Evaluating child helmet protection and testing standards: A study using PIPER child head models aged 1.5, 3, 6, and 18 years.

The anatomy of children's heads is unique and distinct from adults, with smaller and softer skulls and unfused fontanels and sutures. Despite this, most current helmet testing standards for children use the same peak linear acceleration threshold as for adults. It is unclear whether this is reasonable and otherwise what thresholds should be. To answer these questions, helmet-protected head responses for different ages are needed which is however lacking today. In this study, we apply continuously scalable PIPER child head models of 1.5, 3, and 6 years old (YO), and an upgraded 18YO to study child helmet protection under extensive linear and oblique impacts. The results of this study reveal an age-dependence trend in both global kinematics and tissue response, with younger children experiencing higher levels of acceleration and velocity, as well as increased skull stress and brain strain. These findings indicate the need for better protection for younger children, suggesting that youth helmets should have a lower linear kinematic threshold, with a preliminary value of 150g for 1.5-year-old helmets. However, the results also show a different trend in rotational kinematics, indicating that the threshold of rotational velocity for a 1.5YO is similar to that for adults. The results also support the current use of small-sized adult headforms for testing child helmets before new child headforms are available.

Personalization of human body models and beyond via image registration.

Finite element human body models (HBMs) are becoming increasingly important numerical tools for traffic safety. Developing a validated and reliable HBM from the start requires integrated efforts and continues to be a challenging task. Mesh morphing is an efficient technique to generate personalized HBMs accounting for individual anatomy once a baseline model has been developed. This study presents a new image registration-based mesh morphing method to generate personalized HBMs. The method is demonstrated by morphing four baseline HBMs (SAFER, THUMS, and VIVA+ in both seated and standing postures) into ten subjects with varying heights, body mass indices (BMIs), and sex. The resulting personalized HBMs show comparable element quality to the baseline models. This method enables the comparison of HBMs by morphing them into the same subject, eliminating geometric differences. The method also shows superior geometry correction capabilities, which facilitates converting a seated HBM to a standing one, combined with additional positioning tools. Furthermore, this method can be extended to personalize other models, and the feasibility of morphing vehicle models has been illustrated. In conclusion, this new image registration-based mesh morphing method allows rapid and robust personalization of HBMs, facilitating personalized simulations.

A rubberized impact absorbing pavement can reduce the head injury risk in vulnerable road users: A bicycle and a pedestrian accident case study.

OBJECTIVE: Vulnerable Road Users (VRU), including pedestrians and cyclists, are generally the least protected road users and are frequently missed in the planning process of preventive measures. Rubberized asphalt mixtures were originally developed as a possible environmentally friendly solution to recycle the End-of-Life Tires while making the pavements more durable. The objective of the current study was to explore the effects of increasing the rubber content of the common rubberized asphalt mixtures in reducing the head injuries risk for VRUs. METHOD: To achieve this purpose, four different sample series with 0, 14, 28, and 33 weight percent rubber in each were tested. A compressive test without permanent deformation and one with failure were performed on each sample series. The mechanical behavior of each set was modeled using a MAT_SIMPLIFIED_RUBBER material model in LS-Dyna and validated against a standard Head Injury Criterion (HIC) drop test. Ultimately, previously low-speed accident reconstructed cases, a bicycle and a pedestrian one, were used to assess the effect of varying the rubber content on reducing the head injury risk. RESULTS: In the bicycle accident case, the risk of skull fracture was reduced from 0.99 to 0.29 when comparing the non-rubberized asphalt mixture with the 33% rubber mixture. In the same accident case, the risk of concussion, evaluated using the logistic regression method, was reduced from 0.97 in the non-rubberized mixture to 0.81 in the 33% rubber mixture. The initial conditions, linear and rotational velocities, were lower for the pedestrian case compared to the bicycle case (the bicycle case was more severe compared to the pedestrian case), which led to lower strains in the pedestrian case. In the pedestrian accident case, the risk of skull fracture was reduced from 1.00 in the non-rubberized mixture to 0.63 in the 33% rubber mixture, while the risk of concussion was reduced from 0.64 to 0.07. CONCLUSION: The rubberized asphalt mixtures could reduce the head injury risk for the studied cases when the rubber content in the asphalt mixture increases.

Influence of Strain post-processing on Brain Injury Prediction.

Finite element head models are a tool to better understand brain injury mechanisms. Many of the models use strain as output but with different percentile values such as 100th, 95th, 90th, and 50th percentiles. Some use the element value, whereas other use the nodal average value for the element. Little is known how strain post-processing is affecting the injury predictions and evaluation of different prevention systems. The objective of this study was to evaluate the influence of strain output on injury prediction and ranking. Two models with different mesh densities were evaluated (KTH Royal Institute of Technology head model and the Total Human Models for Safety (THUMS)). Pulses from reconstructions of American football impacts with and without a diagnosis of mild traumatic brain injury were applied to the models. The value for 100th, 99th, 95th, 90th, and 50th percentile for element and nodal averaged element strain was evaluated based on peak values, injury risk functions, injury predictability, correlation in ranking, and linear correlation. The injury risk functions were affected by the post-processing of the strain, especially the 100th percentile element value stood out. Meanwhile, the area under the curve (AUC) value was less affected, as well as the correlation in ranking (Kendall's tau 0.71-1.00) and the linear correlation (Pearson's r2 0.72-1.00). With the results presented in this study, it is important to stress that the same post-processed strain should be used for injury predictions as the one used to develop the risk function.

Technology-Enhanced Learning of Human Trauma Biomechanics in an Interprofessional Student Context.

Phenomenon: This study aimed to investigate how students can develop their understanding of trauma biomechanics by means of technology-enhanced learning-an interactive visualization tool developed to enhance understanding of the biomechanics underlying an injury via dynamic imaging sequences. Approach: Students were invited to explore the content as a learning resource during an interprofessional clinical placement on an orthopedic ward. Thirty volunteer medical, nursing, and physiotherapy/occupational therapy students participated in 10 interprofessional groups of three participants. They were video recorded while interacting with learning software that was divided into five sections: Work Up, General Information, Biomechanical Case Study, Biomechanical Risk Assessment, and Treatment. Investigators probed students' learning experiences via four focus group discussions. A sociomaterial perspective was adopted, directing the analytical focus to how students' made use of talk, gestures, bodies, and material objects to understand the visualized phenomena. Findings: When connecting the visualization to a patient case, certain features of the technology stood out as important for promoting engagement and understanding trauma mechanisms. Decreased tempo, showing the directions and dynamics of trauma biomechanics in slow-motion, and color coding of the strain on the affected structures were especially important for evoking the emotional responses. The visualization tool also supported students' explorations of causal relationships between external forces and their biomedical effects. These features emphasize the sociomaterial relation between the design of the technology and the student activities. Insights: Dynamic visualization of biomechanical events has the potential to improve the understanding of injury mechanisms and specifically to identify anatomical structures at high risk of injury. Dynamic visualizations for educational purposes seem to promote possibilities for learners to contextualize visual representations relative to one's own body. Educational methods and practice need explicit attention and development in order to use the full potential of the visualization technology for learning for the health care professions.

Toward a Comprehensive Delineation of White Matter Tract-Related Deformation.

Finite element (FE) models of the human head are valuable instruments to explore the mechanobiological pathway from external loading, localized brain response, and resultant injury risks. The injury predictability of these models depends on the use of effective criteria as injury predictors. The FE-derived normal deformation along white matter (WM) fiber tracts (i.e., tract-oriented strain) recently has been suggested as an appropriate predictor for axonal injury. However, the tract-oriented strain only represents a partial depiction of the WM fiber tract deformation. A comprehensive delineation of tract-related deformation may improve the injury predictability of the FE head model by delivering new tract-related criteria as injury predictors. Thus, the present study performed a theoretical strain analysis to comprehensively characterize the WM fiber tract deformation by relating the strain tensor of the WM element to its embedded fiber tract. Three new tract-related strains with exact analytical solutions were proposed, measuring the normal deformation perpendicular to the fiber tracts (i.e., tract-perpendicular strain), and shear deformation along and perpendicular to the fiber tracts (i.e., axial-shear strain and lateral-shear strain, respectively). The injury predictability of these three newly proposed strain peaks along with the previously used tract-oriented strain peak and maximum principal strain (MPS) were evaluated by simulating 151 impacts with known outcome (concussion or non-concussion). The results preliminarily showed that four tract-related strain peaks exhibited superior performance than MPS in discriminating concussion and non-concussion cases. This study presents a comprehensive quantification of WM tract-related deformation and advocates the use of orientation-dependent strains as criteria for injury prediction, which may ultimately contribute to an advanced mechanobiological understanding and enhanced computational predictability of brain injury.

Ranking and Rating Bicycle Helmet Safety Performance in Oblique Impacts Using Eight Different Brain Injury Models.

Bicycle helmets are shown to offer protection against head injuries. Rating methods and test standards are used to evaluate different helmet designs and safety performance. Both strain-based injury criteria obtained from finite element brain injury models and metrics derived from global kinematic responses can be used to evaluate helmet safety performance. Little is known about how different injury models or injury metrics would rank and rate different helmets. The objective of this study was to determine how eight brain models and eight metrics based on global kinematics rank and rate a large number of bicycle helmets (n=17) subjected to oblique impacts. The results showed that the ranking and rating are influenced by the choice of model and metric. Kendall's tau varied between 0.50 and 0.95 when the ranking was based on maximum principal strain from brain models. One specific helmet was rated as 2-star when using one brain model but as 4-star by another model. This could cause confusion for consumers rather than inform them of the relative safety performance of a helmet. Therefore, we suggest that the biomechanics community should create a norm or recommendation for future ranking and rating methods.

Current playground surface test standards underestimate brain injury risk for children.

Playgrounds surface test standards have been introduced to reduce the number of fatal and severe injuries. However, these test standards have several simplifications to make it practical, robust and cost-effective, such as the head is represented with a hemisphere, only the linear kinematics is evaluated and the body is excluded. Little is known about how these simplifications may influence the test results. The objective of this study was to evaluate the effect of these simplifications on global head kinematics and head injury prediction for different age groups. The finite element human body model PIPER was used and scaled to seven different age groups from 1.5 up to 18 years old, and each model was impacted at three different playground surface stiffness and three head impact locations. All simulations were performed in pairs, including and excluding the body. Linear kinematics and skull bone stress showed small influence if excluding the body while head angular kinematics and brain tissue strain were underestimated by the same simplification. The predicted performance of the three different playground surface materials, in terms of head angular kinematics and brain tissue strain, was also altered when including the body. A body and biofidelic neck need to be included, together with suitable head angular kinematics based injury thresholds, in future physical or virtual playground surface test standards to better prevent brain injuries.

Finite Element Analysis of Long Posterior Transpedicular Instrumentation for Cervicothoracic Fractures Related to Ankylosing Spondylitis.

STUDY DESIGN: Biomechanical finite element model analysis. OBJECTIVES: Spinal fractures related to ankylosing spondylitis (AS) are often treated by long posterior stabilization. The objective of this study is to develop a finite element model (FEM) for spinal fractures related to AS and to establish a biomechanical foundation for long posterior stabilization of cervicothoracic fractures related to AS. METHODS: An existing FEM (consisting of 2 separately developed models) including the cervical and thoracic spine were adapted to the conditions of AS (all discs fused, C0-C1 and C1-C2 mobile). A fracture at the level C6-C7 was simulated. Besides a normal spine (no AS, no fracture) and the uninstrumented fractured spine 4 different posterior transpedicular instrumentations were tested. Three loads (1.5g, 3.0g, 4.5g) were applied according to a specific load curve. RESULTS: All posterior stabilization methods could normalize the axial stability at the fracture site as measured with gap distance. The maximum stress at the cranial instrumentation end (C3-C4) was slightly greater if every level was instrumented, than in the skipped level model. The skipped level instrumentation achieved similar rotatory stability as the long multilevel instrumentation. CONCLUSIONS: Skipping instrumentation levels without giving up instrumentation length reduced stresses in the ossified tissue within the range of the instrumentation and did not decrease the stability in a FEM of a cervicothoracic fracture related to AS. Considering the risks associated with every additional screw placed, the skipped level instrumentation has advantages regarding patient safety.

Learning through a virtual patient vs. recorded lecture: a comparison of knowledge retention in a trauma case.

OBJECTIVES: To compare medical students' and residents' knowledge retention of assessment, diagnosis and treatment procedures, as well as a learning experience, of patients with spinal trauma after training with either a Virtual Patient case or a video-recorded traditional lecture. METHODS: A total of 170 volunteers (85 medical students and 85 residents in orthopedic surgery) were randomly allocated (stratified for student/resident and gender) to either a video-recorded standard lecture or a Virtual Patient-based training session where they interactively assessed a clinical case portraying a motorcycle accident. The knowledge retention was assessed by a test immediately following the educational intervention and repeated after a minimum of 2 months. Participants' learning experiences were evaluated with exit questionnaires. A repeated-measures analysis of variance was applied on knowledge scores. A total of 81% (n = 138) of the participants completed both tests. RESULTS: There was a small but significant decline in first and second test results for both groups (F(1, 135) = 18.154, p = 0.00). However, no significant differences in short-term and long-term knowledge retention were observed between the two teaching methods. The Virtual Patient group reported higher learning experience levels in engagement, stimulation, general perception, and expectations. CONCLUSIONS: Participants' levels engagement were reported in favor of the VP format. Similar knowledge retention was achieved through either a Virtual Patient or a recorded lecture.

The protective effect of a helmet in three bicycle accidents--A finite element study.

There is some controversy regarding the effectiveness of helmets in preventing head injuries among cyclists. Epidemiological, experimental and computer simulation studies have suggested that helmets do indeed have a protective effect, whereas other studies based on epidemiological data have argued that there is no evidence that the helmet protects the brain. The objective of this study was to evaluate the protective effect of a helmet in single bicycle accident reconstructions using detailed finite element simulations. Strain in the brain tissue, which is associated with brain injuries, was reduced by up to 43% for the accident cases studied when a helmet was included. This resulted in a reduction of the risk of concussion of up to 54%. The stress to the skull bone went from fracture level of 80 MPa down to 13-16 MPa when a helmet was included and the skull fracture risk was reduced by up to 98% based on linear acceleration. Even with a 10% increased riding velocity for the helmeted impacts, to take into account possible increased risk taking, the risk of concussion was still reduced by up to 46% when compared with the unhelmeted impacts with original velocity. The results of this study show that the brain injury risk and risk of skull fracture could have been reduced in these three cases if a helmet had been worn.

Comparison of multibody and finite element human body models in pedestrian accidents with the focus on head kinematics.

OBJECTIVE: The objective of this study was to compare and evaluate the difference in head kinematics between the TNO and THUMS models in pedestrian accident situations. METHODS: The TNO pedestrian model (version 7.4.2) and the THUMS pedestrian model (version 1.4) were compared in one experiment setup and 14 different accident scenarios where the vehicle velocity, leg posture, pedestrian velocity, and pedestrian's initial orientation were altered. In all simulations, the pedestrian model was impacted by a sedan. The head trajectory, head rotation, and head impact velocity were compared, as was the trend when various different parameters were altered. RESULTS: The multibody model had a larger head wrap-around distance for all accident scenarios. The maximum differences of the head's center of gravity between the models in the global x-, y-, and z-directions at impact were 13.9, 5.8, and 5.6 cm, respectively. The maximum difference between the models in head rotation around the head's inferior-superior axis at head impact was 36°. The head impact velocity differed up to 2.4 m/s between the models. The 2 models showed similar trends for the head trajectory when the various parameters were altered. CONCLUSIONS: There are differences in kinematics between the THUMS and TNO pedestrian models. However, these model differences are of the same magnitude as those induced by other uncertainties in the accident reconstructions, such as initial leg posture and pedestrian velocity.

A National Survey of Traumatic Brain Injuries Admitted to Hospitals in Sweden from 1987 to 2010.

BACKGROUND: With an increasing and aging population, there is a global demand for improving the primary prevention strategies aimed at reducing traumatic brain injuries (TBIs). The objective of the present epidemiological study was to evaluate the pattern of TBI in Sweden over a 24 years period (1987-2010). METHODS: The Swedish Hospital Discharge Register was used, where in-patient care with a main diagnosis of TBI according to ICD9/10 was included. External factors, age and gender distribution was evaluated. RESULTS: A decreasing number of annual incidence was observed, that is, from 230 to 156 per 100,000 inhabitants. A steady decrease of concussion was observed while other intracranial injuries increased especially traumatic subdural hemorrhage and subarachnoid hemorrhage. The study identified 3 groups of patients - young, adults and elderly. The highest incidence and the largest increase of incidence were seen in the oldest age group (85+ years) while the population under 65 years had a decreasing incidence of TBI. The most frequent etiology was fall accidents (57%) with a relative constant trend over the study period. CONCLUSIONS: More effort should be focused on different strategies for different age groups, especially the elderly group. A well-planned strategy for primary prevention guidelines for different age groups will have the chance to further reduce not only the health-care costs but also complications among elderly care.

Correlation between injury pattern and Finite Element analysis in biomechanical reconstructions of Traumatic Brain Injuries.

At present, Finite Element (FE) analyses are often used as a tool to better understand the mechanisms of head injury. Previously, these models have been compared to cadaver experiments, with the next step under development being accident reconstructions. Thus far, the main focus has been on deriving an injury threshold and little effort has been put into correlating the documented injury location with the response displayed by the FE model. Therefore, the purpose of this study was to introduce a novel image correlation method that compares the response of the FE model with medical images. The injuries shown on the medical images were compared to the strain pattern in the FE model and evaluated by two indices; the Overlap Index (OI) and the Location Index (LI). As the name suggests, OI measures the area which indicates both injury in the medical images and high strain values in the FE images. LI evaluates the difference in center of mass in the medical and FE images. A perfect match would give an OI and LI equal to 1. This method was applied to three bicycle accident reconstructions. The reconstructions gave an average OI between 0.01 and 0.19 for the three cases and between 0.39 and 0.88 for LI. Performing injury reconstructions are a challenge as the information from the accidents often is uncertain. The suggested method evaluates the response in an objective way which can be used in future injury reconstruction studies.

A pilot evaluation of an educational program that offers visualizations of cervical spine injuries: medical students' self-efficacy increases by training.

In this pilot study, a new method for visualization through imaging and simulation (VIS-Ed) for teaching diagnosis and treatment of cervical spine trauma was formatively evaluated. The aims were to examine if medical students' self-efficacy would change by training using VIS-Ed, and if so these changes were related to how they evaluated the session, and the user interface (UI) of this program. Using a one-group, pre-post course test design 43 Swedish medical students (4th year, 17 males, 26 females) practiced in groups of three participants. Overall the practice and the UI were considered as positive experiences. They judged VIS-Ed as a good interactive scenario-based educational tool. All students' self-efficacy increased significantly by training (p < 0.001). Spearman's rank correlation tests revealed that increased self-efficacy was only associated with: how the session was compared to as expected (p < 0.007). Students' self-efficacy increased significantly by training, but replication studies should determine if this training effect is gender-related.

Face validity of VIS-Ed: a visualization program for teaching medical students and residents the biomechanics of cervical spine trauma.

This RCT study aimed to investigate if VIS-Ed (Visualization through Imaging and Simulation - Education) had the potential to improve medical student education and specialist training in clinical diagnosis and treatment of trauma patients. The participants' general opinion was reported as high in both groups (lecture vs. virtual patient (VP)). Face validity of the VIS-Ed for cervical spine trauma was demonstrated and the VP group reported higher stimulation and engagement compared to the lecture group. No significant difference in the knowledge test between both groups could be observed, confirming our null hypothesis that VIS-Ed was on par with a lecture.

Training diagnosis and treatment of cervical spine trauma using a new educational program for visualization through imaging and simulation (VIS): a first evaluation by medical students.

In this pilot study we investigated how medical students evaluated a VIS practice session. Immediately after training 43 students answered a questionnaire on the training session. They evaluated VIS as a good interactive scenario based educational tool.