Prehospital Cervical Spine Motion: Immobilization Versus Spine Motion Restriction.

OBJECTIVE: This study aims to evaluate the efficacy of two different spinal immobilization techniques on cervical spine movement in a simulated prehospital ground transport setting. METHODS: A counterbalanced crossover design was used to evaluate two different spinal immobilization techniques in a standardized environment. Twenty healthy male volunteers (age = 20.9 ± 2.2 yr) underwent ambulance transport from a simulated scene to a simulated emergency department setting in two separate conditions: utilizing traditional spinal immobilization (TSI) and spinal motion restriction (SMR). During both transport scenarios, participants underwent the same simulated scenario. The main outcome measures were cervical spine motion (cumulative integrated motion and peak range of motion), vital signs (heart rate, blood pressure, oxygen saturation), and self-reported pain. Vital signs and pain were collected at six consistent points throughout each scenario. RESULTS: Participants experienced greater transverse plane cumulative integrated motion during TSI compared to SMR (F1,57 = 4.05; P = 0.049), and greater transverse peak range of motion during participant loading/unloading in TSI condition compared to SMR (F1,57 = 17.32; P < 0.001). Pain was reported by 40% of our participants during TSI compared to 25% of participants during SMR (χ2 = 1.29; P = 0.453). CONCLUSIONS: Spinal motion restriction controlled cervical motion at least as well as traditional spinal immobilization in a simulated prehospital ground transport setting. Given these results, along with well-documented potential complications of TSI in the literature, SMR is supported as an alternative to TSI. Future research should involve a true patient population.

Football Equipment Removal Improves Chest Compression and Ventilation Efficacy.

OBJECTIVE: Airway access recommendations in potential catastrophic spine injury scenarios advocate for facemask removal, while keeping the helmet and shoulder pads in place for ensuing emergency transport. The anecdotal evidence to support these recommendations assumes that maintaining the helmet and shoulder pads assists inline cervical stabilization and that facial access guarantees adequate airway access. Our objective was to determine the effect of football equipment interference on performing chest compressions and delivering adequate ventilations on patient simulators. We hypothesized that conditions with more football equipment would decrease chest compression and ventilation efficacy. METHODS: Thirty-two certified athletic trainers were block randomized to participate in six different compression conditions and six different ventilation conditions using human patient simulators. Data for chest compression (mean compression depth, compression rate, percentage of correctly released compressions, and percentage of adequate compressions) and ventilation (total ventilations, mean ventilation volume, and percentage of ventilations delivering adequate volume) conditions were analyzed across all conditions. RESULTS: The fully equipped athlete resulted in the lowest mean compression depth (F5,154 = 22.82; P < 0.001; Effect Size = 0.98) and delivery of adequate compressions (F5,154 = 15.06; P < 0.001; Effect Size = 1.09) compared to all other conditions. Bag-valve mask conditions resulted in delivery of significantly higher mean ventilation volumes compared to all 1- or 2-person pocketmask conditions (F5,150 = 40.05; P < 0.001; Effect Size = 1.47). Two-responder ventilation scenarios resulted in delivery of a greater number of total ventilations (F5,153 = 3.99; P = 0.002; Effect Size = 0.26) and percentage of adequate ventilations (F5,150 = 5.44; P < 0.001; Effect Size = 0.89) compared to one-responder scenarios. Non-chinstrap conditions permitted greater ventilation volumes (F3,28 = 35.17; P < 0.001; Effect Size = 1.78) and a greater percentage of adequate volume (F3,28 = 4.85; P = 0.008; Effect Size = 1.12) compared to conditions with the chinstrap buckled or with the chinstrap in place but not buckled. CONCLUSIONS: Chest compression and ventilation delivery are compromised in equipment-intense conditions when compared to conditions whereby equipment was mostly or entirely removed. Emergency medical personnel should remove the helmet and shoulder pads from all football athletes who require cardiopulmonary resuscitation, while maintaining appropriate cervical spine stabilization when injury is suspected. Further research is needed to confirm our findings supporting full equipment removal for chest compression and ventilation delivery.

Emergent Access to the Airway and Chest in American Football Players.

CONTEXT: American football has the highest rate of fatalities and catastrophic injuries of any US sport. The equipment designed to protect athletes from these catastrophic events challenges the ability of medical personnel to obtain neutral spine alignment and immobilization during airway and chest access for emergency life-support delivery. OBJECTIVE: To compare motion, time, and difficulty during removal of American football helmets, face masks, and shoulder pads. DESIGN: Quasi-experimental, crossover study. SETTING: Controlled laboratory. PATIENTS OR OTHER PARTICIPANTS: We recruited 40 athletic trainers (21 men, 19 women; age = 33.7 ± 11.2 years, height = 173.1 ± 9.2 cm, mass = 80.7 ± 17.1 kg, experience = 10.6 ± 10.4 years). INTERVENTION(S): Paired participants conducted 16 trials in random order for each of 4 helmet, face-mask, and shoulder-pad combinations. An 8-camera, 3-dimensional motion-capture system was used to record head motion in live models wearing properly fitted helmets and shoulder pads. MAIN OUTCOME MEASURE(S): Time and perceived difficulty (modified Borg CR-10). RESULTS: Helmet removal resulted in greater motion than face-mask removal, respectively, in the sagittal (14.88°, 95% confidence interval [CI] = 13.72°, 16.04° versus 7.04°, 95% CI = 6.20°, 7.88°; F(1,19) = 187.27, P < .001), frontal (7.00°, 95% CI = 6.47°, 7.53° versus 4.73°, 95% CI = 4.20°, 5.27°; F1,19 = 65.34, P < .001), and transverse (7.00°, 95% CI = 6.49°, 7.50° versus 4.49°, 95% CI = 4.07°, 4.90°; F(1,19) = 68.36, P < .001) planes. Face-mask removal from Riddell 360 helmets took longer (31.22 seconds, 95% CI = 27.52, 34.91 seconds) than from Schutt ION 4D helmets (20.45 seconds, 95% CI = 18.77, 22.12 seconds) or complete ION 4D helmet removal (26.40 seconds, 95% CI = 23.46, 29.35 seconds). Athletic trainers required less time to remove the Riddell Power with RipKord (21.96 seconds, 95% CI = 20.61°, 23.31° seconds) than traditional shoulder pads (29.22 seconds, 95% CI = 27.27, 31.17 seconds; t(19) = 9.80, P < .001). CONCLUSIONS: Protective equipment worn by American football players must eventually be removed for imaging and medical treatment. Our results fill a gap in the evidence to support current recommendations for prehospital emergent management in patients wearing protective football equipment. Helmet face masks and shoulder pads with quick-release designs allow for clinically acceptable removal times without inducing additional motion or difficulty.

Face mask removal is safer than helmet removal for emergent airway access in American football.

BACKGROUND CONTEXT: In cases of possible cervical spine injury, medical professionals must be prepared to achieve rapid airway access while concurrently restricting cervical spine motion. Face mask removal (FMR), rather than helmet removal (HR), is recommended to achieve this. However, no studies have been reported that compare FMR directly with HR. PURPOSE: The purpose of this study was to compare motion, time, and perceived difficulty in two commonly used American football helmets between FMR and HR techniques, and when helmet air bladders were deflated before HR compared with inflated scenarios. STUDY DESIGN/SETTING: The study incorporated a repeated measures design and was performed in a controlled laboratory setting. PARTICIPANTS: Participants included 22 certified athletic trainers (15 men and seven women; mean age, 33.9±10.5 years; mean experience, 11.4±10.0 years; mean height, 172±9.4 cm; mean mass, 76.7±14.9 kg). All participants were free from upper extremity or central nervous system pathology for 6 months and provided informed consent. OUTCOME MEASURES: Dependent variables included head excursion in degrees (computed by subtracting the minimum position from the maximum position) in each of the three planes (sagittal, frontal, transverse), time to complete the required task, and ratings of perceived exertion. To address our study purposes, we used two-by-two repeated-measures analysis of variance (removal technique×helmet type, helmet type×deflation status) for each dependent variable. METHODS: Independent variables consisted of removal technique (FMR and HR), helmet type (Riddell Revolution IQ [RIQ] and VSR4), and helmet deflation status (deflated [D], inflated, [I]). After familiarization, participants conducted two successful trials for each of six conditions in random order (RIQ-FMR, VSR4-FMR, RIQ-HR-D, VSR4-HR-D, RIQ-HR-I, and VSR4-HR-I). Face masks, helmets, and shoulder pads were removed from a live model wearing a properly fitted helmet and shoulder pads. The participant and an investigator stabilized the model's head. A six-camera three-dimensional motion system and a three-point one-segment marker set were used to record motion of the head. RESULTS: Face mask removal resulted in less motion in all three planes, required less completion time, and was easier to perform than HR. The RIQ helmet resulted in less frontal plane motion and less time to task completion, and was easier to remove than VSR4 helmets. Inflated helmets-regardless of helmet type-required less removal time but did not result in greater cervical spine motion or difficulty. CONCLUSIONS: It is safer to remove the face mask in the prehospital setting for the potential spine-injured American football player than to remove the helmet, based on results from both a traditional and newer football helmet designs. Deflating the air bladder inside the helmet does not provide an advantage.

Maintaining neutral sagittal cervical alignment after football helmet removal during emergency spine injury management.

STUDY DESIGN: Descriptive laboratory study. OBJECTIVE: To determine whether the placement of padding beneath the occiput after helmet removal is an effective intervention to maintain neutral sagittal cervical spine alignment in a position comparable with the helmeted condition. SUMMARY OF BACKGROUND DATA: Current on-field recommendations for managing football athletes with suspected cervical spine injuries call for face mask removal, rather than helmet removal, because the combination of helmet and shoulder pads has been shown to maintain neutral cervical alignment. Therefore, in cases when helmet removal is required, recommendations also call for shoulder pad removal. Because removal of equipment causes motion, any technique that postpones the need to remove the shoulder pads would reduce prehospital motion. METHODS: Four lateral radiographs of 20 male participants were obtained (age = 23.6 ± 2.7 years). Radiographs of participants wearing shoulder pads and helmet were first obtained. The helmet was removed and radiographs of participants with occipital padding were obtained immediately and 20 minutes later and finally without occipital padding. Cobb angle measurements for C2-C6 vertebral segments were determined by an orthopedic spine surgeon blinded to the study's purpose. Intraobserver reliability was determined using intraclass coefficient analysis. Measurements were analyzed using a 1×4 repeated-measures analysis of variance and post hoc pairwise comparisons with Bonferroni correction. RESULTS: Intraobserver analysis showed excellent reliability (intraclass correlation = 1.0; 95% confidence interval [CI], 0.999-1.0). Repeated-measures analysis of variance detected significant differences (F(3,17) = 13.34; P < 0.001). Pairwise comparisons revealed no differences in cervical alignment (all measurements reported reflect lordosis) when comparing the baseline helmeted condition (10.1° ± 8.7°; 95% CI, 6.0-14.1) with the padded conditions. Measurements taken after removal of occipital padding (14.4° ± 8.1°; 95% CI, 10.6-18.2) demonstrated a significant increase in cervical lordosis compared with the immediate padded measurement (9.5° ± 6.9°; 95% CI, 6.3-12.7; P = 0.011) and the 20-minute padded measurement (6.5° ± 6.8°; 95% CI, 3.4-9.7; P < 0.001). CONCLUSION: Although face mask removal remains the standard, if it becomes necessary to remove the football helmet in the field, occipital padding (along with full body/head immobilization techniques) may be used to limit cervical lordosis, allowing safe delay of shoulder pad removal.

A study of emergency American football helmet removal techniques.

PURPOSE: The purpose was to compare head kinematics between the Eject Helmet Removal System and manual football helmet removal. BASIC PROCEDURES: This quasi-experimental study was conducted in a controlled laboratory setting. Thirty-two certified athletic trainers (sex, 19 male and 13 female; age, 33 ± 10 years; height, 175 ± 12 cm; mass, 86 ± 20 kg) removed a football helmet from a healthy model under 2 conditions: manual helmet removal and Eject system helmet removal. A 6-camera motion capture system recorded 3-dimensional head position. Our outcome measures consisted of the average angular velocity and acceleration of the head in each movement plane (sagittal, frontal, and transverse), the resultant angular velocity and acceleration, and total motion. Paired-samples t tests compared each variable across the 2 techniques. MAIN FINDINGS: Manual helmet removal elicited greater average angular velocity in the sagittal and transverse planes and greater resultant angular velocity compared with the Eject system. No differences were observed in average angular acceleration in any single plane of movement; however, the resultant angular acceleration was greater during manual helmet removal. The Eject Helmet Removal System induced greater total head motion. PRINCIPAL CONCLUSIONS: Although the Eject system created more motion at the head, removing a helmet manually resulted in more sudden perturbations as identified by resultant velocity and acceleration of the head. The implications of these findings relate to the care of all cervical spine-injured patients in emergency medical settings, particularly in scenarios where helmet removal is necessary.

National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries.

OBJECTIVE: To provide certified athletic trainers, physicians, and other health care professionals with recommendations on best practices for the prevention of overuse sports injuries in pediatric athletes (aged 6-18 years). BACKGROUND: Participation in sports by the pediatric population has grown tremendously over the years. Although the health benefits of participation in competitive and recreational athletic events are numerous, one adverse consequence is sport-related injury. Overuse or repetitive trauma injuries represent approximately 50% of all pediatric sport-related injuries. It is speculated that more than half of these injuries may be preventable with simple approaches. RECOMMENDATIONS: Recommendations are provided based on current evidence regarding pediatric injury surveillance, identification of risk factors for injury, preparticipation physical examinations, proper supervision and education (coaching and medical), sport alterations, training and conditioning programs, and delayed specialization.

Prehospital emergency removal of football helmets using two techniques.

OBJECTIVE: To compare the Eject Helmet Removal (EHR) System with manual football helmet removal. METHODS: This quasiexperimental counterbalanced study was conducted in a controlled laboratory setting. Thirty certified athletic trainers (17 men and 13 women; mean ± standard deviation age: 33.03 ± 10.02 years; height: 174.53 ± 12.04 cm; mass: 85.19 ± 19.84 kg) participated after providing informed consent. Participants removed a Riddell Revolution IQ football helmet from a healthy model two times each under two conditions: manual helmet removal (MHR) and removal with the EHR system. A six-camera, three-dimensional motion capture system was used to record range of motion (ROM) of the head. A digital stopwatch was used to time trials and to record a split time associated with EHR system bladder insertion. A modified Borg CR10 scale was used to measure the rating of perceived exertion (RPE). Mean values were created for each variable. Three pairwise t-tests with Bonferroni-corrected alpha levels tested for differences between time for removal, split time, and RPE. A 2 x 3 (condition x plane) totally within-subjects repeated-measures design analysis of variance (ANOVA) tested for differences in head ROM between the sagittal, frontal, and transverse planes. Analyses were performed using SPSS (version 18.0) (alpha = 0.05). RESULTS: There was no statistically significant difference in perceived difficulty between EHR (RPE = 2.73) and MHR (RPE = 2.55) (t(29) = 0.76; p = 0.45; d = 0.20). Manual helmet removal was, on average, 28.95 seconds faster than EHR (t(29) = 11.44; p < 0.001). Head ROM was greater during EHR compared with MHR in the sagittal (t(29) = 4.57; p < 0.001), frontal (t(29) = 5.90; p < 0.001), and transverse (t(29) = 8.34; p < 0.001) planes. Head ROM was also greater during the helmet-removal portion of EHR in the frontal (t(29) = 4.44; p < 0.001) and transverse (t(29) = 5.99; p < 0.001) planes, compared with MHR. Regardless of technique, sagittal-plane head ROM was greater than frontal- and transverse-plane movements (F(2,58) = 241.47; p < 0.001). CONCLUSIONS: Removing a helmet manually is faster and creates slightly less motion than removing a helmet using the Eject system. Both techniques were equally easy to use. Future research should analyze the performance of the Eject system in other styles of football helmets and in helmets used in other sports such as lacrosse, motorsports, and ice hockey.

Prevalence and characteristics of general and football-specific emergency medical service activations by high school and collegiate certified athletic trainers: a national study.

OBJECTIVE: To describe frequency and characteristics of emergency medical services (EMS) activations by certified athletic trainers (ATs) and effects of pre-season planning meetings on interactions between ATs and EMS both generally and specifically during football head/neck emergencies. DESIGN: Retrospective cross-sectional survey. SETTING: 2009 Web-based survey. PARTICIPANTS: Athletic trainers (n = 1884; participation rate, 28%) in high school and collegiate settings. INDEPENDENT VARIABLES: Athletic trainer work setting, AT demographics, history of pre-season planning meetings. MAIN OUTCOME MEASURES: Proportions and 95% confidence intervals (CIs) estimated the prevalence of EMS activation, planning meetings, and characteristics of AT-EMS interactions (eg, episodes of AT-perceived inappropriate care and on-field disagreements). Chi square tests tested differences (P < 0.05) in proportions. Associations (odds ratio = OR and 95% CI) between work setting, demographics, preseason meetings and fall 2008 1) episodes of AT-perceived inappropriate care, and 2) on-field disagreements were assessed using multivariate logistic regression. RESULTS: High school ATs activated EMS more frequently than collegiate ATs (eg, fall 2008 EMS activation for football injury, 59.9% vs 27.5%; P < 0.01) and reported fewer pre-season planning meetings (eg, met with EMS to practice, 38.1% vs 55.8%; P < 0.01). During the Fall 2008 football season, high school ATs perceived more episodes of inappropriate care (10.4% vs 3.9%; P < 0.01) and on-field disagreements (5.4 vs 2.2%; P < 0.01) than collegiate ATs. High school work setting was independently associated with episodes of AT-perceived inappropriate care (adjusted OR = 2.76; 95% CI, 1.65-4.62) and on-field disagreements (adjusted OR = 2.33; 95% CI, 1.17-4.64). CONCLUSIONS: Athletic trainer-EMS interactions are common and sometimes involve AT-perceived episodes of inappropriate care and on-field disagreements between emergency care providers.

Emergency face-mask removal effectiveness: a comparison of traditional and nontraditional football helmet face-mask attachment systems.

CONTEXT: Football helmet face-mask attachment design changes might affect the effectiveness of face-mask removal. OBJECTIVE: To compare the efficiency of face-mask removal between newly designed and traditional football helmets. DESIGN: Controlled laboratory study. SETTING: Applied biomechanics laboratory. PARTICIPANTS: Twenty-five certified athletic trainers. INTERVENTION(S): The independent variable was face-mask attachment system on 5 levels: (1) Revolution IQ with Quick Release (QR), (2) Revolution IQ with Quick Release hardware altered (QRAlt), (3) traditional (Trad), (4) traditional with hardware altered (TradAlt), and (5) ION 4D (ION). Participants removed face masks using a cordless screwdriver with a back-up cutting tool or only the cutting tool for the ION. Investigators altered face-mask hardware to unexpectedly challenge participants during removal for traditional and Revolution IQ helmets. Participants completed each condition twice in random order and were blinded to hardware alteration. MAIN OUTCOME MEASURE(S): Removal success, removal time, helmet motion, and rating of perceived exertion (RPE). Time and 3-dimensional helmet motion were recorded. If the face mask remained attached at 3 minutes, the trial was categorized as unsuccessful. Participants rated each trial for level of difficulty (RPE). We used repeated-measures analyses of variance (α  =  .05) with follow-up comparisons to test for differences. RESULTS: Removal success was 100% (48 of 48) for QR, Trad, and ION; 97.9% (47 of 48) for TradAlt; and 72.9% (35 of 48) for QRAlt. Differences in time for face-mask removal were detected (F(4,20)  =  48.87, P  =  .001), with times ranging from 33.96 ± 14.14 seconds for QR to 99.22 ± 20.53 seconds for QRAlt. Differences were found in range of motion during face-mask removal (F(4,20)  =  16.25, P  =  .001), with range of motion from 10.10° ± 3.07° for QR to 16.91° ± 5.36° for TradAlt. Differences also were detected in RPE during face-mask removal (F(4,20)  =  43.20, P  =  .001), with participants reporting average perceived difficulty ranging from 1.44 ± 1.19 for QR to 3.68 ± 1.70 for TradAlt. CONCLUSIONS: The QR and Trad trials resulted in superior results. When trials required cutting loop straps, results deteriorated.

National athletic trainers' association position statement: acute management of the cervical spine-injured athlete.

OBJECTIVE: To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete. BACKGROUND: The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment. RECOMMENDATIONS: Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete.

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.

The combined tool approach for face mask removal during on-field conditions.

CONTEXT: An effective approach to emergency removal of the face mask (FM) from a football helmet should include successful removal of the FM and limitation of both the time required and the movement created during the process. Current recommendations and practice are to use a cutting tool to remove the FM. Researchers recently have suggested an alternate approach that combines the use of a cordless screwdriver and a cutting tool. This combined tool approach has not been studied, and FM removal has not been studied in a practical setting. OBJECTIVE: To investigate the effectiveness and speed of using a combined tool approach to remove the FMs from football helmets during on-field conditions throughout the course of a football season. DESIGN: Randomized multigroup design. SETTING: Practice field of 1 National Collegiate Athletic Association Division II football college. PATIENTS OR OTHER PARTICIPANTS: Eighty-four members of 1 football team. INTERVENTION(S): We used a battery-operated screwdriver for FM removal and resorted to using a cutting tool as needed. MAIN OUTCOME MEASURE(S): We tracked FM removal success and failure and trial time and compared results based on helmet characteristics, weather variables, and the seasonal timing of the removal trial. RESULTS: Of the 84 players, 76 were available for data-collection trials. Overall, 98.6% (75/76) of FM removal trials were successful and resulted in a mean removal time of 40.09 +/- 15.1 seconds. We found no differences in FM removal time throughout the course of the season. No differences in effectiveness or trial time were found among helmet characteristics, weather variables, or the timing of the trial. CONCLUSIONS: Combining the cordless screwdriver and cutting tool provided a fast and reliable means of on-field FM removal in this Division II setting. Despite the excellent overall result, 1 FM was not removed in a timely manner. Therefore, we recommend that athletic trainers practice helmet removal to be prepared should FM removal fail.

Combined tool approach is 100% successful for emergency football face mask removal.

OBJECTIVE: To compare effectiveness of two techniques for removing football face masks: cutting loop straps [cutting tool: FMXtractor (FMX)] or removing screws with a cordless screwdriver and using the FMXtractor as needed for failed removals [combined tool (CT)]. Null hypotheses: no differences in face mask removal success, removal time or difficulty between techniques or helmet characteristics. DESIGN: Retrospective, cross-sectional. SETTING: NOCSAE-certified helmet reconditioning plants. PARTICIPANTS: 600 used high school helmets. INTERVENTIONS: Face mask removal attempted with two techniques. MAIN OUTCOME MEASUREMENTS: Success, removal time, rating of perceived exertion (RPE). RESULTS: Both techniques were effective [CT 100% (300/300); FMX 99.4% (298/300)]. Use of the backup FMXtractor in CT trials was required in 19% of trials. There was significantly (P<0.001) less call for the backup tool in helmets with silver screws (6%) than in helmets with other screws (31%). Mean removal time was 44.51+/-18.79s (CT: 37.84+/-15.37s, FMX: 51.21+/-19.54s; P<0.001). RPE was different between techniques (CT: 1.83+/-1.20, FMX: 3.11+/-1.27; P<0.001). Removal from helmets with silver screws was faster (Silver=33.38+/-11.03, Others=42.18+/-17.64; P<0.001) and easier (Silver=1.42+/-0.89, Other=2.23+/-1.33; P<0.001). CONCLUSIONS: CT was faster and easier than FMX. Most CT trials were completed with the screwdriver alone; helmets with silver screws had 94% screwdriver success. Clinically, these findings are important because this and other research shows that compared to removal with cutting tools, screwdriver removal decreases time, difficulty and helmet movement (reducing potential for iatrogenic injury). The combined-tool approach captures benefits of the screwdriver while offering a contingency for screw removal failure. Teams should use degradation-resistant screws. CLINICAL RELEVANCE: Sports medicine professionals must be prepared with appropriate tools and techniques to efficiently remove the face mask from an injured football player's helmet.

The influence of various factors on high school football helmet face mask removal: a retrospective, cross-sectional analysis.

CONTEXT: Most research on face mask removal has been performed on unused equipment. OBJECTIVE: To identify and compare factors that influence the condition of helmet components and their relationship to face mask removal. DESIGN: A cross-sectional, retrospective study. SETTING: Five athletic equipment reconditioning/recertification facilities. PARTICIPANTS: 2584 helmets from 46 high school football teams representing 5 geographic regions. INTERVENTION(S): Helmet characteristics (brand, model, hardware components) were recorded. Helmets were mounted and face mask removal was attempted using a cordless screwdriver. The 2004 season profiles and weather histories were obtained for each high school. MAIN OUTCOME MEASURE(S): Success and failure (including reason) for removal of 4 screws from the face mask were noted. Failure rates among regions, teams, reconditioning year, and screw color (type) were compared. Weather histories were compared. We conducted a discriminant analysis to determine if weather variables, region, helmet brand and model, reconditioning year, and screw color could predict successful face mask removal. Metallurgic analysis of screw samples was performed. RESULTS: All screws were successfully removed from 2165 (84%) helmets. At least 1 screw could not be removed from 419 (16%) helmets. Significant differences were found for mean screw failure per helmet among the 5 regions, with the Midwest having the lowest failure rate (0.08 +/- 0.38) and the Southern (0.33 +/- 0.72), the highest. Differences were found in screw failure rates among the 46 teams (F(1,45) = 9.4, P < .01). Helmets with the longest interval since last reconditioning (3 years) had the highest failure rate, 0.47 +/- 0.93. Differences in success rates were found among 4 screw types (chi(2) (1,4) = 647, P < .01), with silver screws having the lowest percentage of failures (3.4%). A discriminant analysis (Lambda = .932, chi(2) (14,n=2584) = 175.34, P < .001) revealed screw type to be the strongest predictor of successful removal. CONCLUSIONS: Helmets with stainless steel or nickel-plated carbon steel screws reconditioned in the previous year had the most favorable combination of factors for successful screw removal. T-nut spinning at the side screw locations was the most common reason and location for failure.

Knee-muscle activation during landings: developmental and gender comparisons.

PURPOSE: This study determined anteroposterior knee-joint muscle activation differences among children and adult males and females landing from a self-initiated vertical jump (VJ) under normal and offset-target conditions to further understand physical maturation's influence on anterior cruciate ligament (ACL) injury risk. METHODS: Fifty-five recreationally active volunteer subjects grouped by age (children = 9.5 +/- 0.9 yr; adult = 23.9 +/- 2.8 yr) and gender (females = 28; males = 27) completed motion analysis, ground reaction force, and surface electromyography (SEMG) data collection during a two-footed landing under straight (midline-target) and offset-target (adult = 45.7 cm; child = 30.5 cm) conditions. Target height was 50% of maximum VJ height. Co-contraction ratios (CCR) (hamstrings (HAMS)/vastus medialis (VM) activity) from normalized SEMG root mean squares were analyzed in the prelanding (PRE) (100 ms before initial contact (IC)), reflexive (REF) (100 ms after IC), and voluntary (VOL) (end of REF to maximum knee flexion) muscle activity phases. Repeated-measures statistical analyses determined significant gender, physical maturation, and target differences (P < 0.05) in CCR and associated HAMS and VM activity across landing phases. RESULTS: A significant interaction (P < 0.0001) indicated similar CCR for children and adults during the REF and VOL phases, but during the PRE phase adult CCR (619.04 + 52.01) were two times greater than children's (308.32 +/- 51.04). Significantly more HAMS activity, not less VM activity, increased adult PRE-CCR. Gender and target CCR differences were absent. CONCLUSIONS: Children's decreased preparatory co-contraction about the knee does not seem to be linked to increased ACL injury risk. Thus, adults may strive for preparatory co-contraction levels about the knee that permit adaptability to varied landing tasks.

A comparison of head movement during back boarding by motorized spine-board and log-roll techniques.

CONTEXT: In a patient with a potential cervical spine injury, minimizing or eliminating movement at the head and neck during stabilization and transport is paramount because movement can exacerbate the condition. Any equipment or technique creating less movement will allow for a more effective and safe stabilization of an injured patient, reducing the likelihood of movement and potential secondary injury. OBJECTIVE: To compare the amount of head movement created during the log-roll and motorized spine-board (MSB) stabilization techniques. DESIGN: A 2-condition, repeated-measures design. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Thirteen certified athletic trainers, emergency first responders, and emergency medical technicians (6 men, 7 women). INTERVENTION(S): Subjects rotated through 4 positions for the log roll and 2 positions for the MSB. Each subject performed 3 trials while maintaining manual, inline stabilization of the model's head for each condition. MAIN OUTCOME MEASURE(S): Three-dimensional head movement was measured and expressed as degrees of motion. RESULTS: The log roll created significantly more motion in the frontal and transverse planes compared with the MSB (P = .001 for both measures). No significant difference was noted for sagittal-plane motion (P = .028). CONCLUSIONS: The MSB created less movement at the head than did the log roll in 2 planes of motion and created slightly more motion in 1 plane, although this difference was not significant. The MSB may provide emergency responders with an appropriate alternative method for stabilizing and transporting a supine injured athlete without requiring a log roll.

Football face-mask removal with a cordless screwdriver on helmets used for at least one season of play.

CONTEXT: The Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete recommends leaving a football player's helmet in place and removing the face mask from the helmet "as quickly as possible and with as little movement of the head and neck as possible." Although 2 groups have studied face-mask removal from new equipment, to our knowledge no researchers have investigated equipment that has been previously used. A full season of play may have a significant effect on football equipment and its associated hardware. Countless impacts, weather, playing surfaces, sweat, and other unforeseen or unknown variables might make the face-mask removal process more difficult on equipment that has been used. OBJECTIVE: To determine the percentage of face masks that we could unscrew, with a cordless screwdriver, from football helmets used for a full season. DESIGN: Cross-sectional. SETTING: Three New England high schools. PATIENTS OR OTHER PARTICIPANTS: All football helmets used at 3 local high schools were tested (n = 222, mean games, 9.7 +/- 1.2; mean practice weeks, 13.7 +/- 1.2). INTERVENTION(S): Each helmet was secured to a board, and a cordless screwdriver was used to attempt to remove all 4 screws attaching the face mask to the helmet. MAIN OUTCOME MEASURE(S): Variables included overall success or failure, time required for face-mask removal, and success by screw location. Data were analyzed with chi2, analysis of variance, and Tamhane post hoc tests. RESULTS: Overall, 832 (94%) of 885 screws were unscrewed, and 183 (82.4%) of 222 face masks were removed. Mean removal time was 26.9 +/- 5.83 seconds. Face-mask removal success was significantly different between school 1 (24 [52.2%] of 46) and schools 2 (84 [91.3%] of 92) and 3 (75 [89.3%] of 84; F(2,219) = 24.608; P < .001). The removal success rate was significantly higher at top screws (98%) than at screws adjacent to ear holes (90%) (P < .001). CONCLUSIONS: Based on our results and previous findings that demonstrated quicker access time and reduced head movement associated with the use of the screwdriver compared with cutting tools, the former may be a good tool for face-mask removal. However, an appropriate cutting tool must be immediately available should the screwdriver fail. Helmet hardware adjacent to ear holes was more vulnerable to failure, perhaps because it is protected by less padding than the top hardware. Possible causes of the higher failure rate at school 1 are the use of hardware materials subject to rust and corrosion and differences in helmet brand; these areas warrant future research and rules consideration.

The effects of hamstring stretching on range of motion: a systematic literature review.

STUDY DESIGN: Systematic literature review. OBJECTIVE: Investigate the literature regarding the most effective positions, techniques, and durations of stretching to improve hamstring muscle flexibility. BACKGROUND: Hamstring stretching is popular among physical therapists, athletic trainers, and fitness/coaching professionals; however, numerous stretching methodologies have been proposed in the literature. This fact establishes a need to systematically summarize available evidence in an attempt to determine the most effective stretching approach. METHODS: A list of 28 pertinent manuscripts that included randomized and clinical trials was created according to specific inclusion/exclusion criteria. These manuscripts were critically reviewed for quality according to the Physiotherapy Evidence Database (PEDro) (10-point) scale and descriptive information about the stretching parameters employed in the research. RESULTS: Cumulatively, 1338 healthy subjects were included in the reviewed studies. Methodological quality scores ranged from 2 to 8 (mean +/- SD, 4.3 +/- 1.6). Several methodological flaws were frequently recognized, including failure to conceal group allocation or perform blinded assessment. All studies reported improvements in range of motion after stretching. CONCLUSIONS: Overall, methodological quality was poor, with only 21.4% (6/28) of studies achieving a score between 6 and 8. Thus it was difficult to confidently identify 1 most effective hamstring stretching method. Instead, the evidence appears to indicate that hamstring stretching increases range of motion with a variety of stretching techniques, positions, and durations.

Football equipment design affects face mask removal efficiency.

BACKGROUND: Researchers have investigated the performance of face mask removal tools for spine injury management in football but not the effects of football equipment design. HYPOTHESES: Various styles or designs of football helmet equipment (helmets, face masks, loop straps) affect face mask removal efficiency. A cordless screwdriver performs more efficiently than do cutting tools. STUDY DESIGN: Controlled laboratory study. METHODS: Nineteen certified athletic trainers were randomly assigned to group 1 (cordless screwdriver and the FM Extractor) or group 2 (cordless screwdriver and the Trainer's Angel). Subjects randomly performed face mask removal for 6 conditions composed of helmet (3), face mask (3), and loop strap (5) combinations. Time, head movement, perceived difficulty, and success rates were measured. RESULTS: Multiple significant differences were found in time, movement, and perceived difficulty between the 6 helmet equipment conditions. The Shockblocker loop strap was consistently superior in all variables regardless of the tool used or the helmet it was attached to. The cordless screwdriver created less movement (mean range from any one plane, 2.8 degrees -13.3 degrees ), was faster (mean range, 42.1-68.8 seconds), and was less difficult (mean rating of perceived exertion range, 1.4-2.9) compared to cutting tools (ranges, 4.4 degrees -18.4 degrees in any one plane, 71-174 seconds, rating of perceived exertion, 2.8-7.7). Trial failure was more common with cutting tools than with the screwdriver. CONCLUSION: Differences in football helmet equipment affect face mask removal. The cordless screwdriver is more efficient than the FM Extractor and Trainer's Angel. CLINICAL RELEVANCE: Professionals responsible for the care of football athletes must be knowledgeable in the types of equipment used and the best option available for effective airway access.