Spinal injury rates and specific causation in motor vehicle collisions.

Motor vehicle collisions (MVCs) are a leading cause of acute spinal injuries. Chronic spinal pathologies are common in the population. Thus, determining the incidence of different types of spinal injuries due to MVCs and understanding biomechanical mechanism of these injuries is important for distinguishing acute injuries from chronic degenerative disease. This paper describes methods for determining causation of spinal pathologies from MVCs based on rates of injury and analysis of the biomechanics require to produce these injuries. Rates of spinal injuries in MVCs were determined using two distinct methodologies and interpreted using a focused review of salient biomechanical literature. One methodology used incidence data from the Nationwide Emergency Department Sample and exposure data from the Crash Report Sample System supplemented with a telephone survey to estimate total national exposure to MVC. The other used incidence and exposure data from the Crash Investigation Sampling System. Linking the clinical and biomechanical findings yielded several conclusions. First, spinal injuries caused by an MVC are relatively rare (511 injured occupants per 10,000 exposed to an MVC), which is consistent with the biomechanical forces required to generate injury. Second, spinal injury rates increase as impact severity increases, and fractures are more common in higher-severity exposures. Third, the rate of sprain/strain in the cervical spine is greater than in the lumbar spine. Fourth, spinal disc injuries are extremely rare in MVCs (0.01 occupants per 10,000 exposed) and typically occur with concomitant trauma, which is consistent with the biomechanical findings 1) that disc herniations are fatigue injuries caused by cyclic loading, 2) the disc is almost never the first structure to be injured in impact loading unless it is highly flexed and compressed, and 3) that most crashes involve predominantly tensile loading in the spine, which does not cause isolated disc herniations. These biomechanical findings illustrate that determining causation when an MVC occupant presents with disc pathology must be based on the specifics of that presentation and the crash circumstances and, more broadly, that any causation determination must be informed by competent biomechanical analysis.

Consensus Head Acceleration Measurement Practices (CHAMP): Origins, Methods, Transparency and Disclosure.

The use of head kinematic measurement devices has recently proliferated owing to technology advances that make such measurement more feasible. In parallel, demand to understand the biomechanics of head impacts and injury in sports and the military has increased as the burden of such loading on the brain has received focused attention. As a result, the field has matured to the point of needing methodological guidelines to improve the rigor and consistency of research and reduce the risk of scientific bias. To this end, a diverse group of scientists undertook a comprehensive effort to define current best practices in head kinematic measurement, culminating in a series of manuscripts outlining consensus methodologies and companion summary statements. Summary statements were discussed, revised, and voted upon at the Consensus Head Acceleration Measurement Practices (CHAMP) Conference in March 2022. This manuscript summarizes the motivation and methods of the consensus process and introduces recommended reporting checklists to be used to increase transparency and rigor of future experimental design and publication of work in this field. The checklists provide an accessible means for researchers to apply the best practices summarized in the companion manuscripts when reporting studies utilizing head kinematic measurement in sport and military settings.

Best Practices for Conducting Physical Reconstructions of Head Impacts in Sport.

Physical reconstructions are a valuable methodology for quantifying head kinematics in sports impacts. By recreating the motion of human heads observed in video using instrumented test dummies in a laboratory, physical reconstructions allow for in-depth study of real-world head impacts using well-established surrogates such as the Hybrid III crash test dummy. The purpose of this paper is to review all aspects of the physical reconstruction methodology and discuss the advantages and limitations associated with different choices in case selection, study design, test surrogate, test apparatus, text matrix, instrumentation, and data processing. Physical reconstructions require significant resources to perform and are therefore typically limited to small sample sizes and a case series or case-control study design. Their accuracy may also be limited by a lack of dummy biofidelity. The accuracy, repeatability, and sensitivity of the reconstruction process can be characterized and improved by good laboratory practices and iterative testing. Because wearable sensors have their own limitations and are not available or practical for many sports, physical reconstructions will continue to provide a useful and complementary approach to measuring head acceleration in sport for the foreseeable future.

Laboratory Evaluation of Shell Add-On Products for American Football Helmets for Professional Linemen.

The Guardian Cap NXT (GC NXT) and the ProTech Helmet Cap (ProTech) are commercially available aftermarket products designed to augment the energy attenuation characteristics of American football helmets. The ability of these helmet shell add-on products to mitigate the severity of impacts typically experienced by professional offensive and defensive linemen was evaluated for seven helmet models using two test series. In linear impactor tests, the GC NXT reduced head impact severity as measured by the head acceleration response metric (HARM) by 9% relative to the helmets only, while the ProTech reduced HARM by 5%. While both products significantly improved the performance of the football helmets tested overall, effects varied by impact condition and helmet model with the add-ons worsening helmet performance in some conditions. The GC NXT had a strong effect size (Cohen's d = 0.8) whereas the ProTech had a medium effect (Cohen's d = 0.5). A second study investigated add-on performance for helmet-to-helmet impacts with eccentric impact vectors and resulted in a mixture of increased and decreased HARM when either add-on was placed on one or both helmets. Estimated risk for serious neck injury with add-ons and without differed by less than 4% for these eccentric impacts.

Laboratory Reconstructions of Concussive Helmet-to-Helmet Impacts in the National Football League.

Seventeen concussive helmet-to-helmet impacts occurring in National Football League (NFL) games were analyzed using video footage and reconstructed by launching helmeted crash test dummies into each other in a laboratory. Helmet motion on-field and in the laboratory was tracked in 3D before, during, and after impact in multiple high frame rate video views. Multiple (3-10) tests were conducted for each of the 17 concussive cases (100 tests total) with slight variations in input conditions. Repeatability was assessed by duplicating one or two tests per case. The accuracy of the input conditions in each reconstruction was assessed based on how well the closing velocity, impact locations, and the path eccentricity of the dummy heads matched the video analysis. The accuracy of the reconstruction output was assessed based on how well the changes in helmet velocity (translational and rotational) from the impact matched the video analysis. The average absolute error in helmet velocity changes was 24% in the first test, 20% in the tests with the most accurate input configuration, and 14% in the tests with minimal error. Coefficients of variation in 22 repeated test conditions (1-2 per case) averaged 3% for closing velocity, 7% for helmet velocity changes, and 8% for peak head accelerations. Iterative testing was helpful in reducing error. A combination of sophisticated video analysis, articulated physical surrogates, and iterative testing was required to reduce the error to within half of the effect size of concussion.

Characterization of Concussive Events in Professional American Football Using Videogrammetry.

Sports concussions offer a unique opportunity to study head kinematics associated with mild traumatic brain injury. In this study, a model-based image matching (MBIM) approach was employed to analyze video footage of 57 concussions which occurred in National Football League (NFL) games. By utilizing at least two camera views, higher frame rate footage (> 60 images s-1), and laser scans of the field and helmets involved in each case, it was possible to calculate the change in velocity of the helmet during impact in six degrees of freedom. The average impact velocity for these concussive events was 8.9 ± 2.0 m s-1. The average changes in translational and rotational velocity for the concussed players' helmets were 6.6 ± 2.1 m s-1 and 29 ± 13 rad s-1, respectively. The average change in translational velocity was higher for helmet-to-ground (n = 16) impacts compared to helmet-to-helmet (n = 30) or helmet-to-shoulder (n = 11) events (p < 0.001), while helmet-to-shoulder impacts had a smaller change in rotational velocity compared to the other impact sources (p < 0.001). By quantifying the impact velocities and locations associated with concussive impacts in professional American football, this study provides information that may be used to improve upon current helmet testing methodologies.

Comparison of Laboratory and On-Field Performance of American Football Helmets.

The relationship between laboratory and on-field performance of football helmets was assessed for 31 football helmet models selected from those worn by players in the 2015-2019 National Football League (NFL) seasons. Linear impactor tests were conducted with helmets placed on an instrumented Hybrid III head and neck assembly mounted on a sliding table. Based on impacts to each helmet at six impact locations and three velocities, a helmet performance score (HPS) was calculated using a linear combination of the head injury criterion (HIC) and the diffuse axonal multi-axis general evaluation (DAMAGE). To determine the on-field performance of helmets, helmet model usage, player participation, and incident concussion data were collected from the five NFL seasons and used to calculate helmet model-specific concussion rates. Comparison of laboratory HPS to the helmet model-specific concussion rates on a per play basis showed a positive correlation (r2 = 0.61, p < 0.001) between laboratory and on-field performance of helmet models, indicating that helmets which exhibited reduced impact severity in the laboratory tests were also generally associated with lower concussion rates on-field. Further analysis showed that NFL-prohibited helmet models exhibited a significantly higher odds of concussion (OR 1.24; 95% CI 1.04-1.47; p = 0.017) relative to other helmet models.

Development and Evaluation of a Test Method for Assessing the Performance of American Football Helmets.

As more is learned about injury mechanisms of concussion and scenarios under which injuries are sustained in football games, methods used to evaluate protective equipment must adapt. A combination of video review, videogrammetry, and laboratory reconstructions was used to characterize concussive impacts from National Football League games during the 2015-2017 seasons. Test conditions were generated based upon impact locations and speeds from this data set, and a method for scoring overall helmet performance was created. Head kinematics generated using a linear impactor and sliding table fixture were comparable to those from laboratory reconstructions of concussive impacts at similar impact conditions. Impact tests were performed on 36 football helmet models at two laboratories to evaluate the reproducibility of results from the resulting test protocol. Head acceleration response metric, a head impact severity metric, varied 2.9-5.6% for helmet impacts in the same lab, and 3.8-6.0% for tests performed in a separate lab when averaged by location for the models tested. Overall inter-lab helmet performance varied by 1.1 ± 0.9%, while the standard deviation in helmet performance score was 7.0%. The worst helmet performance score was 33% greater than the score of the best-performing helmet evaluated by this study.

Position-Specific Circumstances of Concussions in the NFL: Toward the Development of Position-Specific Helmets.

Consideration of position-specific features of the NFL concussion environment could enable improved risk mitigation through the design of position-specific helmets to improve self-protection as well as protection for the other player with whom the contact occurs. The purpose of this paper is to quantify position-specific features of scenarios resulting in concussions to NFL players, and the players they contact, by reviewing all game footage (broadcast and non-broadcast) over 4 seasons. Position-specific features were documented for 647 concussions in which a primary exposure could be visualized, including impact source, helmet impact location, activity, and the other player with whom the contact occurred. Findings include the over-representation of helmet-to-ground impacts to the rear of the quarterback's helmet, the high frequency of impacts to the side (upper) location of both concussed players and the players they contacted regardless of position, and distinct differences in the circumstances of concussions to cornerbacks and safeties. The study shows that some features of concussion scenarios are common to all positions, but several position-specific features exist and can inform the design of position-specific helmets for NFL players.

The Effect of Muscle Activation on Head Kinematics During Non-injurious Head Impacts in Human Subjects.

In this study, twenty volunteers were subjected to three, non-injurious lateral head impacts delivered by a 3.7 kg padded impactor at 2 m/s at varying levels of muscle activation (passive, co-contraction, and unilateral contraction). Electromyography was used to quantify muscle activation conditions, and resulting head kinematics were recorded using a custom-fit instrumented mouthpiece. A multi-modal battery of diagnostic tests (evaluated using neurocognitive, balance, symptomatic, and neuroimaging based assessments) was performed on each subject pre- and post-impact. The passive muscle condition resulted in the largest resultant head linear acceleration (12.1 ± 1.8 g) and angular velocity (7.3 ± 0.5 rad/s). Compared to the passive activation, increasing muscle activation decreased both peak resultant linear acceleration and angular velocity in the co-contracted (12.1 ± 1.5 g, 6.8 ± 0.7 rad/s) case and significantly decreased in the unilateral contraction (10.7 ± 1.7 g, 6.5 ± 0.7 rad/s) case. The duration of angular velocity was decreased with an increase in neck muscle activation. No diagnostic metric showed a statistically or clinically significant alteration between baseline and post-impact assessments, confirming these impacts were non-injurious. This study demonstrated that isometric neck muscle activation prior to impact can reduce resulting head kinematics. This study also provides the data necessary to validate computational models of head impact.

Validation of a videogrammetry technique for analysing American football helmet kinematics.

Professional American football games are recorded in digital video with multiple cameras, often at high resolution and high frame rates. The purpose of this study was to evaluate the accuracy of a videogrammetry technique to calculate translational and rotational helmet velocity before, during and after a helmet impact. In total, 10 football impacts were staged in a National Football League (NFL) stadium by propelling helmeted 50th percentile male crash test dummies into each other or the ground at speeds and orientations representative of concussive impacts for NFL players. The tests were recorded by experienced sports film crews to obtain video coverage and quality typically available for NFL games. A videogrammetry procedure was used to track the position and rotation of the helmet throughout the relevant time interval of the head impact. Compared with rigidly mounted retroreflective marker three dimensional (3-D) motion tracking that was concurrently collected in the experiments, videogrammetry accurately calculated changes in translational and rotational velocity of the helmet using high frame rate (two cameras at 240 Hz) video (7% and 15% error, respectively). Low frame rate (2 cameras at 60 Hz) video was adequate for calculating pre-impact translational velocity but not for calculating the translational or rotational velocity change of the helmet during impact.

The biomechanics of concussive helmet-to-ground impacts in the National Football league.

This paper presents a detailed characterization of helmet-to-ground impacts in the National Football League. Video analysis was performed for 16 head-to-ground impacts that caused concussions. Average resultant closing velocity was 8.3 m/s at an angle nearly 45° to the surface. Preimpact rotational velocity of the helmet ranged from negligible to as high as 54.1 rad/s. Helmet impacts were concentrated on the posterior and lateral aspects. To study the interaction in greater detail, a helmeted anthropomorphic test device (ATD) was launched over a football field and fell to the ground in various impact conditions. Substantial decoupling between the helmet and the head was observed, such that the head rebounded within the helmet and underwent changes in linear and rotational motion greater than those of the helmet. Vertical helmet rebound was also observed; the helmet underwent a change in vertical velocity on average 24% greater than the vertical component of its closing velocity. Frictional interaction between the helmet and the ground surface caused the helmet to undergo an average horizontal change in velocity of 57% of the horizontal component of its closing velocity. Finally, the duration of a helmet-to-ground impact was generally in the range of 15 - 30 ms, suggesting that the impact surface provides little ride-down. Lengthening this duration could be beneficial both by reducing the peak linear and rotational acceleration and by shifting the impact toward a time regime where brain strain is related to rotational acceleration rather than rotational velocity.

Relative Motion Between the Helmet and the Head in Football Impact Test.

Approximately 1.6-3.8 million sports-related traumatic brain injuries occur each year in the U.S. Researchers track the head motion using a variety of techniques to study the head injury biomechanics. To understand how helmets provide head protection, quantification of the relative motion between the head and the helmet is necessary. The purpose of this study was to compare helmet and head kinematics and quantify the relative motion of helmet with respect to head during experimental representations of on-field American football impact scenarios. Seven helmet-to-helmet impact configurations were simulated by propelling helmeted crash test dummies into each other. Head and helmet kinematics were measured with instrumentation and an optical motion capture system. The analysis of results, from 10 ms prior to the helmet contact to 20 ms after the loss of helmet contact, showed that the helmets translated 12-41 mm and rotated up to 37 deg with respect to the head. The peak resultant linear acceleration of the helmet was about 2-5 times higher than the head. The peak resultant angular velocity of the helmet ranged from 37% less to 71% more than the head, depending on the impact conditions. The results of this study demonstrate that the kinematics of the head and the helmet are noticeably different and that the helmet rotates significantly with respect to the head during impacts. Therefore, capturing the helmet kinematics using a video motion tracking methodology is not sufficient to study the biomechanics of the head. Head motion must be measured independently of the helmet.

A reanalysis of football impact reconstructions for head kinematics and finite element modeling.

BACKGROUND: Head kinematics generated by laboratory reconstructions of professional football helmet impacts have been applied to computational models to study the biomechanics of concussion. Since the original publication of this data, techniques for evaluating accelerometer consistency and error correction have been developed. This study applies these techniques to the original reconstruction data and reanalyzes the results given the current state of concussion biomechanics. METHODS: Consistency checks were applied to the sensor data collected in the head of each test dummy. Inconsistent data were corrected using analytical techniques, and head kinematics were recalculated from the corrected data. Reconstruction videos were reviewed to identify artefactual impacts during the reconstruction to establish the region of applicability for simulations. Corrected head kinematics were input into finite element brain models to investigate strain response to the corrected dataset. FINDINGS: Multiple reconstruction cases had inconsistent sensor arrays caused by a problematic sensor; corrections to the arrays caused changes in calculated rotational head motion. These corrections increased median peak angular velocity for the concussion cases from 35.6 to 41.5 rad/s. Using the original kinematics resulted in an average error of 20% in maximum principal strain results for each case. Simulations of the reconstructions also demonstrated that simulation lengths less than 40 ms did not capture the entire brain strain response and under-predicted strain. INTERPRETATION: This study corrects data that were used to determine concussion risk, and indicates altered head angular motion and brain strain response for many reconstructions. Conclusions based on the original data should be re-examined based on this new study.

Video Analysis of Reported Concussion Events in the National Football League During the 2015-2016 and 2016-2017 Seasons.

BACKGROUND: Concussions in American football remain a high priority of sports injury prevention programs. Detailed video review provides important information on causation, the outcomes of rule changes, and guidance on future injury prevention strategies. PURPOSE: Documentation of concussions sustained in National Football League games played during the 2015-2016 and 2016-2017 seasons, including consideration of video views unavailable to the public. STUDY DESIGN: Descriptive epidemiology study. METHODS: All reported concussions were reviewed with all available video footage. Standardized terminology and associated definitions were developed to describe and categorize the details of each concussion. RESULTS: Cornerbacks sustained the most concussions, followed by wide receivers, then linebackers and offensive linemen. Half (50%) of concussions occurred during a passing play, 28% during a rushing play, and 21% on a punt or kickoff. Tackling was found to be the most common activity of concussed players, with the side of the helmet the most common helmet impact location. The distribution of helmet impact source-the object that contacted the concussed player's helmet-differed from studies of earlier seasons, with a higher proportion of helmet-to-body impacts (particularly shoulder) and helmet-to-ground impacts and with a lower proportion of helmet-to-helmet impacts. Helmet-to-ground concussive impacts were notable for the high prevalence of impacts to the back of the helmet and their frequency during passing plays. CONCLUSION: Concussion causation scenarios in the National Football League have changed over time. CLINICAL RELEVANCE: The results of this study suggest the need for expanded evaluation of concussion countermeasures beyond solely helmet-to-helmet test systems, including consideration of impacts with the ground and with the body of the opposing player. It also suggests the possibility of position-specific countermeasures as part of an ongoing effort to improve safety.

Inertial Properties of Football Helmets.

The inertial properties of a helmet play an important role in both athletic performance and head protection. In this study, we measured the inertial properties of 37 football helmets, a National Operating Committee on Standards for Athletic Equipment (NOCSAE) size 7» headform, and a 50th percentile male Hybrid III dummy head. The helmet measurements were taken with the helmets placed on the Hybrid III dummy head. The center of gravity and moment of inertia were measured about six axes (x, y, z, xy, yz, and xz), allowing for a complete description of the inertial properties of the head and helmets. Total helmet mass averaged 1834±231 g, split between the shell (1377±200 g) and the facemask (457±101 g). On average, the football helmets weighed 41±5% as much as the Hybrid III dummy head. The center of gravity of the helmeted head was 1.1±3.0 mm anterior and 10.3±1.9 mm superior to the center of gravity of the bare head. The moment of inertia of the helmeted head was approximately 2.2±0.2 times greater than the bare head about all axes.

Case series analysis of hindfoot injuries sustained by drivers in frontal motor vehicle crashes.

Improvements to vehicle frontal crashworthiness have led to reductions in toe pan and instrument panel intrusions as well as leg, foot, and ankle loadings in standardized crash tests. Current field data, however, suggests the proportion of foot and ankle injuries sustained by drivers in frontal crashes has not decreased over the past two decades. To explain the inconsistency between crash tests results and real world lower limb injury prevalence, this study investigated the injury causation scenario for the specific hind-foot injury patterns observed in frontal vehicle crashes. Thirty-four cases with leg, foot, and ankle injuries were selected from the Crash Injury Research and Engineering Network (CIREN) database. Talus fractures were present in 20 cases, representing the most frequent hind-foot skeletal injuries observed among the reviewed cases. While axial compression was the predominant loading mechanism causing 18 injuries, 11 injured ankles involved inversion or eversion motion, and 5 involved dorsiflexion as the injury mechanism. Injured ankles of drivers were more biased towards the right aspect with foot pedals contributing to injuries in 13 of the 34 cases. Combined, the results suggest that despite recent advancement of vehicle performance in crash tests, efforts to reduce axial forces sustained in lower extremity should be prioritized. The analysis of injury mechanisms in this study could aid in crash reconstructions and the development of safety systems for vehicles.

Kinematics and kinetics of vigorous head shaking.

Previous studies on neck muscle strength and motion have assumed or imposed varying constraints on the heads and bodies of the subjects. In this study, we asked 20 subjects to vigorously shake their heads 5-10 times in a completely unconstrained manner. The kinematics and kinetics of the head and neck were measured from video analysis and instrumentation mounted inside the mouth. Subjects shook their heads at self-selected tempos ranging from 1.9-4.7 Hz over a 20-91° range of motion. The motion of each subject's head could be approximated by a fixed center of rotation that was typically located in the midcervical spine, but varied widely among subjects. Significant differences between men and women were observed. Peak head accelerations were low (4.3 ± 1.1 g and 250 ± 103 rad/s2 for men, 3.0 ± 0.9 g and 182 ± 58 rad/s2 for women) and estimated peak generated neck moments at C7/T1 were comparable to values reported in isometric neck strength studies (47 ± 14 N·m in extension and 22 ± 9 N·m in flexion for men, 25 ± 8 N·m in extension and 9 ± 7 N·m in flexion for women).

Factors affecting ejection risk in rollover crashes.

Ejection greatly increases the risk of injury and fatality in a rollover crash. The purpose of this study was to determine the crash, vehicle, and occupant characteristics that affect the risk of ejection in rollovers. Information from real world rollover crashes occurring from 2000 - 2010 was obtained from the National Automotive Sampling System (NASS) in order to analyze the effect of the following parameters on ejection risk: seatbelt use, rollover severity, vehicle type, seating position, roof crush, side curtain airbag deployment, glazing type, and occupant age, gender, and size. Seatbelt use was found to reduce the risk of partial ejection and virtually eliminate the risk of complete ejection. For belted occupants, the risk of partial ejection risk was significantly increased in rollover crashes involving more roof inversions, light trucks and vans (LTVs), and larger occupants. For unbelted occupants, the risk of complete ejection was significantly increased in rollover crashes involving more roof inversions, LTVs, far side occupants, and higher levels of roof crush. Roof crush was not a significant predictor of ejection after normalizing for rollover severity. Curtain airbag deployment was associated with reduced rates of partial and complete ejection, but the effect was not statistically significant, perhaps due to the small sample size (n = 89 raw cases with curtain deployments). A much greater proportion of occupants who were ejected in spite of curtain airbag deployment passed through the sunroof and other portals as opposed to the adjacent side window compared to occupants who were ejected in rollovers without a curtain airbag deployment. The primary factors that reduce ejection risk in rollover crashes are, in generally decreasing order of importance: seatbelt use, fewer roof inversions, passenger car body type, curtain airbag deployment, near side seating position, and small occupant size.