4. Develop better equipment

One potential way to address the concussion and RHI problem is to develop better equipment (e.g. helmets and mouth guards) to attenuate the force associated with brain trauma.

Football helmets 

The problem is that, although helmets have been shown to decrease the incidence of facial injury as well as moderate and severe traumatic brain injury (TBI), and mouth guards help protect against dental and orofacial injury, there is no evidence to date that the newest helmets or mouth guards reduce the incidence of concussions, or the severity of concussion symptoms.^[20]

Indeed, the findings of a study, originally presented as research papers to the 2012 and 2013 meetings of the American Orthopaedic Society for Sports Medicine [21,32] and later published in the American Journal of Sports Medicine,[33] found no definitive data to support the view that advanced football helmet technology and design provides any additional protection against concussion or intracranial hemorrhage.

Researchers at the University of Wisconsin found that the risk of sustaining a concussion in high school football was not affected by the brand or age of the helmet or by the type of mouth guard worn. [21,32,33]

The bottom line is that there are no "concussion proof" helmets currently on the market. Nor have mouth guards been shown by any peer-reviewed study to reduce the risk of concussions [20, 21] So, while researchers are hard at work to design helmets and mouth guards that mitigate the collective impacts absorbed by the brain in such a way as to dissipate the harmful energy that occurs during repeated impacts, such equipment appear to be a long way off.

This is not to say that equipment doesn't play a part in concussion prevention. As a research paper found [20], football players wearing poorly-fitted helmets, especially those with under-inflated air bladder liners, are at increased risk of concussion, so making sure that football helmets fit properly, and that those with air bladder linings are properly inflated, may be two of the simplest but most effective ways to minimize the risk of concussion and catastrophic brain injury.

Despite the players' smaller size and undeveloped neck muscles, notes the 2012 Virginia Tech study of head impacts among young football players,[6] youth helmets are remarkably similar in size, mass and design materials to those worn by adult football players. This fact, combined with data showing that a substantially higher percentage of hits to the helmets of youth players are to the side of the helmet - which the researchers attributed to a differences in the styles of play between the different age groups, as well as the fact that youth players have a tendency to fall to the side when tackled - may result in a youth player being more susceptible to impacting his head on the ground while being tackled than a high school or college player," says the study, knowledge which could aid in the design of youth-specific football helmets.

Unfortunately, the development of a youth-specific football helmet standard has been excruciatingly slow, hampered by a lack of research and public demand for action.  While NOCSAE notes that, "Research continues into a separate standard for youth helmets... [and] that youth-sized helmets have a lower helmet-weight to head-mass ratio than adult-sized helmets", the fact that "preliminary pneumatic ram testing indicates that small-sized helmets which have less mass don't perform as well in rotational tests as medium or large helmets of the same model, which is likely due to their lighter weight" led the standard-setting group to conclude that, "At this time, there is not enough data to suggest a helmet mass limit for youth-sized helmets."

If anything, development of a youth-specific standard seems to be going in reverse.  After deliberation and consideration of input from multiple interested parties, the NOCSAE board voted in January 2012 to change the Youth Football Helmet Standard from "Proposed" to "Draft" so that more input can be received, and to permit development of that standard to follow a separate track.  "Significant hurdles remain to the development of a youth football helmet standard that will address the specific injury risks and biomechanical forces involved in youth football, and that data has not yet been well developed," NOCSAE said. 

There may, however, be light at the end of the tunnel.  In October 2015 came the announcement that Virginia Tech had been awarded a g $3,3 million grant by the National Institutes of Health's National Institute of Neurological Disorders and Stroke to lead a five-year, multi-center study to track on-field head impact and accelerations using sensors installed in hundreds of 9- and 10-year old youth football players' helmets and mouth guards, and to track them via neuropsychological testing.  

Commenting on the study, Dr. Duma said collecting of data "will allow for evidence-based decisions across a range of applications, including improved clinical detection techniques [see #6 below on the use of sensors] as well as a solid foundation for our helmet rating programs and offer ways potentially to improve youth football helmet design."  

Hockey helmets

If anything, the news on hockey helmets is even worse.  According to the recently released report by Virginia Tech on the ability of hockey helmets to attenuate the forces that cause concussions, none of the 32 popular hockey helmets tested were found good enough in protecting against concussion risk to earn four (very good) or five stars (best available), with only 1 rating 3 stars, or "good" in its STAR ratings, 6 rating 2 stars, or "adequate" . 16 earning 1 star, or "marginal" and 9 getting no stars, or "not recommended."  (By comparison, twenty of the 26 football helmets most recently tested by Virginia Tech received ratings of 4 or 5 stars, a significant improvement from 2011, the first year the ratings were issued, when only 6 receiving four or five stars)

Because, compared to football helmets, hockey helmets are smaller, have much thinner padding systems (two thin layers of relatively rigid padding versus a football helmet's three thick layers of soft padding) and less "offset" (which allows for more compression during impact), that they performed poorly in the tests was widely predicted (see, for example, a New York Times article from July 2014 in which one sports equipment testing executive is quoted as saying that the ratings would "hit hockey like a ton of bricks.").   

While the STAR methodology for hockey helmets,[36] has its critics (including USA Hockey), just as there are critics of its football helmet ratings, and come with most of the same limitations as those ratings, the issuance of the ratings, as they did with football, will likely force hockey helmet manufacturers to start to make helmets which can perform better in the Virginia Tech tests. "It's time for hockey to start catching up" with football, said Dr. Stefan Duma, a Virginia Tech professor and the head of the university's biomedical engineering department which issues the STAR ratings.

Stay tuned.