suffer from measurement errors in the worst-case unconstrained mandible condition, future mouthguards should be designed to account for these disturbances and future validation testing should include unconstrained mandibles to ensure proper accuracy.

In Vivo Evaluation of Wearable Head Impact Sensors.

Inertial sensors are commonly used to measure human head motion. Some sensors have been tested with dummy or cadaver experiments with mixed results, and methods to evaluate sensors in vivo are lacking. Here we present an in vivo method using high speed video to test teeth-mounted (mouthguard), soft tissue-mounted (skin patch), and headgear-mounted (skull cap) sensors during 6-13 g sagittal soccer head impacts. Sensor coupling to the skull was quantified by displacement from an ear-canal reference. Mouthguard displacements were within video measurement error (<1 mm), while the skin patch and skull cap displaced up to 4 and 13 mm from the ear-canal reference, respectively. We used the mouthguard, which had the least displacement from skull, as the reference to assess 6-degree-of-freedom skin patch and skull cap measurements. Linear and rotational acceleration magnitudes were over-predicted by both the skin patch (with 120% NRMS error for a(mag), 290% for α(mag)) and the skull cap (320% NRMS error for a(mag), 500% for α(mag)). Such over-predictions were largely due to out-of-plane motion. To model sensor error, we found that in-plane skin patch linear acceleration in the anterior-posterior direction could be modeled by an underdamped viscoelastic system. In summary, the mouthguard showed tighter skull coupling than the other sensor mounting approaches. Furthermore, the in vivo methods presented are valuable for investigating skull acceleration sensor technologies.

Resonance of human brain under head acceleration.

Although safety standards have reduced fatal head trauma due to single severe head impacts, mild trauma from repeated head exposures may carry risks of long-term chronic changes in the brain's function and structure. To study the physical sensitivities of the brain to mild head impacts, we developed the first dynamic model of the skull-brain based on in vivo MRI data. We showed that the motion of the brain can be described by a rigid-body with constrained kinematics. We further demonstrated that skull-brain dynamics can be approximated by an under-damped system with a low-frequency resonance at around 15 Hz. Furthermore, from our previous field measurements, we found that head motions in a variety of activities, including contact sports, show a primary frequency of less than 20 Hz. This implies that typical head exposures may drive the brain dangerously close to its mechanical resonance and lead to amplified brain-skull relative motions. Our results suggest a possible cause for mild brain trauma, which could occur due to repetitive low-acceleration head oscillations in a variety of recreational and occupational activities.

Six Degree-of-Freedom Measurements of Human Mild Traumatic Brain Injury.

This preliminary study investigated whether direct measurement of head rotation improves prediction of mild traumatic brain injury (mTBI). Although many studies have implicated rotation as a primary cause of mTBI, regulatory safety standards use 3 degree-of-freedom (3DOF) translation-only kinematic criteria to predict injury. Direct 6DOF measurements of human head rotation (3DOF) and translation (3DOF) have not been previously available to examine whether additional DOFs improve injury prediction. We measured head impacts in American football, boxing, and mixed martial arts using 6DOF instrumented mouthguards, and predicted clinician-diagnosed injury using 12 existing kinematic criteria and 6 existing brain finite element (FE) criteria. Among 513 measured impacts were the first two 6DOF measurements of clinically diagnosed mTBI. For this dataset, 6DOF criteria were the most predictive of injury, more than 3DOF translation-only and 3DOF rotation-only criteria. Peak principal strain in the corpus callosum, a 6DOF FE criteria, was the strongest predictor, followed by two criteria that included rotation measurements, peak rotational acceleration magnitude and Head Impact Power (HIP). These results suggest head rotation measurements may improve injury prediction. However, more 6DOF data is needed to confirm this evaluation of existing injury criteria, and to develop new criteria that considers directional sensitivity to injury.