BIOMECHANICS OF HEADING IN YOUTH SOCCER by ERIN HANLON DISSERTATION Submitted to the Graduate School of Wayne State University, Detroit,

Michigan in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY 2009 MAJOR: BIOMEDICAL ENGINEERING Approved by: Advisor Date

UMI Number: 3387316

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 COPYRIGHT BY ERIN HANLON 2009 All Rights Reserved

DEDICATION For my parents, for all of their love, support, and patience

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ACKNOWLEDGMENTS This work was supported by in part by the National Operating Committee for Standards in Athletic Equipment (NOCSAE). In addition to funding provided by NOCSAE the author would like to acknowledge partial support from the Anthony and Joyce Danielski Kales Scholarship. The author would like to thank her advisor, Dr. Cynthia Bir, and her committee members, Dr. John Cavanaugh, Dr. Pamela VandeVord, and Dr. Kenneth Podell for all of their guidance, support, and expertise. The author would also like to thank the Sports and Ballistics group for all of their assistance with test preparation, data collection, and insight. Specifically, the author would like to thank Charlene Brain, Sarah Stojsih, Demario Tucker, and Jacob Mack for assistance with data collection and to Jonathan Beckwith for assistance with data processing. Thank you to Nathan Dau and Donald

Sherman for input on testing methods and test setup. Thank you to Amanda Esquivel and James Kopacz for assistance with subject recruitment. Thank you to all athletes for taking time to participate in the study. Finally, the author would like to thank her friends and family for their support for the duration of this process. Thank you to my Mom and Dad, Brian, and Alison. Thank you for your support and, most importantly, your patience.

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TABLE OF CONTENTS DEDICATION ........................................................................................................ ii ACKNOWLEDGMENTS ...................................................................................... iii LIST OF TABLES................................................................................................. iv LIST OF FIGURES ............................................................................................... v CHAPTER 1 - INTRODUCTION ........................................................................... 1 1.1 Statement of the Problem..................................................................... 1 1.2 Background and Significance ............................................................... 2 1.3 Specific Aims...................................................................................... 15 CHAPTER 2 - NEISS DATABASE ...................................................................... 17 2.1 Introduction ........................................................................................ 17 2.2 Methodology....................................................................................... 23 2.3 Results ............................................................................................... 24 2.4 Discussion .......................................................................................... 29 CHAPTER 3 - HEADING FREQUENCY IN YOUTH SOCCER .......................... 33 3.1 Introduction ........................................................................................ 33 3.2 Methodology....................................................................................... 37 3.3 Results ............................................................................................... 40 3.4 Discussion .......................................................................................... 47 CHAPTER 4 - HEADING BIOMECHANICS IN YOUTH SOCCER ..................... 50 4.1 Introduction ........................................................................................ 50 4.2 Methodology....................................................................................... 54 4.3 Results ............................................................................................... 60

4.4 Discussion .......................................................................................... 86 CHAPTER 5 - ACCELERATION MEASUREMENT SYSTEM VALIDATION ...... 90 5.1 Introduction ........................................................................................ 90 5.2 Methodology....................................................................................... 93 5.3 Results ............................................................................................... 99 5.4 Discussion ........................................................................................ 110 CHAPTER 6 - ON FIELD MEASUREMENT OF HEAD ACCELERATION........ 115 6.1 Introduction ...................................................................................... 115 6.2 Methodology..................................................................................... 120 6.3 Results ............................................................................................. 122 6.4 Discussion ........................................................................................ 132 CHAPTER 7 - CONCLUSIONS AND FUTURE RECOMMENDATIONS .......... 137 7.1 Conclusions...................................................................................... 137 7.2 Future Recommendations ................................................................ 141 APPENDIX A HIC APPROVALS.................................................................... 143 ABSTRACT ....................................................................................................... 160 BIOGRAPHICAL STATEMENT ........................................................................ 162

LIST OF TABLES Table 1.1: Player Symptoms Following Soccer Heading .................................... 5 Table 2.1: Head injuries by mechanism ............................................................ 26 Table 2.2: Ball to head only injuries ................................................................... 27 Table 3.1: Number of games monitored outlined by age, gender and division of play ..................................................................................................................... 38 Table 3.2: Maximum headers by any one player for a single game ................... 40 Table 3.3: Average total headers/game/team for male population ..................... 43 Table 3.4: Average total headers/game/team for female population .................. 44 Table 3.5: Total headers in each field position for females ................................ 45 Table 3.6: Total headers in each field position for males ................................... 46 Table 4.1: Heading Scenarios ............................................................................ 59 Table 4.2: Average angles at impact for each heading task .............................. 78 Table 4.3: Mean peak RMS EMG values for each muscle and each task ......... 82 Table 4.4: Average head acceleration on impact for each heading task ........... 85 Table 4.5: Average head flexion for each task ................................................... 87 Table 5.1: Average Peak Linear Accelerations for Ball to Head Conditions..... 104 Table 5.2: Average Peak Angular Accelerations for Ball to Head Conditions .. 105 Table 5.3: Average Peak Linear Accelerations for Head to Head Conditions .. 106 Table 5.4: Average Peak Angular Accelerations for Head to Head Conditions 106 Table 6.1: Average results for headers by location .......................................... 125 Table 6.2: Description of non header impacts and the player that impacted.... 128

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LIST OF FIGURES Figure 2.1: NEISS database hospitals by strata ............................................... 18 Figure 2.2: Soccer head injuries including both males and females .................. 25 Figure 2.3: Male and female ball only head injuries by age ............................... 28 Figure 2.4: Ball only head injuries by diagnosis ................................................. 29 Figure 3.1: Soccer Field Diagram ..................................................................... 39 Figure 3.2: Comparison of number of headers/minute, male versus female

across age groups .............................................................................................. 41 Figure 3.3: Number of headers/minute for the male population ......................... 42 Figure 3.4: Number of headers/minute for the female population ...................... 45 Figure 3.5: Total number of headers in each field position ............................... 47 Figure 4.1: FAB System with size scale ............................................................. 53 Figure 4.2: Example of player wearing FAB sensors ......................................... 55 Figure 4.3: Side view of head and trunk body angles ........................................ 56 Figure 4.4: Top view of head rotation................................................................. 56 Figure 4.5: Neck musculature used for EMG testing a) sternocleidomastoid; b) trapezius ............................................................................................................. 57 Figure 4.6: Torso flexion for all male players during task 2 ............................... 61 Figure 4.7: Head flexion for all male players during task 2 ............................... 62 Figure 4.8: Head rotation for all males during task 2 .......................................... 63 Figure 4.9: Torso flexion for all females during task 2........................................ 64 Figure 4.10: Head flexion for all females during task 2 ..................................... 64 Figure 4.11: Head rotation for all females during task 2 .................................... 65 v

Figure 4.12: Example of single male participants torso flexion for all header tasks that lack modifications (1, 2, 3, and 7) ...................................................... 66 Figure 4.13: Example of single male participants head flexion for all header tasks that lack modifications (1, 2, 3, and 7) ....................................................... 66 Figure 4.14: Example of single male participants head rotation for all header tasks that lack modifications (1, 2, 3, and 7) ...................................................... 67 Figure 4.15: Example of single female participants torso flexion for all header tasks that lack modifications (1, 2, 3, and 7) ...................................................... 68 Figure 4.16: Example of single female participants head flexion for all header tasks that lack modifications (1, 2, 3, and 7) ...................................................... 68 Figure 4.17: Example of single female participants head rotation for all header tasks that lack modifications (1, 2, 3, and 7) ...................................................... 69 Figure 4.18: Example of single male participants torso flexion for all passing header tasks (2, 4, 5, and 6) ............................................................................... 70 Figure 4.19: Example of single male participants head flexion for all passing header tasks (2, 4, 5, and 6) ............................................................................... 71 Figure 4.20: Example of single male participants head rotation for all passing header tasks (2, 4, 5, and 6) ............................................................................... 71 Figure 4.21: Example of single female participants torso flexion for all passing header tasks (2, 4, 5, and 6) ............................................................................... 72 Figure 4.22: Example of single female participants head flexion for all passing header tasks (2, 4, 5, and 6) .............................................................................. 73

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Figure 4.23: Example of single female participants head rotation for all passing header tasks (2, 4, 5, and 6) ............................................................................... 73 Figure 4.24: Example of single male participants torso flexion for all clearing header tasks (7 and 8) ........................................................................................ 74 Figure 4.25: Example of single male participants head flexion for all clearing header tasks (7 and 8) ....................................................................................... 75 Figure 4.26: Example of single male participants head rotation for all clearing header tasks (7 and 8) ....................................................................................... 75 Figure 4.27: Example of single female participants torso flexion for all clearing header tasks (7 and 8) ....................................................................................... 76 Figure 4.28: Example of single female participants head flexion for all clearing header tasks (7 and 8) ....................................................................................... 76 Figure 4.29: Example of single male participants head rotation for all clearing header tasks (7 and 8) ....................................................................................... 77 Figure 4.30: Peak EMG for all male players for each muscle a) left

sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius ............................................................................................................ 80 Figure 4.31: Peak EMG for all female players for each muscle a) left

sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius ............................................................................................................ 81 Figure 4.32: Sample RMS EMG for one male player for each muscle a) left sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius ............................................................................................................ 83 vii

Figure 4.33: Sample RMS EMG for one female player for each muscle a) left sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius ............................................................................................................ 84 Figure 5.1: HIT system ...................................................................................... 91 Figure 5.2: Back of HITS headband with circles marking accelerometer

placement .......................................................................................................... 94 Figure 5.3: Air cannon with soccer barrel........................................................... 96 Figure 5.4: Head to head impact test setup for forehead testing ...................... 97 Figure 5.5: Linear regression of linear acceleration for HIII and HITS ball to head conditions ......................................................................................................... 100 Figure 5.6: Linear regression of angular acceleration for HIII and HITS ball to head conditions ................................................................................................ 100 Figure 5.7: Linear regression of linear acceleration for HIII and HITS head to head conditions ................................................................................................ 101 Figure 5.8: Linear regression of angular acceleration for HIII and HITS head to head conditions ................................................................................................ 102 Figure 5.9: Linear regression of linear acceleration for HIII and HITS ball to head and head to head conditions combined ........................................................... 103 Figure 5.10: Linear regression of angular acceleration for HIII and HITS ball to head and head to head conditions combined .................................................. 103 Figure 5.11: Linear acceleration for both HIII and HITS for one ball to head forehead impact at the 12 m/s condition .......................................................... 107

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Figure 5.12: Linear acceleration for both HIII and HITS for one ball to head right side impact at the 12 m/s condition .................................................................. 108 Figure 5.13: Linear acceleration for both HIII and HITS for one ball to head left temple impact at the 12 m/s condition .............................................................. 108 Figure 5.14: Linear acceleration for both HIII and HITS for one head to head forehead impact at the 4.75 m/s condition ....................................................... 109 Figure 5.15: Linear acceleration for both HIII and HITS for one head to head left side impact at the 4.75 m/s condition ............................................................... 109 Figure 6.1: Wayne State University Tolerance Curve ...................................... 118 Figure 6.2: HITS headgear fitted to HIII headform .......................................... 121 Figure 6.3: Linear head acceleration by location for each header only impacts .......................................................................................................................... 122 Figure 6.4: Angular head acceleration by location for each header only impacts .......................................................................................................................... 123 Figure 6.5: HIC values for headers by location with mTBI tolerance level ...... 124 Figure 6.6: Linear head acceleration for header impacts for individual players .......................................................................................................................... 126 Figure 6.7: Angular head acceleration for all header impacts for individual

players ............................................................................................................. 126 Figure 6.8: Linear head acceleration for all non header impacts by location ... 129 Figure 6.9: Angular head acceleration for all non header impacts by location 130 Figure 6.10: HIC for all non header impacts by location ................................. 130

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Figure 6.11: Linear head acceleration for all non header impacts for individual players ............................................................................................................. 131 Figure 6.12: Angular head acceleration for all non header impacts for individual players ............................................................................................................. 132

1 CHAPTER 1 INTRODUCTION 1.1 Statement of the Problem Soccer is one of the most popular sports throughout the world; Fdration Internationale de Football Association (FIFA) has approximately 200 million registered players worldwide (Dvorak and Junge, 2000). A large increase in participation has taken place recently in the United States. This is seen clearly in the American Youth Soccer Organization (2006) which today has 50,000 youth soccer teams and over 650,000 players registered after starting out in 1964 with only nine teams (2006). Unfortunately, the increase in youth players has caused an increase in injuries (Metzl, 1999). Soccer injuries not only cause trauma to the player, they also create a large socioeconomic cost. Dvorak et al. (2000) reviewed relevant soccer injury data and determined that approximately $30 billion dollars are spent annually for treatment of soccer related injuries worldwide. While this value uses an average injury rate, it also uses a conservative estimate of cost per injury (Dvorak and Junge, 2000). As pointed out by Dvorak et al. (2000), this cost estimate does not take into account lost wages or anything not directly related to primary medical costs. Head injuries are of particular concern due to their traumatic nature and the lack of knowledge related to these injuries and their mechanisms, specifically mild traumatic brain injury (mTBI). Head injuries represent up to 22% of all

soccer injuries (Ruchinskas, et al., 1997). A unique aspect of soccer is that there

2 are both intentional and unintentional head impacts. Intentional impacts, or

heading the ball, occur when a player purposefully uses their head to redirect the ball. Unintentional impacts include: player to player impacts, player to

ground impacts, player to goalpost impacts, and unintentional player to ball impacts. The purpose of this study is to investigate the effect of the intentional head impacts that occur during soccer play. Initial steps will be taken to determine the frequency and severity of heading episodes in the field using both field observation and a novel head band measurement system developed for use in soccer play. Additionally, many laboratory studies have been performed on the adult soccer population, but very few have focused on children. Therefore, an analysis of the biomechanics of heading in youth soccer needs to be performed. Comparisons will be made between youth and adult heading biomechanics to determine if there is a difference based on age. Also, a comparison between the youth heading biomechanics and the youth heading field data will be made. This will provide valuable information as to whether the laboratory data collected in previous studies is representative of actual on-field situations. 1.2 Background and Significance Injury Epidemiology Due to the increase in soccer participation, more injuries are occurring (Metzl, 1999). Although the majority of soccer injuries are to the lower extremity (Agel, et al., 2007, Arnason, et al., 2004, Backous, et al., 1988, Dvorak and Junge, 2000, Elias, 2001, Junge and Dvorak, 2007, Keller, et al., 1987, Le Gall,

3 et al., 2008, Leininger, et al., 2007, Nielsen and Yde, 1989, Peterson, et al., 2000, Poulsen, et al., 1991, Sandelin, et al., 1985, Schmidt-Olsen, et al., 1985), head injuries are of specific concern due to the potential for long-term debilitating effects. The American Academy of Pediatrics has classified soccer as a contact sport, but many still believe that soccer is a safe alternative to American Football (Patlak, et al., 2002). This may not be true when considering the previously established concussion rates (Green and Jordan, 1998). When studying sports in the National Collegiate Athletic Association (NCAA) Green et al. (1998) found similar concussion rates in American football and mens and womens soccer. Using the NCAA Injury Surveillance System (ISS) to determine the incidence of concussion in various sports (Green and Jordan, 1998). Concussions were

measured per 1000 athlete exposures, where each exposure is the equivalent of one practice or game. They found that womens soccer actually has a higher rate of concussion (.33 concussions/1000 athlete exposures) than both mens soccer (.31 concussions/1000 athlete exposures) and football (.31

concussions/1000 athlete exposures). This demonstrates the high risk of head injury during soccer play. Covassin et al. (2003) found that mens and womens soccer are in the group of athletes at the highest risk for concussions (Covassin, et al., 2003). Womens soccer had the highest number and injury rate of concussions of the 15 NCAA womens sports included in the study indicating that further research into the area is necessary (Covassin, et al., 2003). Small stature, a greater ball-tohead ratio, and potentially weaker neck muscles have been suggested as the

4 potential causes (Covassin, et al., 2003). All of these issues would also be

applicable to the youth population in addition to their lower skill level and lack of experience. Keller et al. (1987) found that younger players generally have a higher rate of head and face injury (Keller, et al., 1987). They attributed this fact to a lack of heading proficiency and the increase in ball to head weight ratio. Both of these factors would indicate heading as a potential problem in youth soccer. This is of significant importance because it has been indicated that younger athletes may take longer to regain baseline neuropsychological levels following a concussion (Field, et al., 2003). Barnes et al. (1998) interviewed 144 elite soccer players in the 1993 US Olympic Festival. Players were asked to estimate the number of times that they head the ball during games and during practices. They were also asked to list any symptoms that they had experienced as a result of heading and if they had any previous head injuries. Sixty-five women aged 17-30 and 72 men aged 1722 completed the surveys. Using an odds ratio of the total concussions for men and women it was found that men had an increased risk of concussion of 2.16 times that of women. Seventy-four concussions were reported in men and 28 in women with 27 players reporting multiple concussions, 24 men and 3 women. That indicates that 52% of players interviewed had experienced a concussion. Of these concussions, 18% reported the mechanism of injury as collision with the ball. Additionally 89% of men and 43% of women had previously had some type of acute head injury during their soccer careers. Many of the players had

5 symptoms following heading the soccer ball (Table 1.1) with headache being the highest reported symptom (Barnes, et al., 1998). These symptoms indicate that, at a minimum, soccer heading creates a short-term problem. Table 1.1: Player Symptoms Following Soccer Heading (Barnes, et al., 1998) Symptom Men (%) Women (%) Headaches Dazed Dizziness Decreased Concentration Blurred Vision Lost Conciousness Numbness/Tingling Amnesia 54.0 31.0 18.1 9.7 11.1 1.4 12.8 0.0 55.0 49.0 38.5 10.8 4.6 0.0 7.7 3.1

In another study looking at concussion in soccer, Boden et al. (1998) found similar concussion rates as Barnes et al. (Barnes, et al., 1998, Boden, et al., 1998). Athletic trainers for each of the 15 Atlantic Coast Conference (ACC) mens and womens soccer teams were asked to fill out a questionnaire for each concussion occurring during the 1995 and 1996 seasons. In the 1995 season, 188 women and 162 men competed in ACC soccer, and in the 1996 season there were 188 women and 163 men. During these two seasons 29 concussions occurred in 26 players. This resulted in a concussion rate of 0.49

concussions/1000 athlete exposures, 0.6 concussions/1000 male athlete exposures and 0.4 concussions/1000 female athlete exposures. Contact with the

6 ball was the second most common injury mechanism (24 %), but no injuries were attributed to intentional heading. The concussion rates in this study were

significantly higher than those found in the NCAA data. This could be due to the different levels of play in the NCAA with this conference being in the highest division, Division I. One problem when comparing these studies is the use of differing definitions of concussion. Sandelin et al. (1985) used insurance reports to determine soccer related injuries for 1980 in Finland. After eliminating exertion injuries, researchers

determined that 2072 soccer injuries occurred that year, with 13 % of these located in the head and neck region. Another significant finding in this study was the lack of differences between the genders and positions played, but there were significantly more injuries in the two highest skill divisions (Sandelin, et al., 1985). The results also coincide with Barnes et al. (1998) that gender was not a significant factor in head injury occurrence (Barnes, et al., 1998). This study included youth players, but the average age of those included was 26 for the men and 23 for women. It was not determined whether or not age was a

significant factor in injury occurrence. Mechanism of soccer related head injury has been studied previously in adults (Agel, et al., 2007, Andersen, et al., 2004, Boden, et al., 1998, Dick, et al., 2007, Dvorak, et al., 2007, Fuller, et al., 2005), but many of these studies have significant limitations when looking strictly at injuries related to heading the soccer ball. One significant problem is the lack of a set injury definition which is required when comparing literature. Many studies use definitions that require a

7 loss of practice or play in order to be quantified as an injury which generally eliminates those players that are just having post-heading symptoms. This

definition creates a problem in tabulating the total number of people that have symptoms following heading a soccer ball. Soccer Heading Studies Research has been performed in the area of soccer heading and its effects on players neuropsychological abilities and mental imaging scans (Guskiewicz, 2002, Janda, et al., 2002, Tysvaer and Storli, 1981, Tysvaer and Storli, 1989, Tysvaer, et al., 1989). These previous studies have provided very

contrasting results in which no clear understanding of what is occurring during or following heading can be made. Without understanding what happens

biomechanically during heading events on the field, there is no way to determine injury risk. The majority of the previous research has been performed on adults, some of which are retired soccer players. Very little focus has been on the effect of heading in the youth population, and there has still been no biomechanical assessment of youth soccer players heading the soccer ball in the lab. Additionally, previous studies have not isolated heading from other potential deficit causes such as alcohol use and previous non-soccer related head injury. Therefore, further research needs to be done to look at the effect heading has on the youth population. Although much research has been devoted to the adult population, especially the elite players, the risks to the youth population have not been studied in great detail. In fact, the risks to children are potentially greater. This is

8 primarily due to their size versus the force being applied by the ball (Lees and Nolan, 1998). It has been reported that ball mass, impact velocity, and size of the individual all contribute to the potential for injury (Lees and Nolan, 1998). Additionally, the importance of proper technique may be especially true in the youth population, since their skill level has not been well developed to control their head motion when heading the ball. Therefore, the youth population could be at an increased risk for sustaining head injuries due to rotational acceleration. Given the increase in youth soccer participation over the past decade and additional injury risk, it is necessary to focus research on the youth population. Many of the earlier studies indicated that repeatedly heading the soccer ball increased players risk for neuropsychological deficits and long-term symptoms. Tysvaer et al. (Tysvaer and Storli, 1981, Tysvaer and Storli, 1989, Tysvaer, et al., 1989) was one of the first researchers to investigate this occurrence. In the first study, Tysvaer et al. (1981) studied 128 retired Questionnaires

Norwegian soccer players with an average age of 25 years.

were sent to each player asking about their previous soccer play. Of the 128 players, 64 had once had symptoms related to heading the soccer ball, some of which required hospitalization. The study does not provide information on the number of headers to which each player was subjected. Therefore, no

association between the number of headers and injury can be made. Two additional studies were done using EEG and neuropsychological testing to determine if active and retired soccer players displayed deficits related to their soccer play (Tysvaer and Storli, 1989, Tysvaer, et al., 1989). Sixty-nine

9 active players were compared to controls while a parallel study of 37 retired players used the same tests to determine long-term effects. Eighty-one percent of the players showed a deficit in neuropsychological tests ranging from mild to severe (Tysvaer, et al., 1989). For the study involving active players, it was found that there was an increase in abnormal EEG findings in soccer players with respect to controls. It was also determined that the highest abnormal findings were in the younger players (Tysvaer and Storli, 1989). Neuropsychological testing has been the basis for many of the previous studies. In one such study Guskiewicz et al. (2002) studied soccer heading in players playing in the NCAA. Six neurocognitive tests were performed on 91 soccer players, 96 other athletes, and 53 control subjects. The battery of tests included the Trail Making Test, the Controlled Oral Word Association Test, the Stroop Color Word Test, the Hopkins Verbal Learning Test, the Symbol Digit Modalities Test, and the Wechsler Digit Span Test. These tests evaluated a wide range of cognitive abilities including: orientation, concentration, visuospatial

capacity, problem-solving, verbal associations, cognitive flexibility, attention span, verbal memory, visual tracking, incidental learning, concentration, and immediate memory. Scholastic Aptitude Test (SAT) scores were also evaluated. Researchers determined that there was no actual significant difference (Guskiewicz, 2002). One test (the Hopkins Verbal Learning Test) approached statistical significance, but once previous concussions and learning disabilities were controlled for, significance was not found. This test was specific for

immediate memory recall which could indicate that bouts of heading can cause

10 immediate deficits, but further research is needed to determine why these deficits may exist. Additionally, an attempt to correlate soccer exposure to test

performance was conducted. Correlations were only made in the Wechsler Digit Span Test. This study indicated that soccer exposure did not affect

neuropsychological ability. Similar neuropsychological testing was conducted on 53 active

professional soccer team members from The Netherlands (Matser, et al., 1998). Both players and 27 controls were interviewed and tested using a battery of neuropsychological examinations. The tests included in the battery differed

slightly from those used by Guskiewicz et al. (2002) as did the results. Fourteen tests were administered including: Raven Progressive Matrices Test, Wisconsin Card Sorting Task, Paced Auditory Serial Addition Task, Digit Symbol Test, Trail Making Test, Stroop Test, Bourdon-Wiersman Test, Wechsler Memory Scale, Complex Figure Test, 15-Word Learning Test, Bentons Facial Recognition Test, Figure Detection Test, Verbal Fluency Test, and the Puncture Test. The number of headers experienced by each player was estimated based on position played and number of games. Soccer players exhibited impaired performance in

memory, planning and visuoperceptual processing in comparison to the controls with the level of impairment related to the position and number of headers as well as concussions. The authors suggest that these data may indicate professional soccers connection to neurocognitive impairment (Matser, et al., 1998). In a similar study, Putukian et al. (2004) corroborated these results by studying Division I male and female college athletes. Athletes were studied

11 prospectively during two practice sessions and served as their own controls. Neuropsychological testing was conducted before and after each practice session with the number of headers monitored during the session. A practice effect was noted between the pre- and post-test scoring for attention and concentration. However, there was no significant difference between the header and non-header groups in either the pre- or post-test scores (Putukian, 2004). Therefore, further tests would be required to determine the cause of the deficits. Janda et al. (2002) performed one of the few studies involving soccer heading in the youth population. Fifty-seven youth soccer players from five

teams having an average age of 11.5 years were studied for three seasons. Neurocognitive testing was used to determine the effects of heading. Four

cognitive tests were included in this study: Verbal Learning, Digit Span, Symbol Digits Modality Test, and Verbal Learning Delay. Symptoms following heading and heading exposure were also observed throughout the duration of the study by the coaching staffs. All impacts were included in the data sheet returned to the researchers by the coaching staffs including those that were unintentional. Symptoms following heading included headaches, blurred vision, nausea, and ringing in the ears with headaches being the most common. It was also

determined that there is an inverse relationship between increased heading and verbal learning (Janda, et al., 2002). In a recent study, Witol and Webbe (2003) studied 60 male players at varying levels of skill with the youngest being high school students. Using a control of 12 males who had never played soccer, neuropsychological testing

12 was administered to evaluate a number of functions including: abstract reasoning, general intellectual function, attention, mental flexibility, information processing, verbal and nonverbal memory. These tests included: Shipley

Institute of Living Scale, Trail Making Test, Paced Auditory Serial Addition Test, Test of Facial Recognition, Rey Osterreith Complex Figure Test, and Rey Auditory Verbal Learning Test. Players were asked to self-report their heading exposure which allowed for a cumulative heading measure to be developed to estimate career heading. Also, players were asked in their history about A decrease in the scales measuring

symptoms during or following games.

attention, concentration, cognitive flexibility and general intellectual functioning correlated with an increase in the number of headers (Witol and Webbe, 2003) which supports the conclusions of Janda et al. (2002). Researchers also found that those players described as typical headers had significantly more dizziness indicating that there are short term effects caused by performing soccer headers. Stephens et al. (2005) performed a study on 23 youth soccer players, 23 youth rugby ranging in age from 13-16 years, and age matched controls for both the contact sports who were participants in only non-contact sports. The battery of 13 tests included: Rey Complex Figure, WAIS-R Digit Symbol, WAIS-R Digit Span, Trail Making, Stroop, WMS-R Logical Memory Immediate and Delayed, the Alertness, Divided Attention, Covert Attention Shift, Flexibility and Working Memory subtests of Test of Attention Performance, Wisconsin Card Sorting, 64item version, and Alternate Uses. The study showed no significant difference between soccer players and their controls. There was also no correlation found

13 between the number of headers and neuropsychological test results (Stephens, et al., 2005). Imaging has also been looked at as a method to detect injuries in both current and retired soccer players, although to a more limited extent. Tysvaer et al. (1989), in one of the earliest soccer heading studies, used EEG to detect abnormalities, which although it is not necessarily an imaging technique, was the first use of brain scans in the field (Tysvaer and Storli, 1989, Tysvaer, et al., 1989). Since the earlier studies, imaging advances have been achieved and researchers have used MRI and computer tomography (CT) scans (Jordan, et al., 1996, Rutherford, et al., 2003, Sortland and Tysvaer, 1989). As with the neuropsychological testing, the imaging studies have also returned conflicting results. Sortland et al. (1989) performed CT scans on former international soccer players. Thirty-three retired players were given scans with nine of these being categorized as typical headers. No definition was provided by the authors, but both the player and their teammates had categorized themselves as typical headers. Scans were evaluated visually and by taking linear measurements. When compared to normative scans, one third of the former players had widening of the lateral ventricles. This was determined to be central cerebral atrophy. This could also be a symptom of alcohol abuse, but this issue wasnt

addressed. Significant differences did not occur between typical headers and the other players (Rutherford, et al., 2003, Sortland and Tysvaer, 1989).

14 In one of the initial studies in the United States, Jordan et al. (1996) reported on twenty males with an average age of 24.9 years from the US National Soccer team. A cohort of 20 male elite-track athletes was identified. Players completed questionnaires regarding positions played, history of head injury, number of headers and number of years played. A scaling system was used to estimate the number of headers for each player based on level and type of play. All study participants were examined using magnetic resonance imaging (MRI) to determine any neurological deficits. Based on this testing, no

differences were noted between the soccer players and the control group, but nine of the US National Soccer players were found to have abnormal MRI results with three of those players having multiple findings (Jordan, et al., 1996). These results included cortical atrophy in three players, ventricular enlargement in three players, focal atrophy in three players, cavum septum pellucidum in three players, and cerebellar atrophy in one player. MRI was also used in a study by Autti et al. (1997). Both soccer and American football players were given MRI scans and were compared to the scans of age-matched, non-athlete controls. High-signal foci were found in 11 soccer players, seven American football players, and in five of the controls. This indicates axonal rarefaction or non-ischaemic demyelination. The majority of

these high-signal foci were not found in both T2-weighted imaging and proton density-weighted imaging. High-signal foci were also seen on both the T2-

weighted imaging and the proton density-weighted imaging which indicates microinfarts or ischaemic tissue damage has occurred. Of these foci found on

15 both scans, the majority were in soccer players. Autti et al. (1997) suggests that due to the lack of helmet use in soccer, foci are being caused by slight brain injuries taking place during play (Autti, et al., 1997). One problem with all of the previous studies is that the biomechanics and the physiological effects of heading is not understood completely and, therefore, cannot be ruled out or assigned blame for injuries. As Kirkendall and Garrett (2001) state, it is difficult to blame purposeful heading for the reported cognitive deficits when actual heading exposure and details of the nature of head-ball impact are unknown (Kirkendall and Garrett, 2001). In order to determine

whether or not heading is causing cumulative damage, it is necessary to further understand what is taking place during actual heading events. The proposed study will focus on studying the frequency and severity of headers as well as a biomechanical evaluation of soccer heading in the youth soccer population. By evaluating youth soccer players, both in the lab and on the field, assessments can be made about differences between adult and youth heading biomechanics. These differences, or lack thereof, will provide insight as to whether the youth soccer population is at higher risk for injury due to soccer heading. Additionally, by recreating previously performed laboratory tests, it will be possible to compare lab and field data. 1.3 Specific Aims Although previous research has been conducted to determine the effects of repetitive heading in soccer, the results are very controversial. Conflicting results have been observed in studies throughout the history of soccer heading

16 research. Many of these previous studies have had significant challenges within the methodology, including the lack of controls or using improper control groups and many have not taken into account other outside factors that could be contributing to results. In order to determine the effects of the repetitive

subconcussive head impacts associated with heading, an in-depth analysis of the biomechanics of heading needs to be performed. project include: 1) To determine the incidence of head injury in youth soccer related only to head to ball impacts. This will be accomplished using the National Electronic Injury Surveillance System (NEISS) database which was created by the United States Consumer Product Safety Commission (CPSC). 2) To determine the frequency of heading in youth soccer based on age, gender, and skill level. 3) To validate a novel headband system to measure head impact frequency during soccer play. 4) To measure the biomechanical response of youth soccer players The specific aims of this

during heading events using the Functional Assessment of Biomechanics motion capture system and compare them to adults. 5) To measure head impact frequency and severity using the Head By using a

Impact Telemetry System (HITS) (Simbex, Lebanon, NH).

wireless acceleration measurement system, actual field data may be collected.

17 CHAPTER 2 NEISS DATABASE 2.1 Introduction The United States Consumer Product Safety Commission (CPSC) established a sample of hospitals which gather information on each emergency room patient who has an injury related to a consumer product. Using this sample data, estimations can be made for the entire population. The collective database is called the National Electronic Injury Surveillance System (NEISS). The NEISS database was designed in its original form in 1970 using a sample of 119 hospitals. Updates have taken place throughout the duration of its existence in order to maintain a statistically applicable hospital sample and estimation technique. The current database collects data from 100 hospitals nationwide using 5 strata, or divisions based on size. Hospital size is determined by the number of visits that the emergency department handles yearly. The current strata represent hospitals of four different sizes as well as childrens hospitals from across the United States (Figure 2.1).

18

Figure 2.1: NEISS database hospitals by strata (Consumer Product Safety Commission 2000) The database can be searched using different variables to eliminate unwanted cases. Variables which can be looked at include: date, product, sex, age, diagnosis, disposition, locale, and body part. Additionally, short notes are often available along with the case information providing a more detailed description of the injury and related circumstances. Product codes for each

consumer product are available and any injury that was related to the use of the specific product is reported and can be searched for based on that product code. Statistical weight is calculated for each hospital for each month and the estimates are calculated using these values. The calculation of the statistical weights takes into account any non-response of hospitals, merging hospitals, and any additional alterations made within the sampling frame (CPSC 2001). Statistical weights are calculated using the following equation (CPSC 2001):

19

Where: Nh = Number of hospitals in the 1995 sampling frame for sampling for stratum h nh = Number of hospitals selected for the NEISS sample for stratum h nh = Number of in-scope hospitals in the NEISS sample for stratum h rh = Number of NEISS hospitals participating in stratum h for the given month Rh = Ratio adjustment for combined stratum h Using the weights for each hospital, the estimates can then be calculated. The following equation is used to calculate the estimates for each hospital (2001):

Where: m = Number of strata in the NEISS sample during the given time period Nh = Number of hospitals in the NEISS sampling frame for sampling for stratum h nh = Number of hospitals selected for the NEISS sample for stratum h nh = Number of in-scope hospitals in the NEISS sample for stratum h rh = Number of NEISS hospitals participating in stratum h for the given month Rh* = Ratio adjustment for combined stratum h xhi = Number of cases for a specified product or type of injury reported by hospital i in stratum h for the given month

20 Since sporting equipment is considered a consumer product, injuries related to equipment are a part of the NEISS database. The NEISS database has been used in previous studies related to sports injury (Conn, et al., 2006, Hostetler, et al., 2005, Hostetler, et al., 2004, Sosin, et al., 1996, Xiang, et al., 2005, Yard and Comstock, 2006, 2006, Yard, et al., 2007), some of which are specific to soccer (Adams and Schiff, 2006, Delaney, 2004, Leininger, et al., 2007), to determine the injuries relating to the sport that have presented to the Emergency Departments over a specified time period. In addition to soccer, sports which have been researched using the NEISS database include martial arts, ice hockey, lacrosse, field hockey, water skiing, wakeboarding, snow skiing, snowboarding, cycling, skateboarding, and rugby (Adams and Schiff, 2006, Hostetler, et al., 2005, Hostetler, et al., 2004, Leininger, et al., 2007, Pickett, et al., 2005, Sosin, et al., 1996, Xiang, et al., 2005, Yard and Comstock, 2006, 2006, Yard, et al., 2007). The majority of these studies include all injuries

reported during the specified activity, but there are also those that focus on a specific variable such as the region of the body or level of injury. For example, one study focused specifically on head injuries which led to fatalities during bicycling (Sosin, et al., 1996). Previous studies using the NEISS database to research the frequency of soccer injuries in the pediatric population have been performed. These studies have looked at the overall injuries sustained (Adams and Schiff, 2006, Leininger, et al., 2007) and total head injuries in multiple sports (Delaney, 2004). Injuries were investigated by examining any factor taking place during a soccer match

21 and the details of those injuries. Although these studies discuss body region and injury cause, further investigating head injuries, specifically those caused by impact with the ball, can provide specific information related to the injuries associated with soccer heading. Although previous research has been conducted to determine whether soccer heading is injurious, the results are varied. Conflicting results have been observed in studies throughout the history of soccer heading research (Guskiewicz, 2002, Jordan, et al., 1996, Matser, et al., 1998, Putukian, 2004, Tysvaer and Storli, 1981, Tysvaer and Lochen, 1991, Tysvaer and Storli, 1989, Witol and Webbe, 2003). Therefore, it has yet to be determined if injury occurs strictly from head contact with the ball. The purpose of the current study is to gain insights into the occurrence of head injuries from contact with the ball only. By reviewing hospital emergency room data coded through the NEISS data it can be determined if ball only impacts can be a mechanism of injury in soccer. Gender differences have been hypothesized as being an issue in soccer heading related issues due to the ball to weight ratio differences (Barnes, et al., 1998, Covassin, et al., 2003). Previous studies of the NEISS database have found that the majority of players injured while playing soccer were boys (Adams and Schiff, 2006, Leininger, et al., 2007). Leinenger et al. (2007) found that 58.6 % of total injuries were to boys, and they were also more likely to have head and neck injuries. While the number of injuries was higher in boys than girls, the concussion rates remained similar (Leininger, et al., 2007). Similarly, Adams and Schiff (2007) found that boys had a higher number of total injuries (55.5 %).

22 While both of these studies found that boys have a higher incidence of injury, it is necessary to determine if girls have a higher incidence of ball to head related injuries. It has been hypothesized previously that girls have a higher rate of head injuries, specifically concussions, due to their smaller stature, greater ball to head ratio, and potentially weaker neck muscles (Covassin, et al., 2003). Player age is also considered a possible factor for increased risk of soccer head injuries specifically related to heading the ball. Previous studies have found conflicting results as to which age group has a higher likelihood of experiencing head injuries during soccer play (Adams and Schiff, 2006, Leininger, et al., 2007). Leinenger et al. (2007) found that younger players were more likely to have head/neck/face injuries, but Adams and Schiff (2006) found that head and face injuries occurred more frequently in the oldest age group (15-19 years old). This is most likely due to the fact that Leinenger et al. (2007) included 2-4 year old players in their study, and they were not included in the other previous studies. Although these studies looked at head injuries, the mechanism of injury was not determined. This is necessary to determine if younger children are more likely to suffer from ball to head injuries related to soccer heading. Delaney (2004) studied head injuries in ice hockey, soccer, and football. Using the NEISS database, head injuries to anyone participating in any of the three sports during a ten year span, 1990 1999, were calculated. Results were not limited by gender or age. The inclusion criteria were limited to sport being played and body region injured. Total head injuries for the ten year period were found to be the highest in football (204,802), followed by soccer (86,697) and ice

23 hockey (17,008). The total number of concussions during the ten year span also followed a similar pattern with football (68,860) being the highest, followed by soccer (21,714) and ice hockey (4,820) respectively. Although the total number of injuries was higher for football and soccer than hockey, the injury rate was found to be similar. Injury rate was determined by dividing the number of injured athletes by the total number of athletes. Although this study investigates head injuries during soccer play, injury mechanism, gender, and age were all neglected as pure between sport comparisons were made (Delaney, 2004). The previous studies performed a broad soccer injury analysis using the NEISS database. In-depth analyses have not been completed on the types of head injuries or the cause of these injuries. The current study will focus on head injuries caused by intentional or unintentional head contact with the ball and their diagnoses. This will represent the occurrence of injuries caused purely by ball contact. 2.2 Methodology Data were collected using the United States Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS). The database was queried using for soccer injuries that occurred to the head using product code 1267. Injuries considered were limited based on age, body region injured, and year taking place. The injuries that were included were head injuries in children ranging in age from 5 18 years that occurred from 2002 2007. Using statistical weights collected as part of the data set for each case, national estimates were made.

24 Included cases are both game and practice injuries. In order to focus on ball-to-head injury, the injury mechanism for each case was investigated. Using the narrative description provided with each case, the estimated number of head injuries resulting from impact with the ball only, the ground, collision with another player, the goal post, and unknown mechanism were calculated. Additionally, age, gender, and diagnosis were assessed for injuries that occurred from impact with the ball only. Age groups were broken down into 5-9 years old, 10-14 years old, and 15-18 years old. Diagnoses included all of those that were seen after limited other variables and include: concussion, contusion, laceration, internal organ injury, and other. Internal organ injuries included such things as closed head injuries. Statistical analysis was performed using the Kruskal-Wallis test for testing more than 2 groups in a hypothesis. Whenever this was significant, Mann-

Whitney tests were performed. It was determined by the Institutional Review Board that this study did not require approval for the study of human subjects. 2.3 Results A total of 62,022 soccer head injuries were estimated to take place from 2002 to 2007 in the United States. Following 2003, a significant increase in the number of head injuries was seen in 2004. This increased from 9022 head

injuries in 2003 to 11,762 head injuries in 2004 (Figure 2.2). The increase held relatively steady through 2007 which had a total of 10,122 head injuries. Throughout the six years included in the study, ball to head injuries remained

25 consistent. The year 2004 was statistically higher than all other years, except 2005, which it was statistically lower than.

Figure 2.2: Soccer head injuries including both males and females The majority of soccer head injuries from 2002 to 2007 were caused by a collision with another player (38 %). Injuries caused by impact with the ball only represent 16 % of soccer head injuries (Table 2.1). Additional injuries with an unknown mechanism could cause an under prediction of the four main mechanisms investigated, but was required due to a lack of description for these injuries. Also, goalpost injuries comprised 5.75 % of total injuries and included impact with the wall in indoor soccer.

26 Table 2.1: Head injuries by mechanism Actual, n Selected Characteristics Weighted N Injury Mechanism Ball Only Head Injuries Unknown Ground Goalpost Collision with Player n = 2081 309 471 424 117 760 N = 62024 9861 12720 12471 3569 23404 % 100.00 15.90 20.51 20.11 5.75 37.73

Although males made up the majority of soccer head injuries (53.99%), they did not have the highest percentage of ball only head injuries. Females had 59.64% of those injuries caused by impact with the ball only (Table 2.2). The only age group in which males had a higher percentage of ball only injuries was the 5-9 year olds where females only consisted of 19.68% of the injuries. The gender difference had the largest increase of females in comparison to males in the 15-18 year old age group where males only made up 29.87% of the ball to head injuries. Total head injuries were significantly different between genders (p=.015), but ball to head injuries were not. Hospitalization following ball to head injury was not common, with 99.67 % of players being treated and released.

27 Table 2.2: Ball to head only injuries Selected Characteristics Actual, n Weighted N Gender Male Female Age 5-9 10-14 15-18 Diagnosis Concussion Contusion Laceration Internal Organ Other n = 309 134 175 n = 309 46 130 133 n = 309 100 36 3 163 7 N = 9861 3980 5881 N = 9861 1232 3789 4840 N = 9861 3526 1793 99 4317 126 % 100.00 40.36 59.64 100.00 12.49 38.42 49.08 100.00 35.76 18.18 1.00 43.78 1.28

The lowest number of injuries took place in the 5-9 year old age group (1231.66) and the highest was in the 15-18 year old age group (4840.38). The

15-18 year old age group had significantly higher ball to head injuries than both other age groups (Figure 2.3). There was no statistical difference between the two younger age groups. Although the females had an increase in injuries from the younger age group to the older, the males did not. Males had an increase in injury from the 5-9 year olds to the 10-14 year olds.

28

Figure 2.3: Male and female ball only head injuries by age. *p < 0.05 Both male and female soccer players had similar patterns of injury diagnosis (Figure 2.4). Internal organ injuries represent the highest percentage of injuries with 44 % for each gender. These injuries occurred significantly more frequently than both concussions and contusions. The second most frequent diagnosis for males and females was concussion with 38.27% and 34.06% respectively. Additionally, concussions occurred significantly more than

contusions which accounted for only 18% of ball to head injuries. Lacerations were not frequent injuries, but were seen more frequently in males versus females, 2.18% and 0.21% respectively.

29

Figure 2.4: Ball only head injuries by diagnosis 2.4 Discussion Although many studies have used the NEISS database to study the incidence of soccer injuries (Adams and Schiff, 2006, Delaney, 2004, Leininger, et al., 2007), this is the first to focus specifically on youth head injuries. Previous studies have looked at the total incidence of soccer injury presenting to the emergency departments, specific body areas injured, and the adult population, but studying the incidence of head injury in the youth population is novel along with investigating mechanism of injury specific to ball to head only head impacts. This makes direct comparisons with previous studies challenging due to different inclusion criteria. During the study period, high school soccer participation steadily increased from 339,101 boys participants and 295,265 girls participants in the 2001-2002 school year to 377,999 boys participants and 337,632 girls participants in the 2006-2007 school year. Due to this increase in player

participation it was expected that an increase in ball to head injuries would occur

30 steadily as well. This steady increase did not occur demonstrating a non-linear relationship between the number of participants and the number of head injuries. It is, however, challenging to determine a total number of participants due to the inclusion of organized and non-organized soccer injuries. Additionally, the

previous comparison was made for high school age players and did not include of the entire study age population. Ball only injuries comprised 15.9% of total head injuries. These injuries were not necessarily caused by heading the soccer ball, as some of the impacts were due to unintentional ball to head impact, but many of the cases were described as heading related. It was challenging to delineate the mechanisms further due to the limited case descriptions. However, these data indicate that heading alone can result in injuries severe enough to require medical attention. Injury severity for these types of injuries is also cause for concern. While contusions are limited to skin bruising, lacerations and concussions are more serious. Lacerations are skin tears that are generally caused by blunt trauma, i.e. impact, and can require suturing. The most serious diagnosis, internal organ injuries, was also found to be the most frequent diagnosis in the ball only head injuries for both males and females, followed by concussion. There are a limited number of possible diagnoses that can be input into the NEISS database, which is why many of the injuries listed are internal organ injuries. This is an unspecific diagnosis that includes closed head injuries, cerebral bleeding, and brain contusion (Delaney, 2004). This is relevant in that it shows that impact with the

31 ball only can cause significant injury level. This diagnosis was given to 43.84% of female injuries, and 43.68% of male injuries. Concussions are serious injuries, also representing injuries to the brain, as opposed to contusions and lacerations which are skin injuries. They were the second most frequent diagnosis for both males and females. A total of 100 concussions were reported at the participating hospitals during the study period. This correlates to almost 36% of the ball only impacts being treated. There is no way to determine the severity of these concussions; therefore, they can range from mild to a more severe injury. However, several narratives describe

scenarios where the child would complain of a headache after heading the ball during a practice or game without any other etiology. There are limitations when examining these severe injuries in terms of percentage of total injuries. The more serious injuries most likely are over

represented when using the NEISS data alone due to the fact that the injuries included in this study are only those which have reported to the emergency department. Therefore, it is less likely that less severe injuries are taken to the emergency department. Players could be experiencing symptoms related to ball to head impacts, but if they did not go to the emergency department, these injuries were not included. The current study most likely underestimates both total injuries and ball to head injuries because many less severe injuries would not be included. This is an inherent problem with using the NEISS database to estimate injuries. Therefore, the current study represents the more severe

cases, and is potentially an underestimate of the total injury occurrences.

32 More ball to head only injuries occurred in the older age groups, which contradicts Leininger et al. (2007) who found that the majority of head injuries occurred to the youngest players. Leininger et al. (2007) included all head

injuries, not just those specific to ball impacts, and included a younger set of players. This could be due to the introduction of heading in those two age

groups. Additionally the majority of those two age groups use the adult ball size, a standard size 5 soccer ball weighing 450 g with a 22 cm diameter, as opposed to the smaller size 4 soccer ball which weighs approximately 390 g and has a diameter of 21 cm. Also, they would presumably have higher kick velocities. Therefore, it was expected that an increase in ball to head only injuries occurred. Although much research has been devoted to the adult population with respect to soccer heading, especially the elite players, the risks to the youth population have not been studied in great detail. The risks to children are

potentially greater due to their size versus the force being applied by the ball (Lees and Nolan, 1998). It has been reported that ball mass, impact velocity, and size of the individual all contribute to the potential for injury (Lees and Nolan, 1998). The importance of proper technique may be especially true in the youth population, since their skill level has not been well developed to control their head motion when heading the ball. The current study demonstrates that injuries can occur from ball to head impact only. It is recognized that all of these injuries may not be the result of purposeful heading, but it is challenging to differentiate them from the unintentional ball to head impacts. The data do establish the possibility of being injured based on an impact with the ball alone.

33 CHAPTER 3 HEADING FREQUENCY IN YOUTH SOCCER 3.1 Introduction Soccer, one of the most popular team sports worldwide, has recently shown considerable growth among the United States youth population. This is seen clearly in the American Youth Soccer Organization (AYSO) which today has 50,000 youth soccer teams and over 650,000 players registered after starting out in 1964 with only nine teams (2006). With this increase in the number of players, an increase in injuries has also occurred. Dvorak et al. (2000) determined that approximately 30 billion dollars are spent annually worldwide on the treatment of soccer injuries. It has been estimated that up to 22% of all injuries in soccer are to the head (Ruchinskas, et al., 1997). These injuries can occur from

unintentional or intentional impacts. Intentional impacts, or heading the soccer ball, are a standard practice within the game that is taught at the youth level. Heading is a technique where a player intentionally uses their head to redirect the soccer ball. Generally, players are instructed to start with their feet

approximately shoulder width apart and knees bent in a slightly staggered stance, body squared to the ball with their torso in an extended position. While keeping their eyes on the ball, players move their torso into a flexed position and impact the ball at the hairline on their forehead. Following impact, players are instructed continue through the ball with follow-through and to decelerate their motions following impact (Shewchenko, et al., 2005). There are still conflicting results as to whether repetitive sub-concussive forces associated with heading

34 are a cause of long term health problems (Tysvaer and Lochen, 1991). Several studies have been conducted to look at these effects, but one of the main limitations has been the estimation of exposure incident. One of the first steps in delineating the effects of repetitive heading should be to determine an accurate exposure incidence. In most studies, the incidence of heading

exposure is reported by the players themselves; often times as broad estimates. There are several limitations related to having players self report their exposure rate especially in a retrospective manner. In one of the first studies conducted (Tysvaer and Storli, 1989), EEG results of current Norwegian First Division League Clubs players were reviewed with results showing the highest abnormal results occurred in the youngest players. Another study conducted in 1991 by Tysvaer and Lchen (1991) of retired players showed neuropsychological deficits in 81% of the 37 participants. In the two Tysvaer et al. (1989, 1991) studies, players were also asked if they were typical headers however a definition was not provided as to the criteria for being a typical header. 14% of the 69 active players interviewed and 27% of the 37 retired players interviewed reported that they were typical headers, however a quantitative value was not reported (Tysvaer and Lochen, 1991, Tysvaer and Storli, 1989). Matser et al. (1998) estimated the number of headers that each of the 53 active professional soccer team members from The Netherlands who participated based on their position and number of games (Matser, et al., 1998). A

classification system was used and categorized midfielders and goalkeepers as

35 non-headers with forwards and defensive players as headers. Matser et al. (1998) also reported the number of headers per match and in a season. The number of headers per match and the number of matches were obtained through player interviews. Players reported a range of 1 to 42 headers during games with 16 being the median number of headers in a single game. These numbers along with the total number of games were then used to calculate headers per season. A range of 50 to 2100 headers in a season were calculated which resulted in a median of 800 headers in a season. The number of average headers/per game by an individual player was then stratified into three groups: 0-10 (47%), 11-20 (36%), or >21 (17%) (Matser, et al., 1998). In a recent study, Witol and Webbe (2003) studied 60 male players at varying levels of skill. The number of headers each player experienced was determined based on player reporting in an interview. Players were asked if they considered themselves a header and how many headers they experience in a typical game. Players were then placed in one of four categories: control (no heading), low (0-4 headers/game), moderate (5-8 headers/game), or high (>9 headers/game). The results showed that 12 players were in the control group, 19 players were in the low group, 20 players were in the moderate group, and 21 players were in the high headers/game group (Witol and Webbe, 2003). These studies demonstrate a reliance on estimations and player memory with a lack of data on the actual exposure rate. As reported in Chapter 1, soccer players may have deficits in the area of memory (Matser, et al., 1998) which could provide for inaccurate recollections. Very few studies actually observe

36 players to determine their frequency of heading. Two studies have reported

results based on this type of observation. The first by Tysvaer et al. (1981) reported results after following 20 games. These games broke down as follows: 10 First Division games, 6 English games, and 4 International games. Tysvaer et al. (1981) reported average headers per game which were 117, 124, and 94 respectively, but the number of headers per specific player was not reported (Tysvaer and Storli, 1981). The second study which observed headers is also one of the few studies conducted in the youth population (Janda, et al., 2002). A total of 57 players participated with an average age of 11.5 years. All players were followed for at least three seasons, with 18 players followed for two years. The number of headers per player was monitored by the individual coaches. Over the period of one year, players heading the ball an average of 185.9 times with the maximum number for one player being 450 times/year one. For the second year, the 18 players monitored had an average of 129.6 headers with a maximum of 344 for all three seasons (Janda, et al., 2002). Although these studies provide some information regarding the number of headers sustained during the play of soccer, they are focused on the specific age and skill level studied, with only one study focusing on the youth population (Janda, et al., 2002). The frequent use of athlete reporting in studies relating heading frequency to findings is unreliable and a better method of estimation is required. Therefore, the purpose of this study is to explore the frequency of soccer heading in the youth population across age groups, skill levels and

37 gender. These data are essential to conduct the controlled laboratory

experiments needed to ultimately determine the effects of repetitive heading. Given the increase in youth soccer participation over the past decade and the continued expected growth, the current research focused on the youth population. 3.2 Methodology Males and females teams ranging in ages from U12 (under 12 years old) to U18 (under 18 years old) were observed during the 2006 Canton Cup Soccer Tournament, a weekend long tournament in Canton, MI. The tournament

director, along with the Wayne State University Human Investigations Committee, granted approval prior to the event. Only teams participating in the top two divisions of their age bracket were included in the study. The highest division was given the designation by the tournament of blue and the next highest level was red. These designations were maintained throughout the

study. A total of 158 games were observed throughout the tournament. Table 3.1 outlines the breakdown in terms of number of teams and number of games monitored at each division, age and gender group. It should be noted that due to the fact that soccer is a spring sport for high school aged females in Michigan, the highest age division for the tournament was U14.

38 Table 3.1: Number of games monitored outlined by age, gender and division of play Female Male Age/Gender U12 U13 U14 U12 U13 U14 U15 U16 U17 U18 Number of Teams Number of Games Blue Red Blue Red 6 6 8 8 8 8 11 10 6 7 8 12 5 8 6 9 8 6 11 8 8 8 10 10 8 8 7 11 8 N/A 10 N/A 8 N/A 9 N/A 8 N/A 10 N/A

Games were monitored by 22 individuals with a minimum of five years of experience as a soccer player. At each game, a stopwatch was started at the kick-off. This was then allowed to run throughout the entire game, including halftime. Each header that took place during the game was recorded on a data sheet that contained a grid outline of the soccer field (Figure 3.1). Both the player number and time of occurrence were noted within the specific area of the grid where the header took place. Player position was not noted, but defensive and offensive position was defined by which half of the field the header took place on. No personal identifiers were recorded. Different colors were used to denote different teams to allow for a better representation of defensive versus offensive position on the field.

39

Figure 3.1: Soccer Field Diagram Data were normalized using time due to the differences in game length for varying age divisions. This was done by dividing the total number of headers per team by the total number of minutes that each team was monitored throughout the tournament. This resulted in a value of headers/minute for each team for the tournament. The data were then analyzed using a repeated measures ANOVA using gender, age group, division, game day, game number within the day, and game number within the tournament as the independent variables and headers/minute as the independent variable. All analyses were stratified by

gender in order to account for different age groups within gender. Total headers were also determined for each game by team, half, and field area (12 total areas). The total number of headers was analyzed using the generalized estimating equation (GEE). Poisson regression analysis was then

40 used to determine if there was a significant association between the number of headers and age, division, offensive field placement, defensive field placement, game day, game number within the day, game number within the tournament, and position on the field. 3.3 Results Maximum headers Maximum headers in one game by a single player were monitored to determine the highest exposure incidence. The maximum number of headers in a single game by a player was 13 headers. This was observed in a U14 male blue division game. The range of maximum headers in one game by one player was from 4 to 13 headers (Table 3.2). Table 3.2: Maximum headers by any one player for a single game. Female Male Age/Gender U12 U13 U14 U12 U13 U14 U15 U16 U17 U18 Maximum Headers Blue Red 7 4 5 4 7 4 11 5 8 5 13 7 9 7 7 N/A 7 N/A 9 N/A

Gender effects Significant differences were reported between the male and female populations following adjustment for age and division (p<0.0001). The male

populations were observed to have a higher header/minute ratio than their female counterparts with a mean of 0.135 0.079 headers/minute for females and 0.283 0.122 for males (Figure 3.2). The total number of headers was also significantly different between males and females. Therefore, all further analyses

41 were stratified by gender.

Figure 3.2: Comparison of number of headers/minute, male versus female across age groups. Males Age (p<.0001), division (p<.0001), and game number (p=.015) all demonstrated significant findings with regard to headers/minute within the male population. Age groups U14 and higher were found to have significantly more headers/minute than the U12 and U13 age groups. Also, a consistent positive increase regression was noted in the male blue division from U12 to U15, however from U15 to U18 there was no significant increase with age (Figure 3.3). The number of headers/minute was also significantly higher in the blue division when compared with the red and white divisions. Also of interest,

headers/minute was significantly higher for game 1 of the tournament when compared to both games 2 and 3.

42

Figure 3.3: Number of headers/minute for the male population. The total number of headers (Table 3.3) was significantly lower for both the red and white division when compared to the blue division (p<.0001), but there was no difference between the red and white divisions. The number of headers increased with increasing age group, with the exception of U17/18 which was slightly lower than U15/16. All age groups 13 or higher had significantly higher number of headers compared to U12 (p<.0001). U13 players had lower adjusted mean number of headers compared to all older age groups (p<.01), and U14 players were lower than U15/16 and U17/18 (p<.001). No significant

difference was observed between U15/16 and U17/18 (p=0.307). Players on defense had a higher adjusted mean number of headers (0.62 0.02) compared to players on offense (0.47 0.02) (p<.0001). The adjusted mean number of headers was lower on Saturday and Sunday compared to Friday (p<.01) with no difference between Saturday and Sunday (p=0.056).

43 Table 3.3: Average total headers/game/team for male population Age Division Average Headers/Game/Team 12 R B R B R B R B W B B R B 9.8 11.8 9.9 15.6 16.3 16.8 19.7 23.3 17.0 23.7 23.8 17.1 23.4

13

14

15 15/16 16 17 17/18 18 Females

The average value of headers/minute was highest in the U14 girls (0.153 headers/minute). Headers/minute showed no significant associations between headers/minute and any of the dependent variables. However, the total number of headers (Table 3.4) had several parameters which were significant predictors. Within the female population, division (p=.0009), length field position (p<.0001), width field position (p=.0002), and age group (p=.036) were found to be predictors of the number of headers.

44 It was determined that the blue division players had more headers than those in the red division. Differences were also seen within age groups.

Significantly more headers took place in the U14 age group when compared with both U12 and U13, but no differences were found between U12 and U13. Table 3.4: Average total headers/game/team for female population Average Age U 12 Division R B R B R U 14 B 10.8 Headers/Game/Team 5.9 6.5 5.5 8.7 7.0

U 13

A positive increase in headers/minute with age trend similar to that observed in the male population was also noted in the blue division of the female population. Due to the lack of data in the older age groups, the stabilization effect with age was unable to be assessed (Figure 3.4).

45

Figure 3.4: Number of headers/minute for the female population. Field Position Table 3.5: Total headers in each field position for females Field Position Age U12 U13 U14 Totals 1A 2A 3A 4A 1B 2B 3B 4B 1C 2C 3C 4C Totals 1 2 5 8 7 11 15 33 2 16 16 34 5 1 6 12 5 9 13 27 11 18 22 51 12 19 22 53 6 9 4 19 11 4 8 23 9 9 15 33 14 13 13 40 2 4 6 12 85 115 145 345

The total number of headers in each portion of the field is shown in Figure 3.5. The majority of the headers, for both male and female, took place in the middle of the field. The occurrence of headers in the four corner regions was significantly less than all other regions on the field. Females had fewer total headers in each field position when compared with males of the same age group (Table 3.5, 3.6).

46 Table 3.6: Total headers in each field position for males Field Position Age U12 U13 U14 U15 U15/16 U16 U17 U17/18 U18 Totals 1A 6 6 14 6 3 5 3 0 7 50 2A 15 19 23 31 7 16 22 17 11 161 3A 21 15 18 32 10 18 18 11 13 156 4A 2 2 9 10 4 4 2 5 2 1B 9 12 30 52 12 28 23 9 27 2B 18 37 50 77 20 33 37 13 45 3B 18 24 39 57 24 33 36 17 42 4B 9 19 28 36 8 21 24 11 29 1C 3 10 6 15 5 3 3 4 7 2C 14 23 22 45 5 14 14 12 16 3C 13 25 24 33 8 18 13 15 20 4C Totals 5 6 7 13 2 6 2 2 10 53 133 198 270 407 108 199 197 116 229 1857

40 202 330 290 185

56 165 169

47

Figure 3.5: Total number of headers in each field position 3.4 Discussion Putukian et al. (2004) followed college soccer players for a season to perform neuropsychological testing (Putukian, 2004). Heading contacts and

minutes played were also counted for all home games by team trainers and physicians, and it was found that male college age players had an average of 0.783 headers/minute during a single season and females had an average of 0.753 headers/minute. Both of these values are much higher than those found in the current study. This is most likely due to the fact that actual minutes played by the player were used as opposed to game length. The average headers/minute of for U15/16 males was the highest at 0.303 headers/minute, and for the females 0.153 headers/minute for the U14 age group. It is expected that players

48 at the college level would have more headers/minute than those playing at the lower skill and age level observed in the current study. Also, following teams within the younger age group for an entire season could provide a more detailed look at the differences noted between these two skill levels. Matser et al. (1998) found that 47% of the players that were studied headed the ball between 0 and 10 times per game. Looking at the maximum number of headers by a single player in a game, only two players fell outside of that range throughout the tournament. The first, a male, blue division player in the U12 age bracket had 11 headers in a single game, and the second, also a male, blue division player in the U14 age group had 13 headers in a single game. These findings are similar to Matser et al. (1998) because the majority of players were found to remain in the lower header per game category. The current study is limited by the fact that data was collected over a weekend long tournament and that a maximum of three games were observed for each team as opposed to following teams for an entire season. Additionally, it would have been an improvement if more female age groups had been available for analysis, but due to high school scheduling that was not possible. Even with these limitations, important trends were evident. One of these trends was noted in the positive correlation between age and headers/minute within the higher division in both the males and females. This occurs up until the age division of U15 in the male population at which point a plateau occurs. Although there is currently no data available for the higher age groups within the female population, it is expected that there would be a similar

49 trend based on the data available for the U12-U14 age groups. This indicates that there is an increase in the amount of headers players experience during the years in which they are learning the skill, but that in the upper skill levels they experience essentially the same amount throughout. It was also noted that the vast majority of heading occurred in the middle of the field. This is most likely related to this being the area where long kicks, from both the goalie and players trying to cross the field, are targeted allowing for players to align themselves for headers. The regions directly in front of the goal (1B and 4B in Figure 3.5) lend themselves to areas of heading due to corner kicks being directed to those regions and the desire to redirect the ball into the goal. However, this can also be the most dangerous position due to the number of players near the goal during a corner kick and proximity of the goal posts. Game number within the tournament was also determined to be a factor in the number of headers/minute in the male population. This is of interest

because the number of headers/minute seems to decrease after the first game. This could be due to symptoms felt following the initial game. Further research needs to be conducted to understand the cause of this reduction following the initial game in the tournament.

50 CHAPTER 4 HEADING BIOMECHANICS IN YOUTH SOCCER 4.1 Introduction The overall goal of heading is redirection of the ball. Depending on the approach of the player and the intent of the redirection, the player may move his/her head in particular manner. Alignment of the head, neck and torso can vary and are often dependent on the intent of the redirection i.e. clearing, passing, or controlling (Shewchenko, et al., 2005, 2005). All of these scenarios require a specific skill level to accomplish the intent of the redirection through the use of correct techniques. Proper techniques and skill level often come with age. Younger players who are learning good techniques may not always perform the skill as taught. This may be to a variety of reasons including improper ball size for child size, not eliciting neck muscles, and using top of head instead of forehead. All of these factors change the biomechanics of heading the ball. Size differences between the player and the ball have been a recognized concern not just for heading but for the development of foot skills as well, therefore age recommended sizes have been developed (Lees and Nolan, 1998). The recruitment of neck muscles plays a big part in proper heading techniques. Incorporation of entire body mass

allows for the mass of the ball to be negligible in comparison. And, finally, ball placement affects the impact vector through the head itself. One of the first studies to look at the biomechanics of soccer heading, specifically head and neck motion, was performed by Ludwig (1999). Twenty-

51 four college age female soccer players performed 10 standard headers served to them at 8 m/s. Standard camcorders were used at 120 frames per second to capture trunk motion and various acceleration measurements during each header. It was determined that frequent headers and non-frequent headers, as self-described by the players, used different technique when heading the ball and that trunk range of motion and neck motion played a part in this difference. This indicates that players with less heading experience, i.e. non-frequent headers, use a different technique which could be similar to the less practiced youth population. The study did not investigate differences specific to soccer

experience level or gender. Neck muscle activation was also not investigated as a possible contributing factor to changes between the groups. EMG has also been studied previously during soccer heading (Bauer, et al., 2001). Again, this study focused solely on female college soccer players. Players were asked to perform a series of soccer headers, all at the same ball speed, 6.8 m/s, while instrumented with EMG sensors on both their left and right sternocleidomastoid and trapezius muscles. Three types of headers were

performed by each participant in an effort to represent the various headers seen in the field, clearing, passing, and shooting. Each of these three types of

headers were performed while standing and also while jumping to get a more diverse representation. It was determined that muscle activation was not

significantly different for the various header scenarios studied. One of the more comprehensive analyses of common scenarios was recently conducted using both head and neck motion analysis techniques and

52 EMG (Shewchenko, et al., 2005). Seven adult soccer players ranging in age from 20 to 23 years old were asked to perform various soccer headers. Subjects were attempting to head the ball to a target with a pre-determined level of neck muscle activation in the sternocleidomastoid and trapezius: normal, pre-tensed, or relaxed. Soccer balls were presented to players at two different speeds in order to elicit a wider range of response. The authors also reported a wide variability between subjects when looking at head angle, back angle, relative head to back angle, and neck muscle activity. In addition, it was suggested that additional scenarios would produce additional results (Shewchenko, et al., 2005). This variation of biomechanical scenarios of soccer heading will only be increased in the youth population due to the varying skill levels. The current study aims to determine if there is a difference between adult soccer players and youth soccer players with respect to soccer heading technique. In order to accomplish this aim, heading scenarios that have been previously used (Shewchenko, et al., 2005) in adults were recreated in the youth population. Using the Functional Assessment of Biomechanics (FAB) system, a novel motion analysis system, various head and torso body angles were measured to provide comparisons to previous studies and to participants within the current study. The FAB system (Figure 4.1) uses a combination of accelerometers, gyroscopes, and magnetometers to provide real-time kinematic and kinetic data. Angle, force, torque, velocity, acceleration, power, and foot sole weight and pressure are all calculated for each body segment (Biosyn Systems). The

53 system has a maximum data collection of 100 Hz and a battery life up to 12 hours. The current study will use the system for measuring head a and torso angles with an accuracy of 2 degrees. The system allows for motion analysis without the limitations of using a traditional camera system For example, space system. or limitations and marker occlusion, which are common issues with using a occlusion, traditional motion analysis system, are both eliminated.

Figure 4.1 FAB System with size scale 4.1: In addition to comparing head and torso angles between youth players and adult players, the current study will investigate differences soccer heading technique between genders in the youth population. Neck muscle activity levels . will also be examined to establish their level of involvement during various

54 heading scenarios in the youth population. This will be done using traditional EMG techniques and measuring the neck muscle activity of the

sternocleidomastoid and the trapezius muscles during heading events. These muscles are both superficial and have been used previously to determine neck muscle activation during soccer heading (Bauer, et al., 2001, Shewchenko, et al., 2005). 4.2 Methodology Fifteen youth soccer players, 9 females and 6 males, participated in the current study to investigate the biomechanics of soccer heading. Players ranged in age from 14 to 16 years old, with an average age of 15 for the females and 16 for the males. Players performed a sequence of headers while wearing

instrumentation to assess muscle activation and body position during heading events. Prior to any instrumentation, anthropometric measurements were taken to provide an accurate representation in the FAB measurements. Height, weight, trunk length, upper arm length, forearm length, thigh length, and calf length were measured and recorded for each participant. Additionally, player age, gender, and skill level were recorded. Following initial measurements, players were instrumented for data collection. Players were fitted with the FAB (Biosyn Systems, Surrey BC,

Canada). The system uses 13 wireless sensors each of which is approximately 4 cm x 7 cm x 2 cm and is attached to the subject using an elastric strap with velcro attachment. One sensor was placed on the head, one on the chest, one

55 around the waist, one on each upper arm, one on each wrist, one on each thigh, one below each knee, and one at each ankle (Figure 4.2).

Figure 4.2: Example of player wearing FAB sensors Data were sampled at 100 Hz and recorded for post-processing. Head and trunk body angles will be collected including: cervical flexion and extension, cervical lateral flexion, trunk flexion and extension, and trunk lateral flexion (Figures 4.3, 4.4). Prior to data collection using the FAB, a player calibration was performed. The player was instructed to stand facing forward with arms to the side and feet shoulder width apart while the system performed calibration procedures. Zero degree measurements are taken from the initial calibration position, and the trunk and head angles measured represent a change from that initial position.

56 0 Head Sensor Upper Back Sensor Low Back Sensor 0

Head Sensor Upper Back Sensor

a)

b)

Figure 4.3: Side view of head and trunk body angles a) torso flexion (+ ) and extension (- ); b) head flexion (+ ) and extension (- ) 0

Head Sensor Figure 4.4: Top view of head rotation left (+ ) and right (- )

57 Players were also be instrumented with electromyography (EMG) sensors. Surface EMG data was collected at 256 samples/second using the BioCapture physiological monitoring system (Cleveland Medical Devices Inc., Cleveland, OH). Sensors were placed bilaterally on the sternocleidomastoid and the

trapezius muscles (Figure 4.5) with a reference sensor behind the left elbow. After preparing the skin using an alcohol swab, Ag/AgCl electrodes were placed over the muscle belly approximately 2 cm apart. Tape was placed over each sensor to maintain solid contact during all movements. Data were collected

continuously for the duration of the tests for each participant. Impact times were marked for each heading scenario within the data collection files.

a)

b)

Figure 4.5: Neck musculature used for EMG testing a) sternocleidomastoid; b) trapezius (Gray, et al., 1995)

58 Following instrumentation, players performed 8 heading scenarios (Table 4.1). The headers were performed at two speeds, 6 m/s (low) and 8 m/s (high). Balls were launched at subjects from 6 m away, providing ample reaction time at both test speeds. Three types of headers were evaluated, passing, clearing, and controlling. A passing header is when the player attempts to redirect the ball to another player at a medium distance away, a clearing header is when the player attempts to redirect the ball as far downfield as possible, and a controlling header is when the player attempts to head the ball a very short distance down and in front of them self. Additionally, three neck muscle activity levels were explored. Prior to

heading the ball players were instructed to either pre-tense their neck muscles, to perform headers with their muscles activated as they would normally, or to have their neck muscles completely relaxed. Along with neck muscle activation levels, prior to impact, subjects were also instructed to try to head the ball at a certain target. This was done to try to represent the majority of heading scenarios that players would see in the field as well as to provide comparisons to previous adult data (Shewchenko, et al., 2005).

59 Table 4.1: Heading Scenarios (Shewchenko, et al., 2005) Heading Ball Speed Modification Ball Target Scenario 1 Controlling Low None Front, down, 2.5 m from player 2 Passing Low None Front, down, 5.5 m from player 3 Clearing Low None Up and away, as far as possible 4 Passing Low Neck tensing Front, down, 5.5 m from player 5 Passing Low Follow through Front, down, 5.5 m from player 6 Passing Low Torso alignment 7 Clearing High None Front, down, 5.5 m from player Up and away, as far as possible 8 Clearing High Neck tensing Up and away, as far as possible EMG data was processed using MyoResearch XP Master Edition 1.07 (Noroxan, Inc., Scottsdale, AZ). Data were filtered using a notch filter to remove the noise at 60 Hz prior to any additional processing. Following filtering, EMG data were full-wave rectified and then the RMS was calculated using a 50 ms

Task

60 moving average. descriptions. The point of impact is designated as time 0 s for all

Generally, all header related motion took place during the 50 ms

pre and post impact. Torso angle, head angle, and relative head to torso angle were recorded for each impact. Each angle was measured using the FAB from the original neutral position that the player stood in during calibration. Therefore, the 0 Additionally,

degree position is the original calibration stance (Figure 4.2).

positive designation was given to flexion and a negative designation was assigned to extension for both head and torso motion. For the twist motions, positive was assigned to left twist and negative to right twist. Motion data were analyzed to determine the differences between the various heading scenarios within each subject. Additionally, each heading scenario was analyzed

individually to determine subject variability. Head acceleration was also recorded for each impact using the FAB. These data were not taken at the center of gravity of the head will not be used to determine injury risk. The data will be used strictly as a comparative between tasks. 4.3 Results Torso flexion, head flexion, and head rotation were measured for each task. Focus was placed on the tasks that required no modification, tasks 1, 2, 3, and 7. Task 2 was used for the standard heading case. Extensive subject variability occurred for all tasks. Head rotation was the most consistent between

61 subjects because it at seemed to have similar patterns although actual angles varied. In task 2, used as the typical header case, male torso flexion ranged from -14.81 to 27.13 degrees (41.94 degree span) at the point of impact (Figure 4.6) with an average of 14.90 15.49 degrees (Table 4.2). Peak torso flexion took place following impact in 83 % (5 subjects) of the male players. In the remaining 17 % (1 subject), the entire task was performed in negative flexion, or torso extension, with the minimum extension occurring just prior to impact. Peak torso flexion ranged from -10.13 to 30.52 degrees with an average of 21.96 17.06 for the males during task 2.

Male Torso Flexion

50 40 30
Angle (Degrees)

Player 1 Player 2 Player 3 50 100 Player 4 Player 5 Player 6

20 10 0 -100 -50 -10 0 -20 -30 -40 Time (ms)

Figure 4.6: Torso flexion for all male players during standard heading scenario (task 2) Subject variability was also seen in head flexion. Male head flexion for task 2 ranged from -22.54 to 34.61 degrees on impact (Figure 4.7). The average head flexion on impact was 0.91 19.56 degrees with an average peak head flexion of 8.44 21.94 degrees. Although all male participants started in head

62 extension for task 2, half of the participants had positive head flexion during task 2 and half did not. Therefore 3 of the participants peak head flexion, which ranged from -22.54 to 34.69 degrees, was their minimum head extension.

Male Head Flexion

50 40 30 20 10 0 -10 0 -20 -30 -40 -50 -60 Time (ms)

Player 1 Player 2 Player 3 50 100 Player 4 Player 5 Player 6

Angle (Degrees)

-100

-50

Figure 4.7: Head flexion for all male players standard heading scenario (task 2) Head rotation for the male population remained relatively consistent throughout task 2 (Figure 4.8). Each subject had a stable head rotation

throughout the task, but variability still existed between subjects. Head rotation ranged from -22.54 to 34.61 degrees on impact with an average of 9.81 25.90 degrees. The maximum values for head rotation ranged from -28.06 to 43.33 degrees with an average maximum of 19.27 25.91 degrees.

63

Male Head Rotation

60 40
Angle (Degrees)

20 0 -100 -50 -20 -40 -60 -80 Time (ms) 0 50 100

Player 1 Player 2 Player 3 Player 4 Player 5 Player 6

Figure 4.8: Head rotation for all males during standard heading scenario (task 2) Female torso flexion for task 2 was similar to the males with a lack of consistency between players (Figure 4.9). A large range occurred for the impact torso flexion of 0.10 to 35.03 degrees. All players impacted the ball with their torso in flexion with only 1 player starting with their torso extended. This pattern is quite similar to the males. The average torso flexion on impact was 15.96 10.77 degrees. The peak torso flexion ranged from 4.78 to 37.38 degrees with an average of 24.07 9.68. Although there is no clear pattern between subjects, 67 % of participants had a peak torso flexion in the between 24.40 and 29.51.

64

Female Torso Flexion

40 Player 7 30
Angle (Degrees)

Player 8 Player 9 Player 10

20 10 0 -100 -50 -10 -20 Time (ms) 0 50 100

Player 11 Player 12 Player 13 Player 14 Player 15

Figure 4.9: Torso flexion for all females during standard heading scenario (task 2) Female head flexion ranged from -26.91 to 10.31 degrees upon impact (Figure 4.10) with an average impact flexion of 1.09 12.99 degrees. Maximum head flexion ranged from -17.56 to 17.10 degrees averaging 4.58 12.29 degrees. The peak head flexion generally occurred just prior to impact.

Female Head Flexion

30.00 20.00 10.00
Angle (Degrees)

Player 7 Player 8 Player 9 50 100 Player 10 Player 11 Player 12 Player 13 Player 14 Player 15

0.00 -100 -50 -10.00 0 -20.00 -30.00 -40.00 -50.00 -60.00 Time (ms)

Figure 4.10: Head flexion for all females during standard heading scenario (task 2)

65 Female head rotation is similar to the males in that it stays relatively consistent for each participant across the entire task (Figure 4.11). Impact head rotation ranged from -20.84 to 44.69 degrees with an average of 2.81 20.57 degrees.

Female Head Rotation

60 50 40
Angle (Degrees)

Player 7 Player 8 Player 9 Player 10 Player 11 50 100 Player 12 Player 13 Player 14 Player 15

30 20 10 0 -100 -50 -10 0 -20 -30 -40 Time (ms)

Figure 4.11: Head rotation for all females during standard heading scenario (task 2) In general, the within subject header tasks seemed to develop a more consistent pattern. Although the subjects did not start or finish in the same

orientation for each task, the peaks and valleys of the torso and head flexion generally occurred at similar time points with relationship to the impact. When this varied, it generally did so during the high speed task (task 7). This pattern is evident in Figures 4.10 4.12. The example male participants torso flexion ranged from 11.96 to 18.14 degrees for the four different heading tasks investigated that did not require modification (Figure 4.12). This is a much smaller range than that seen when comparing between participants when they were performing the same task.

66

Male Torso Flexion

30 25 20
Angle (Degrees)

15 10 5 0 -100 -50 -5 0 -10 -15 Time (ms) 50 100

Task 1 Task 2 Task 3 Task 7

Figure 4.12: Example of single male participants torso flexion for all header tasks that lack modifications (1, 2, 3, and 7) The example male participants head flexion showed a very distinct pattern (Figure 4.13). Although the flexion ranged from -22.70 to 3.93 degrees, the maximum extension took place at the same time for all four tasks, -60 ms. The maximum flexion also took place at the same time, -10 ms, for all four tasks.

Male Head Flexion

20 10 0
Angle (Degrees)

-100

-50

-10 0 -20 -30 -40 -50 -60 -70 -80 Time (ms)

50

100 Task 1 Task 2 Task 3 Task 7

Figure 4.13: Example of single male participants head flexion for all header tasks that lack modifications (1, 2, 3, and 7)

67 The example male participants head rotation has similar angles for the first three tasks, but the high speed header (task 7) falls further out (Figure 4.14). The range of head rotation on impact for the first three tasks is -8.73 to 8.18 degrees while the head rotation angle for task 7 was -27.88 degrees. indicates a change in technique when the ball is moving at a higher speed. This

Male Head Rotation

60 40
Angle (Degrees)

20 0 -100 -50 -20 -40 -60 Time (ms) 0 50 100

Task 1 Task 2 Task 3 Task 7

Figure 4.14: Example of single male participants head rotation for all header tasks that lack modifications (1, 2, 3, and 7) The female example participants torso flexion, head flexion, and head rotation are very consistent for the first 3 tasks and then they do not follow similar patterns for task 7 (Figures 4.15 - 4.17). This shows that the female patterns are similar to the males. It is also further evidence of a technique change for higher speed impacts. Female torso flexion on impact ranges from 14.7 to 22.79

degrees for tasks 1 3, but has a torso flexion of 70.48 degrees on impact for task 7 (Figure 4.15). Similar patterns were found in head flexion with an impact angle range of -15.5 12.91 degrees for the first three tasks and an impact angle of -59.13 degrees for task 7 (Figure 4.16). Differences between the first three

68 tasks and task 7 were very apparent in the head rotation during the pre-impact stage (Figure 4.17). The impact head rotation ranged from 1.25 7.21 degrees for the first three tasks with -9.84 degrees for task 7. Similar patterns were seen throughout the male and female participants.

Female Torso Flexion

80 70
Angle (Degrees)

60 50 40 30 20 10 0 -100 -50 0 Time (ms) 50 100 Task 1 Task 2 Task 3 Task 7

Figure 4.15: Example of single female participants torso flexion for all header tasks that lack modifications (1, 2, 3, and 7)

Female Head Flexion

40 20
Angle (Degrees)

0 -100 -50 -20 0 -40 -60 -80 -100 -120 Time (ms) 50 100 Task 1 Task 2 Task 3 Task 7

Figure 4.16: Example of single female participants head flexion for all header tasks that lack modifications (1, 2, 3, and 7)

69

Female Head Rotation

100 80 60
Angle (Degrees)

40 20 0 -100 -50 -20 0 -40 -60 -80 -100 Time (ms) 50 100 Task 1 Task 2 Task 3 Task 7

Figure 4.17: Example of single female participants head rotation for all header tasks that lack modifications (1, 2, 3, and 7) In addition to comparing all of the un-modified tasks, comparable tasks were also compared. The four passing tasks were compared (tasks 2, 4, 5, and 6) and the two clearing tasks were also compared (tasks 7 and 8). These tasks were compared for both males and females. All figures are representative of an example participant. The first tasks that were compared were the passing tasks. Male torso flexion upon impact for the passing was relatively consistent within participants. For the male example participant, torso flexion ranged from 16.5 to 22.55 degrees (Figure 4.18). This within subject consistency was expected, especially since all four tasks were at the low ball impact speed.

70

Male Torso Flexion

45 40 35 30 25 20 15 10 5 0 -100 -50 0 Time (ms) 50 100
Angle (Degrees)

Task 2 Task 4 Task 5 Task 6

Figure 4.18: Example of single male participants torso flexion for all passing header tasks (2, 4, 5, and 6) The male example participants head flexion for the passing tasks was not as consistent on impact, but did show a similar pattern of flexion over the duration of the task. The head flexion ranged from -22.54 to 5.53 degrees

(Figure 4.19). Two of the impacts, tasks 2 and 5, were performed with the head in extension, while tasks 4 and 6 were performed with the head in flexion. The maximum extension took place at very similar time points for the four tasks.

71

Male Head Flexion

20 10 0
Angle (Degrees)

-100

-50

-10 0 -20 -30 -40 -50 -60 -70 Time (ms)

50

100

Task 2 Task 4 Task 5 Task 6

Figure 4.19: Example of single male participants head flexion for all passing header tasks (2, 4, 5, and 6) During the passing tasks, similarly to the non modified tasks, the head rotated very little during the activity. For the male example participant, head rotation upon impact ranged from -4.18 to 7.78 degrees (Figure 4.20). This a very small range, indicating that head rotation was not altered between tasks.

Male Head Rotation

40 30
Angle (Degrees)

20 Task 2 10 Task 4 0 -100 -50 -10 -20 -30 Time (ms) 0 50 100 Task 5 Task 6

Figure 4.20: Example of single male participants head rotation for all passing header tasks (2, 4, 5, and 6)

72 The female example participant showed similar consistency between the four passing tasks. When inconsistencies arose, they were with task 5, which was modified to include extended follow through. Therefore, the high torso

flexion for task 5 can be attributed to the follow through. The female example participant had a torso flexion on impact that ranged from 14.24 to 15.99 degrees for task 2, 4, and 6. Task 5, however, had a torso flexion on impact of 47.23 degrees (Figure 4.21).

Female Torso Flexion

60 50
Angle (Degrees)

40 30 20 10 Task 6 0 -100 -50 0 Time (ms) 50 100 Task 2 Task 4 Task 5

Figure 4.21: Example of single female participants torso flexion for all passing header tasks (2, 4, 5, and 6) Female head flexion showed consistency with the pattern of flexion, the minimum flexion took place at approximately the same time point for each task, as did the maximum flexion (Figure 4.22). For the female example participant, head flexion ranged from -6.76 to 11.86 degrees with three of the four tasks taking place with the head in extension. Only task 4 took place with the head in the flexion position.

73

Female Head Flexion

30 20 10
Angle (Degrees)

0 -100 -50 -10 0 -20 -30 -40 -50 -60 Time (ms) 50 100

Task 2 Task 4 Task 5 Task 6

Figure 4.22: Example of single female participants head flexion for all passing header tasks (2, 4, 5, and 6) Female head rotation was similar for tasks 2, 4, and 6. Task 5, the task with the follow through modification, was performed with the head rotated right, but to a similar degree as the other three tasks (Figure 4.23). The three tasks with a leftward rotation ranged from 5.25 to 7.63 degrees while the task with rotation to the right was rotated -7.35 degrees on impact.

Female Head Rotation

20 15
Angle (Degrees)

10 5 0 -100 -50 -5 0 -10 -15 -20 Time (ms) 50 100 Task 2 Task 4 Task 5 Task 6

Figure 4.23: Example of single female participants head rotation for all passing header tasks (2, 4, 5, and 6)

74 Tasks 7 and 8 showed slightly more inconsistency within participants than the others previously discussed. This is mostly attributed to some abnormalities within task 7 for both male and female participants. The differences are noted in both the example male and female torso flexion and head rotation. The oddities were at similar time points for both participants and took place prior to impact. This is most likely due to task 7 being the first high speed task performed, and the participants had yet to get used to the new ball speed.

Male Torso Flexion

25 20
Angle (Degrees)

15 10 5 0 -100 -50 -5 0 -10 -15 Time (ms) 50 100 Task 7 Task 8

Figure 4.24: Example of single male participants torso flexion for all clearing header tasks (7 and 8) Male torso flexion upon impact was 15.9 degrees for task 8 and 19.36 for task 9. Although some differences did occur, they were at the very beginning of the task and flexion upon impact remained very similar (Figure 4.24). For head flexion, a very similar pattern occurred with minimum flexion and maximum flexion occurring at approximately the same time for tasks 7 and 8 (Figure 4.25). Head rotation for the males was -2.8 degrees for task 7 and -27.88 degrees for task 8 (Figure 4.26).

75

Male Head Flexion

20 10
Angle (Degrees)

0 -100 -50 -10 0 -20 -30 -40 -50 -60 Time (ms) 50 100 Task 7 Task 8

Figure 4.25: Example of single male participants head flexion for all clearing header tasks (7 and 8)

Male Head Rotation

60 40
Angle (Degrees)

20 0 -100 -50 -20 -40 -60 Time (ms) 0 50 100 Task 7 Task 8

Figure 4.26: Example of single male participants head rotation for all clearing header tasks (7 and 8) Females had similar patterns to the males for the clearing tasks. Torso flexion was 70.48 degrees for task 7 and 23.69 degrees for task 8 upon impact (Figure 4.27). Head flexion was also like the male head flexion in that the impact angles were not alike, but the pattern of flexion over the event remained similar (Figure 4.28). Head rotation was also much like the males for the clearing tasks

76 with differences between the tasks occurring in the early stages of the event. The impact head rotation for task 7 was -9.84 degrees and 21.83 degrees for task 8 (Figure 4.29).

Female Torso Flexion

80 70
Angle (Degrees)

60 50 40 30 20 10 0 -100 -50 0 Time (ms) 50 100 Task 7 Task 8

Figure 4.27: Example of single female participants torso flexion for all clearing header tasks (7 and 8)

Female Head Flexion

0 -100
Angle (Degrees)

-50 -20 -40 -60 -80 -100

50

100

Task 7 Task 8

-120 Time (ms)

Figure 4.28: Example of single female participants head flexion for all clearing header tasks (7 and 8)

77

Female Head Rotation

100 80 60
Angle (Degrees)

40 20 0 -100 -50 -20 0 -40 -60 -80 -100 Time (ms) 50 100 Task 7 Task 8

Figure 4.29: Example of single male participants head rotation for all clearing header tasks (7 and 8) Averages for each task for head flexion, head rotation, and torso flexion are presented in Table 4.2. The large standard deviations indicate the sizeable subject variability. Averages were not statistically compared between males and females because of the large subject variability within their own populations.

78 Table 4.2: Average angles at impact for each heading task

Head Flexion Heading Task (degrees) Male 4.99 1 14.29 0.91 2 19.56 -12.18 3 22.21 -0.09 4 15.92 7.99 5 20.90 12.78 6 20.40 -4.60 7 15.56 3.88 8 14.01 Female 12.99 13.74 1.09 12.99 -3.78 13.42 7.83 15.16 -5.94 21.56 9.58 16.33 -15.02 19.88 -6.05 11.81 Head Rotation (degrees) Male 14.94 24.23 9.81 25.90 17.91 29.34 3.44 27.01 10.54 25.16 0.95 13.77 11.28 34.74 7.51 35.76 Female 5.06 24.80 2.81 20.57 11.48 22.34 6.89 22.52 6.96 26.44 6.60 22.97 5.02 20.15 4.59 19.99 Torso Flexion (degrees) Male 18.55 11.88 14.90 15.49 8.53 6.67 14.10 14.35 17.50 12.21 11.21 16.59 9.12 8.02 8.99 10.02 Female 14.14 8.11 15.96 10.77 13.60 10.22 10.97 12.22 13.74 17.67 15.48 13.69 23.66 19.48 12.60 10.72

EMG values provided similarly variable results as the body position angles. For the males, this variability was more noticeable in the trapezius

muscles (Figure 4.30). The females had a more overall inconsistency as the variation was not limited to a specific muscle group (Figure 4.31). There was also considerable variation within the subjects when comparing tasks. However,

79 it was not limited to a specific task as it was in the body position data. The mean peak RMS EMG, used to provide a clearer view of muscle activation, values (Table 4.3) indicate a much more consistent appearance of the peaks when comparing players than the overall values provide (Figure 4.30, 4.31).

80

Figure 4.30: Peak EMG for all male players for each muscle a) left sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius

81

Figure 4.31: Peak EMG for all female players for each muscle a) left sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius

82 Table 4.3: Mean peak RMS EMG values for each muscle and each task
Task 1 Mean Peak Muscle Left Sternocleidomastoid Right Sternocleidomastoid Left Trapezius Gender M F M F M F Right Trapezius M F (mV) 1.17 0.46 1.26 1.17 1.68 1.02 1.07 0.71 1.86 2.18 1.15 1.35 2.01 1.43 1.23 1.07 Task 2 Mean Peak (mV) 1.63 0.77 1.18 0.77 1.15 0.31 1.32 1.25 1.46 1.28 0.97 0.56 2.40 2.18 1.29 1.02 Task 3 Mean Peak (mV) 1.89 0.53 1.45 1.25 1.36 0.91 1.68 1.75 1.95 1.51 1.68 1.32 2.23 1.61 1.08 0.71 Task 7 Mean Peak (mV) 2.29 1.38 1.33 0.85 1.48 0.70 1.06 0.52 1.45 0.34 1.39 1.51 2.60 1.66 1.13 0.57

The majority of the muscle activation takes place prior to the impact event. This is true for both the male and female participants (Figure 4.32, 4.33). Muscle activation prior to and at impact being higher than that post-impact was seen throughout the participants. Subjects varied as to how even their contractions were. As seen in Figure 4.32, the male example participant had relatively

consistent contraction on both the left and right sides. In contrast, the female example participant had much less contraction in the right trapezius versus the left (Figure 4.33). These data also indicate subject variability.

83

Figure 4.32: Sample RMS EMG for one male player for each muscle a) left sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius

84

Figure 4.33: Sample RMS EMG for one female player for each muscle a) left sternocleidomastoid, b) right sternocleidomastoid, c) left trapezius, d) right trapezius

85 Head acceleration was evaluated for each task for both males and females. When looking at average head acceleration for each task, the head acceleration appears much less variable than the biomechanics and the EMG between tasks. There is still a wide range between players in each task which is evident by the standard deviations (Table 4.4). Tasks 7 and 8 do not have higher head acceleration than the low speed header tasks. Also the modifications do not appear to have caused a change in head acceleration. however, have higher head acceleration for each task. The males do, When evaluating

individual players for each task, there was a consistency in the head acceleration between tasks for each player, generally with one to two tasks being lower than the rest. These tasks did not show a pattern between subjects. Table 4.4 : Average angular head acceleration on impact for each heading task Head Acceleration (radians/s2) Heading Task 1 2 3 4 5 6 7 8 Male 89.47 33.20 100.33 18.47 97.92 39.07 95.47 18.25 95.61 48.61 75.00 20.99 109.73 42.58 85.46 42.58 Female 60.09 23.08 60.90 20.05 79.62 30.30 63.44 16.25 49.50 22.19 48.93 14.07 75.04 25.60 81.05 28.47

86 4.4 Discussion Head and back angles were found to have similar tendencies to previous studies (Shewchenko, et al., 2005). Shewchenko et al. (2005) found that some players tend to flex their head during contact while others extend. The current study found this to occur as well. Overall, the torso angle was in flexion for the majority of players at ball contact which contrasted with the previous findings where players seemed to remain in a relatively neutral position upon impact and move into flexion during follow through (Shewchenko, et al., 2005). Players were found to continue with torso flexion in the follow through period in the youth population as well. It appears that they arrive at this state earlier than the adult players. This trend was found in all scenarios, both un-modified and modified. Table 4.5 describes the average head flexion for the previous study (Shewchenko, et al., 2005) in comparison to the current study.

87 Table 4.5: Average head flexion for each task Shewchenko et al. Heading Task 1 2 3 4 5 6 7 8 Current Study Male (n = 6) 5 1 -12 0 8 13 -5 4 Female (n = 9) 13 1 -4 8 -6 10 -15 -6 (2005) Male (n = 7) 33 18 9 18 14 15 4 16

Due to the overall variation in player body position, it is expected that these results would vary from previous results found in adult players. The player variation is consistent with previous findings (Shewchenko, et al., 2005). This is most likely due to the many possible heading scenarios. Therefore, players do not use muscle memory to perform the task in the same manor every time, but instead learn to adjust to whatever scenario occurs. This provides unlimited possibilities for heading scenarios and would most likely result in additional variation in results. The current study only looked at redirection directly at the source of the ball launch. If additional scenarios were introduced to provide redirection in other ways, additional distinctions would be made particularly in head rotation and EMG activity.

88 EMG activity provided insight into the activation of the neck muscles during the phases of heading. The majority of neck muscle activity during soccer head was found to take place prior to impact and during impact. Overall, the peak values were similar, but otherwise there was extensive subject variability. In addition to inconsistency between subjects, there were also differences from one task to another within the same subject. Although this was less noticeable in the EMG results as in the body position results. Angular head acceleration was compared between tasks to determine if any of the modifications that were instituted in the study provided a decrease in head acceleration which could lead to suggested alterations to current heading methods. It was found that none of the modifications decreased the average linear head acceleration for the males or the females. When looking at individual players, decreases were seen between tasks, but no pattern was visible from one player to the next. This just reiterates that there is extensive player

variability and what works at reducing injury risk for one player may not work for another. Comparisons between genders or between tasks were challenging to make. Based on the results of the current study, it indicates that differences are not related these variables, but that the differences occur between each player. This also made making a comparison with the adult players unproductive as any difference would most likely have nothing to do with age, but with the players being different and the scenarios being slightly different.

89 One of the main limitations of the current study was the method of head acceleration measurement. This limited the overall usefulness of the study since we lacked the ability to make comparisons with previous studies. Also, due to the method of head acceleration measurement, no injury criteria could be evaluated. Initial trials were performed with a head acceleration measurement system in place, but due to system interference the system that allowed for angular head acceleration measurement and linear head acceleration

measurement at the center of gravity of the head was not possible. It would be of interest in future studies to measure head acceleration in the youth population during heading events to determine if any modifications or technique changes can reduce linear or angular head acceleration.

90 CHAPTER 5 ACCELERATION MEASUREMENT SYSTEM VALIDATION 5.1 Introduction Previous studies of soccer heading have lacked the ability to measure real-time game impacts (Naunheim, et al., 2003, Naunheim, et al., 2000, Shewchenko, et al., 2005, 2005, 2005). These previous head acceleration

measurements were done using re-creations in a laboratory or restricted setting. By using a novel head acceleration measurement system, the Head Impact Telemetry System (HITS) (Simbex, Lebanon, NH), linear and angular head acceleration can be measured during actual games. The system has been

implemented and validated in both football helmets and boxing headgear (Beckwith, et al., 2007, Duma, et al., 2005, Manoogian, et al., 2006). Previously HITS (Figure 5.1) was implemented in football helmets (Duma, et al., 2005), and is now commercially available for use (Duma, et al., 2005). The data processing algorithm, previously developed by Crisco et al. (2004), allows for calculation of both linear and angular head acceleration (Crisco, et al., 2004). System and algorithm validation was performed using a HIII dummy instrumented with a 3-2-2-2 accelerometer setup for both football and boxing (Crisco, et al., 2004, Duma, et al., 2005). Correlations were found to be strong with an R2 = .97 (Duma, et al., 2005). This system uses six wireless accelerometers which are placed inside a football helmet along with a wireless transceiver, data acquisition, and on-board memory (Duma, et al., 2005). The accelerometers are spring-mounted so that

91 they are closely coupled to the head (Duma, et al., 2005). This ensures that head acceleration is measured as opposed to helmet acceleration. Recording of impact data occurs when any accelerometer registers above the threshold of 10 g. When the threshold is reached, 40 ms of data are recorded. This information is then time stamped and downloaded to the sideline computer for later processing using the algorithm (Crisco, et al., 2004).

Figure 5.1: HIT system The HIT system has recently been modified for use in boxing headgear (Beckwith, et al., 2007). The system is much like the football system, but the boxing headgear has a total of twelve accelerometers as opposed to six. Additionally, accelerometer placement was more of a concern because the headgear has no outer shell and the accelerometers had to be placed where it

92 was least likely for impacts to occur. Therefore, the accelerometers were placed toward the back of the headgear. The battery pack and transmitter were placed in the back panel. This system was validated using a Hybrid III (HIII) head and neck (Beckwith, et al., 2007). Using a 3-2-2-2 accelerometer array mounted in the HIII head, linear and angular accelerations were calculated to compare to those calculated using the HIT system. Facial, forehead, side, and left chin

impacts were performed using a pendulum impactor at 3 m/s, 5 m/s, and 7 m/s. Four impacts were performed at each location and speed, with the exception of forehead impacts not being performed at 7 m/s. Linear head acceleration, angular head acceleration, impact location, GSI, and HIC were calculated for both systems. High correlations, r2 = .91, for both linear and angular head acceleration were found. Estimations made by the HITS headgear were slightly low (2%) for linear acceleration and high (8%) for angular acceleration. RMS error was calculated over the time series and was an average of 5.9 2.6 g for linear acceleration and 595 405 rad/s2. Additionally,

correlations between the two systems were calculated for HIC and GSI. Again, high correlations were found, r2 = .88 and r2 = .89, for HIC and GSI respectively. It was found that a limitation of the headgear development was the need to place accelerometers in the back of the headgear. While this potentially creates error, it is necessary for avoiding direct accelerometer impact. This could also be a problem during development of the soccer headgear because impacts will take place in the forehead region and there will be no padding. Therefore,

accelerometers will need to be placed in the rear portion of the headgear.

93 Implementation of this device into a headband system that can be worn during normal soccer play would allow for collection of real-time game head accelerations without restricting player movement. The headband system will be modeled after a commercially available headgear, but will provide none of the protective effects to the players. The limitation of this system is that it does require the player to wear some type of headband to allow for player instrumentation to take place. The system has previously been used in sports that require helmets or headgear of some type, but in soccer this is not the case. Although headgear is available for soccer players, it is not a required piece of equipment. HITS Validation Prior to any field testing, laboratory validation of the HITS headgear was executed. This was done by testing various possible scenarios that could occur during soccer games. These scenarios included head to head impacts and head to ball impacts. These impacts were done using a modified 50th percentile HIII head (Denton ATD, Milan, OH) instrumented with a 3-2-2-2 accelerometer setup. The HIII head was then fitted with a HITS headgear. The scenarios were tested using an air cannon (head to ball) and a linear impactor (head to head). Comparisons will then be made between the HIII accelerations and the HITS accelerations. The level of error obtained from HITS will be analyzed. 5.2 Methodology A soccer headband HITS (Simbex Inc., Lebanon, NH), similar to those commercially available, was instrumented with 6 ( 250 G) single-axis linear

94 accelerometers (Analog Devices, Inc.) (Figure 5.2). In order to measure forces normally seen during the play of soccer, no padding was placed in the headband. All accelerometers were placed in the back of the headband in order to avoid ball contact during heading events. The battery pack, placed in the back of the

headband, is a rechargeable Nickel Metal-Hydride battery which allows for extended use, 1 2 weeks depending on use, and minimal additional weight, with the entire headband system weighing 147 g. The headband has a threshold level of 10 g, meaning that when any accelerometer registers a reading of 10 g or greater, the impact will be downloaded. Once an impact above the threshold is recognized, 8 ms prior to the impact and 32 ms post impact will be recorded. Data are downloaded to the sideline computer as long as players remain within range, approximately 200 yards. If players are out of range, up to 100 impacts can be stored within the headgear itself until the player returns within range.

Figure 5.2: Back of HITS headband with circles marking accelerometer placement

95 The 50th percentile male Hybrid III (HIII) head was used as the standard of comparison for the linear and angular head accelerations for the HITS headband. The HIII head was instrumented with nine linear accelerometers (Endevco 7264C and 7264D) in the 3-2-2-2 setup which was mounted inside the modified HIII head (Padgaonkar, et al., 1975) with a tri-axial linear block placed at the center of gravity (CG) of the head form. HIII head acceleration data were collected at 20,000 Hz while HITS acceleration data were collected at 1,000 Hz. The

headband was placed on the HIII head and Velcro straps were tightened to the manufacturers specifications allowing all accelerometers to make firm contact with the head form. Impacts occurred at the forehead, side, and temple of the HIII head using an air cannon and a linear impactor. No impacts were performed with an impact direction going directly through the center of gravity of the head as this would be highly unlikely in an on-field data collection scenario. Both ball to head and head to head contacts were simulated. Ball to head impacts were performed using an air cannon with a barrel fitted to accommodate a soccer ball (Figure 5.3). A standard size 5 soccer ball with a mass of 450 g, a diameter of 22 cm, and an inflation pressure of 10 psi was used for all testing. The ball was shot through a three screen chronograph in order to obtain velocity readings. In order to obtain velocities representative of soccer impacts, Helium was used in the air cannon. Impacts were performed at 8 m/s, 10 m/s, and 12 m/s based on previous research performed (Withnall, et al., 2005). Ten impacts were performed at each velocity to the forehead (n=30), right side (n=30), and left temple of the head (n=30). These locations were

96 chosen to represent various impacts seen during soccer play, as well as to provide a variety of impact locations possible in soccer games while not impacting accelerometers directly.

Figure 5.3: Air cannon with soccer barrel Head to head impacts were conducted by mounting one HIII head and neck face down, to a linear impactor and placing another on a trolley in front of the impactor (Figure 5.4). By placing the head and neck on the impactor, some flex was possible allowing for an impact more closely representative of an onfield situation. The head on the trolley was instrumented as described above and the HITS headgear was placed on it. Tests were run at three velocities: 2.5 m/s, 3.5 m/s, and 4.75 m/s based on previous research on head to head field impacts (Withnall, et al., 2005). Ten impacts were performed at each of these velocities at two locations: the forehead (n=30), and to the right side (n=30). These

97 locations represent standard impacts seen during soccer play, and provide a more severe impact condition than the ball to head impacts.

Figure 5.4: Head to head impact test setup for forehead testing Data analysis was conducted to determine the agreement between the HIII and the HITS headgear. Linear head acceleration and angular head The HITS system data was

acceleration were calculated for both systems.

processed using an algorithm previously described in detail by Chu et al. (2006) which calculates both linear and angular head acceleration based on the 6 accelerometer measurements (Chu, et al., 2006). Linear regression was used to compare the systems for the ball to head impacts, the head to head impacts, and then all impacts together. accelerations. Additionally, root mean square (RMS) error was calculated using the This was done for both linear and angular head

98 equation below for the duration of the impacts for linear head acceleration. This will provide information about specific portions of the curve and how closely they match up in value. Cross correlation was also calculated for linear head

acceleration. These values provide insight into how strongly the variables are related. Cross correlation values were assessed using a scale to determine

correlation strength: >0.95 was considered excellent, >0.85 was considered good, and >0.75 was considered acceptable. Due to the fact that the HIT System has built-in data acquisition and wireless communication, the HIII and HITS could not be linked. In order to compare HITS data and HIII data during post-processing, data was synchronized at the point of minimum RMS error. The two resultants were synchronized by shifting the HIII data incrementally until a 40 ms span of the HIII gave the lowest cross correlation factor. Due to the fact that data were collected at different frequencies, HITS data must be time matched to HIII data. In order to do this, the HIT System data was first up sampled to match the sampling frequency of the HIII so that no HIII data was lost and the overall numbers from the HIT System output was unaffected. The two resultants were then synchronized by shifting the HIII data incrementally until a 40 ms span of the HIII gave the lowest cross correlation factor. Where: x1 = HITS measurement at single time point x2 = HIII measurement at the same time point
, ,

99 5.3 Results Linear regressions were performed for the ball to head impacts, head to head impacts, and all impacts combined. All impact locations are combined in the linear regressions. Regressions for both linear and angular accelerations are shown below with each impact location denoted by a different shape (Figures 5.5 5.10). Ball to head comparisons provided minimal correlation for both linear and angular acceleration, R2 = 0.3403 and R2 = 0.5716 respectively (Figure 5.5, 5.6). Correlations were also investigated for each location separately. For ball to head testing, the forehead had the highest correlation for linear acceleration (R2 = 0.4419), followed by the right side (R2 = 0.3975) and the left temple (R2 = 0.2446). Angular acceleration had the highest correlation in the right side

impacts (R2 = 0.8022), followed by the left temple (R2 = 0.2832) and the forehead (R2 = 0.1600). The minimal correlation is most likely due to the fact that although various impact velocities were tested, a range of linear and angular head accelerations were not obtained. Output accelerations for both the HIII and HITS systems were very limited in range when impacted over the three ball to head impact velocities. Although the correlations are not ideal due to the lack of

acceleration range, the average difference between the two acceleration measurements is minimal. This is especially true for the linear head acceleration which has an average difference of 2.25 g. The angular head acceleration has an average difference of 100.58 rad/s2.

100

Figure 5.5: Linear regression of linear acceleration for HIII and HITS ball to head conditions

Figure 5.6: Linear regression of angular acceleration for HIII and HITS ball to head conditions Head to head comparisons provided strong correlations for both linear and angular acceleration, R2 = 0.8940 and R2 = 0.8998 respectively (Figure 5.7, 5.8). The forehead location had a higher correlation in both linear acceleration (R2 = 0.9653) and angular acceleration (R2 = 0.9799) than the left side which had an R2 = 0.8411 for linear acceleration and R2 = 0.8979 for angular acceleration. A

101 much wider range of output velocities was provided from the three impact velocities used in the head to head impact conditions providing a much stronger dataset for linear regression. This demonstrates that the HITS is a very good system for measuring higher velocity impacts. The average differences between the two systems are -2.01 g for the linear acceleration measurements and 1721.05 rad/s2 for the angular acceleration measurements. These differences are calculated over all three impact velocities.

Figure 5.7: Linear regression of linear acceleration for HIII and HITS head to head conditions

102

Figure 5.8: Linear regression of angular acceleration for HIII and HITS head to head conditions Linear regressions were also performed for all head impacts, ball to head and head to head, combined. This was done to determine the overall accuracy of the system for the range of velocities over which it will be used. Very strong correlations were found over all of the impact conditions, R2 = 0.9437 and R2 = 0.9194 for linear acceleration and angular acceleration respectively (Figure 5.9, 5.10). This provides a very strong basis for using the system for future soccer research.

103

Figure 5.9: Linear regression of linear acceleration for HIII and HITS ball to head and head to head conditions combined

Figure 5.10: Linear regression of angular acceleration for HIII and HITS ball to head and head to head conditions combined Peak linear and rotational acceleration was also calculated for each of the impacts. These values for both the HITS and HIII systems are shown in Tables 5.1 - 5.4. All values shown are the average for the impact condition listed.

104 The HITS system slightly over predicts linear head acceleration in the ball to head impacts. This can be seen in all impact conditions, except the forehead condition at 12 m/s. At this condition the HITS provides a slight under prediction (Table 5.1). Table 5.1: Average Peak Linear Accelerations for Ball to Head Conditions 8 m/s 10 m/s 12 m/s Impact Location HITS (g) 15.20 Forehead 0.49 18.03 Right Side 4.85 18.03 Left Temple 3.53 HIII (g) 12.14 0.64 13.31 0.76 13.39 0.46 HITS (g) 18.23 1.51 19.93 3.20 18.72 3.26 HIII (g) 16.57 0.70 17.67 0.87 18.08 0.46 HITS (g) 18.70 2.54 22.98 4.02 21.64 4.33 HIII (g) 21.09 1.35 21.13 0.93 21.45 1.11

Angular head acceleration for the ball to head impacts provides a different pattern for the peak values. The HITS system over predicts angular head

acceleration in the ball to head impacts for all conditions except the forehead impacts. Forehead impacts at all three velocities have the HITS under predicting angular acceleration (Table 5.2).

105 Table 5.2: Average Peak Angular Accelerations for Ball to Head Conditions 8 m/s 10 m/s 12 m/s Impact Location HITS (rad/s2) 822.07 Forehead Right Side Left Temple 244.4 1416.29 94.57 1958.79 425.65 HIII (rad/s2) 833.12 74.40 1343.23 197.30 1321.29 179.61 HITS (rad/s2) 857.74 259.28 1828.96 334.27 1453.86 535.28 HIII (rad/s2) 954.86 95.32 1509.16 152.15 1281.71 282.16 HITS (rad/s2) 949.57 362.40 1882.67 318.00 1917.18 348.35 HIII (rad/s2) 1450.81 252.08 1715.39 378.91 1695.22 347.64

Linear head acceleration for the head to head impacts shows a general over prediction by the HITS for the two lower impact velocities. At the 4.75 m/s impact condition, the HITS under predicts linear head acceleration for both the forehead and left side conditions. Although a general over prediction occurs, values are very similar as shown by the strong correlations between the two systems (Table 5.3).

106 Table 5.3: Average Peak Linear Accelerations for Head to Head Conditions 2.5 m/s 3.5 m/s 4.75 m/s Impact Location HITS (g) 33.68 Forehead 0.55 37.14 Left Side 3.46 HIII (g) 32.54 0.69 30.58 2.06 HITS (g) 74.26 4.10 69.58 10.12 HIII (g) 66.93 1.85 63.18 3.31 HITS (g) 115.45 8.02 95.82 13.02 HIII (g) 125.14 2.80 119.65 4.94

Angular head acceleration for the head to head impacts shows that the HITS under predicts the angular head acceleration slightly for nearly all the impact conditions. The HITS system only over predicts angular head

acceleration in the head to head impacts for one impact condition, the left side at 2.5 m/s. This is shown in Table 5.4 below. Table 5.4: Average Peak Angular Accelerations for Head to Head Conditions 2.5 m/s 3.5 m/s 4.75 m/s Impact Location HITS (rad/s2) 1245.63 Forehead 109.99 2795.55 Left Side 179.72 HIII (rad/s2) 1544.50 32.89 2366.77 456.59 HITS (rad/s2) 2013.79 176.65 5629.58 550.05 HIII (rad/s2) 3177.79 205.66 6020.31 365.15 HITS (rad/s2) 6930.20 530.95 9801.20 1413.74 HIII (rad/s2) 9414.49 218.99 16218.41 855.65

Root mean square (RMS) error was calculated for each impact on a point by point basis. An example of the waveforms being compared is shown in

107 Figures 5.11 5.15. An average was then calculated for each impact and each impact condition. The average RMS error of the linear accelerations for ball to

head impacts at the 8 m/s condition was 2.04 0.25 for forehead impacts, 3.55 0.44 for right side, and 2.20 0.74 for left temple impacts. Similarly RMS error for the 10 m/s condition was 2.35 0.27 for forehead impacts, 3.86 0.62 for right side, and 1.97 0.54 for left temple impacts. The 12 m/s conditions had RMS errors of 2.55 0.77 for forehead impacts, 3.08 0.94 for right side, and 3.89 1.21 for left temple impacts.

Figure 5.11: Linear acceleration for both HIII and HITS for one ball to head forehead impact at the 12 m/s condition

108

Figure 5.12: Linear acceleration for both HIII and HITS for one ball to head right side impact at the 12 m/s condition

Figure 5.13: Linear acceleration for both HIII and HITS for one ball to head left temple impact at the 12 m/s condition RMS errors were also calculated for the head to head conditions (Figure 5.14, 5.15). Head to head impacts RMS errors were 2.69 0.32 for the forehead and 5.83 0.67 for the left side at the 2.5 m/s condition, 5.82 0.65 for the forehead and 15.19 1.30 for the left side at the 3.5 m/s condition, and 9.47 0.57 for the forehead and 21.89 2.62 for the left side at the 4.75 m/s condition.

109 These values are higher due to the higher accelerations provided from the head to head impact conditions.

Figure 5.14: Linear acceleration for both HIII and HITS for one head to head forehead impact at the 4.75 m/s condition

Figure 5.15: Linear acceleration for both HIII and HITS for one head to head left side impact at the 4.75 m/s condition Cross correlations were performed and demonstrate a strong relationship between the two systems. Average cross correlation (r) values were 0.95 0.01 for forehead impacts, 0.88 0.05 for right side, and 0.95 0.04 for left temple

110 impacts for the 8 m/s condition, 0.94 0.01 for forehead impacts, 0.87 0.04 for right side, and 0.96 0.02 for left temple impacts for the 10 m/s condition, and 0.95 0.03 for forehead impacts, 0.96 0.02 for right side, and 0.92 0.04 for left temple impacts for the 12 m/s condition. Head to head impacts had cross correlation values of 0.97 0.01 for the forehead and 0.94 0.01 for the left side at the 2.5 m/s condition, 0.98 0.00 for the forehead and 0.88 0.04 for the left side at the 3.5 m/s condition, and 0.94 0.00 for the forehead and 0.83 0.02 for the left side at the 4.75 m/s condition. All ball to head conditions fell either

within the good or excellent range when looking at cross correlation values. Of the nine ball to head conditions, five of them were above the 0.95 value required for an excellent rating. Head to head conditions also provided very strong cross correlation values, with five of six conditions falling into either the good or excellent categories. 5.4 Discussion Although attempts have been made to determine head acceleration during soccer heading events, a system for on field data collection had not been previously available. A system has now been created for research purposes, however validation was necessary before the system could be used to collect data during a game or scrimmage situation. The results show that the new

soccer HITS system correlates well with the standard measurement system of the HIII 3-2-2-2 accelerometer system. Locations and impact velocities were chosen to simulate events that take place in normal soccer play.

111 Good cross correlation values were found for the linear accelerations for all conditions with two of the conditions having excellent correlation. The lowest correlation value of 0.83 0.02 was for the left side during head to head impact and is not a location that is expected to be frequently impacted during soccer play. Even as the lowest correlation, it still shows an acceptable level of

agreement. Additionally, all other linear acceleration cross correlation values exceeds the 0.85 value and shows a very well matched system. Strong correlations were found between the systems for both linear and angular head acceleration for the head to head condition, 0.8940 and 0.8998 respectively. Additionally, very strong correlation was found for overall use of the system. This was shown by performing linear regression over all conditions with results of 0.9437 for linear acceleration and 0.9194 for angular acceleration. The ball to head condition did not have a strong correlation, but this is due to the lack of velocity distribution as all of the impacts were at a very low magnitude. Although these impacts have low R2 values, they did have a very small absolute difference, 2.25 g for linear head acceleration and 100.58 rad/s2 for angular head acceleration. Also, all average peak values for linear acceleration were well

below 66 g which has been previously established as a 25 % risk of injury (Zhang, et al., 2004). This indicates that a difference of 2.25 g would not be clinically significant. RMS error values showed a consistency between the two waveforms for each of the conditions (Figures 5.11 5.15). Slightly higher average RMS error values were found in some waveforms, but upon further inspection it seems as

112 though the discrepancy in the waveforms took place in the tail of the impact or in a small secondary impact but not in the peak. Therefore, even in the impacts with a slightly higher average RMS error the peaks were still similar. One limitation of this system is that it requires the player to wear some type of headband to allow for player instrumentation to take place. The system has previously been used in sports that require helmets or headgear of some type, but in soccer this is not the case. Although headgear is available for soccer players, it is not a required piece of equipment. Therefore, it could be more challenging to find players willing to wear the system during play. An additional concern with the system is movement during play (Beckwith, et al., 2007). This was not a problem during validation testing, but when used in the field it may be an issue due to player hair as opposed to the HIII skin. Although this is a

concern, movement would most likely just alter the accuracy of the impact location (Beckwith, et al., 2007). Headband slippage was not a problem in

laboratory tests, and impact location is not a primary interest for use with this system. Therefore, headband slippage is not considered a major concern but on-field research is warranted to assess these concerns. During soccer play, many impact scenarios exist, and although the current study made every effort to recreate scenarios typically seen during soccer play, it was impossible to include all scenarios. One limitation is the limited impact

locations and velocities included. Soccer has a wide range of impact locations and although they are not all included, the range included provided sufficient simulation of events to validate the system. An additional limitation is the

113 simulation of on-field scenarios accurately. Using two HIII heads in head to head impacts as opposed to just an impactor ram provided some give due to the neck flexion on the impactor, but may not be an exact replication of on-field impacts. The current study was not designed to recreate exact scenarios, but to provide reasonable recreations in order to determine a correlation between the acceleration measurement systems. Therefore, the system needs to be used in on-field situations to determine fully its ability to accurately measure soccer head impacts. Rotational acceleration for left side, head-to-head impacts had the largest difference measurement for any test method. For these impacts, the HITS under predicted the HIII by 6417.21 rad/s2. While this discrepancy is of concern, it is unclear how translatable these results will be to in vivo data collection. These test conditions are intended to be representative of on-field events, however, the complex biomechanical interactions that take place during live impacts may not be completely captured by our simulated event as it was impossible to recreate every possible impact scenario. Due to the high correlation found for all other test combinations, we suggest the HITS is a viable method for recording impacts during competition, however, while linear acceleration measures appear acceptable, caution should be taken when evaluating rotational acceleration for impacts similar to our head-to-head condition. As part of this ongoing work,

future studies will address this concern by identifying head to head impacts through video analysis and comparing on-field measures with those recorded here.

114 In conclusion, this system provides a much needed method to measure head acceleration in soccer players during normal play. It allows for accurate measurements to be taken which could potentially lead to an injury threshold specific to certain soccer impacts. Additionally, this system will allow a

comparison between different types of impacts that occur during soccer play.

115 CHAPTER 6 ON FIELD MEASUREMENT OF HEAD ACCELERATION 6.1 Introduction Head acceleration has been successfully measured during sporting events previously (Duma, et al., 2005, Stojsih, et al., 2008), but it has been a challenge for researchers to successfully do this during soccer games or scrimmages due to the lack of headgear (Naunheim, et al., 2003, Naunheim, et al., 2000, Shewchenko, et al., 2005). Attempts have been made to instrument helmets from other sports in order to collect data from soccer heading events (Naunheim, et al., 2000). Although these efforts provide a starting point, data do not

represent actual on-field events as they are recreations and by adding a hard shell helmet the impact event is altered. Naunheim et al. (2000, 2003) previously studied head acceleration in soccer. In the first of these studies (Naunheim, et al., 2000), researchers used a football helmet with a tri-axial accelerometer mounted on the helmets vertex to measure head accelerations of high school soccer, football and hockey players. Football and hockey impact acceleration data were collected during games, but the soccer impacts were done in a simulated game situation. The soccer players headed a ball kicked 30 yards while wearing the instrumented football helmet. Significant neurological damage was not anticipated from any single impact based on standard threshold values for Gadd Severity Index, Head Injury Criterion, and peak linear acceleration. Soccer players did see higher values for the three reported results than the football and hockey players. The data,

116 however, does not accurately represent the accelerations that soccer players would see when heading the ball in a game. This is due to the fact that soccer players would not be wearing a protective helmet, but they would instead be heading the ball with no head protection at all. In order to address the issues with the first study, Naunheim et al. (2003) instrumented players with an instrumented headpiece, designed specifically for the study, and a mouthpiece to measure linear and angular accelerations. Subjects were asked to head a ball which was launched from a distance of six meters. Linear accelerations of up to 199 + 27 m/s2 were measured. Angular accelerations were reported to be 1.46 + .297 krad/s2. Although the study

provided some basiline data, the ability to measure on-field data was lacking (Naunheim, et al., 2003). Shewchenko et al. (2005) also performed a study measuring head acceleration during soccer heading. This study used seven current soccer

players to measure kinematics, head acceleration, and muscle activity in the neck. The subjects were asked to recreate heading scenarios in a laboratory while wearing reflective targets, EMG electrodes, and a bite plate instrumented with linear and angular accelerometers. Ten scenarios were performed using two ball speeds, 6 m/s and 8 m/s, while high speed video, acceleration, and EMG data were recorded. Results showed that the average peak linear acceleration did not exceed 194 40 m/s2 for any of the 10 scenarios. Average peak angular accelerations were also calculated and did not exceed 2.41 1.81 krad/s2 for the

117 scenarios recorded. Although the study is comprehensive, it still did not provide actual field data representing what occurs in a soccer game. Laboratory recreations have provided insight into heading impact events (Naunheim, et al., 2003, Shewchenko, et al., 2005). These recreations provide valuable kinematic and muscle activation data, but are only representative of the least severe cases for head acceleration. During these recreations, players were wearing reflective targets, EMG electrodes, and an instrumented bite plate (Shewchenko, et al., 2005). All of this instrumentation changes the ability of the player to move freely and, therefore, alters the dynamic of the impact. Although, linear acceleration results from two laboratory recreation studies are similar, there is no way to know that this is what takes place during actual game play (Naunheim, et al., 2003, Shewchenko, et al., 2005). Ultimately, a wireless

acceleration measurement system which does not inhibit movement and provides no head protection is needed to determine the linear and angular head accelerations during actual soccer play. The exact contribution of linear versus angular acceleration for a given impact when heading the ball is related to several factors including how quickly the neck muscles are recruited and the overall intent of the redirection (Naunheim, et al., 2003, Shewchenko, et al., 2005, 2005). Players may

purposely rotate their head in an effort to redirect the ball towards a particular target i.e. the goal. There is much debate as to whether linear or angular

acceleration should be investigated when studying mTBI since both have been shown to predict injury (Gurdjian, et al., 1966, Ommaya and Hirsch, 1971). For

118 the current study, each will be evaluated independently along with various other head injury criteria which have established thresholds for mTBI. Two major injury criteria can be assessed along with linear and angular head acceleration. These are the Head Injury Criterion (HIC) and the Gadd Severity Index (GSI). HIC and GSI were developed primarily for automotive impact. Both criteria take into account acceleration over a period of time (Gadd, 1966, Newman, et al., 2000). Each of these criteria is useful only to assess one individual impact. There are still no suggested head acceleration limits for

multiple subconcussive impact events.

Figure 6.1: Wayne State University Tolerance Curve (Cory, et al., 2001) The Wayne State Tolerance curve (Figure 6.1) provided the basis for both GSI and HIC (Gurdjian, et al., 1966). Gadd (1966) developed the Severity Index using the Wayne State Tolerance Curve plotted on a log-log scale. The slope of

119 the resulting curve was -2.5 which provided the power which is used in the calculation. It has been suggested that life threatening injuries are increasingly likely when GSI values are greater than 1000.
.

Where: a(t) = CG resultant translational acceleration T = duration of acceleration HIC is the most widely used within automotive testing. This criterion is based on the GSI calculation and the Wayne State Tolerance curve. HIC is an optimization of the GSI formula (Versace, 1971). As opposed to using the total impact duration, a time interval providing the maximum value is used. Various recommended HIC limits exist, with 1000 being the original limit for automotive testing. This limit was based on the probability of life-threatening injury, and represented a 16 % risk of serious brain injury or skull fracture (Prasad and Mertz, 1985), and has now been reduced to 700 which represents a 5 % risk for automotive impacts. Pellman et al. (2003) recommended a mTBI HIC limitation value of 250 based on American football concussions (Pellman, et al., 2003). 1 Where: t1, t2 = time points which provide maximum HIC value (generally 15 ms interval is used) a(t) = CG resultant translational acceleration
.

120 In addition to HIC and GSI, other head injury measurement values have been previously established (Newman, et al., 2000, Ommaya, et al., 2002, Zhang, et al., 2004) for both linear and angular head acceleration which are described below. Zhang et al. (2004) used data from football head impact

recreations (Newman, et al., 2000) and finite element modeling to determine an injury threshold for mTBI. Using data from these recreations as input values, the Wayne State Brain Injury Model was used to determine probability of injury (Zhang, et al., 2004). The model was used to calculate the brains mechanical responses which were then related to an injury severity and the resultant probability of injury. For linear head acceleration, a 25 % risk of mTBI was found at 66 G, a 50 % risk at 82 G, and an 80 % risk at 106 G. Angular head

acceleration thresholds were also determined and were 25 % at 4600 rad/s2, 50 % at 5900 rad/s2, and 80 % at 7900 rad/s2. One limitation of using these mTBI threshold levels in the current study is that they were developed based on impacts that occurred between helmeted individuals and are valid for single impact events only. The values are, however, based directly on sports injury data and are not scaled from an animal model which provides a solid basis for use when evaluating sports injury data. 6.2 Methodology A total of 24 girls youth soccer players in the U14 age group agreed to participate in the study. Prior to any testing, approval from Wayne State All players were

Universitys Human Investigation Committee was obtained.

fitted with the Head Impact Telemetry System (HITS) headgear (Figure 6.2),

121 described in detail in Chapter 6, and then asked to participate in a scrimmage. Some participants were involved in more than one scrimmage and were processed as a new player for each. Players wore the headgear for the duration of the scrimmages which lasted 30 to 65 minutes. Data were collected at

1000 Hz and downloaded to the sideline computer for later analysis. Games were videotaped for later analysis in determining what type of impacts occurred at each downloaded time point.

Figure 6.2: HITS headgear fitted to HIII headform Following field data collection, data analysis was performed using a validated algorithm provided by Simbex (Chu, et al., 2006, Crisco, et al., 2004). Each individual impact was analyzed using this algorithm. Information obtained included several parameters including HIC and resultant linear and angular acceleration. Along with all of this information, number of headers, location of impact, and incidence of other impact events (player collisions with other players, player falls, collisions with goalposts, and unintentional collisions with the ball) were also determined from the video.

122 6.3 Results The majority of header impacts took place to the front location (n = 17) and ranged in peak linear acceleration from 4.5 g to 34.3 g with an average peak linear acceleration of 17.4 g (Figure 6.3). Additionally, peak angular

accelerations ranged from 493.3 rad/s2 to 3649.7 rad/s2 with an average of 1657.5 rad/s2. established. None of these values exceed tolerance levels previously

Figure 6.3: Linear head acceleration by location for each header only impacts The second highest number of header impacts by location took place at the top of the head (n = 9) and ranged in peak linear acceleration from 11.1 g to 44.4 g with an average peak linear acceleration of 19.5 g. Additionally, peak angular accelerations ranged from 598.0 rad/s2 to 3637.2 rad/s2 with an average of 1851.8 rad/s2 (Figure 6.4). Again, none of these values exceed tolerance values for mTBI.

123

Figure 6.4: Angular head acceleration by location for each header only impacts The left and right sides had the next highest number of header impacts with 7 and 8 respectively. The right side impacts ranged in peak linear

acceleration from 5.5 g to 62.9 g with an average peak linear acceleration of 17.4 g. Additionally, peak angular accelerations for the right side ranged from 523.7 rad/s2 to 8869.1 rad/s2 with an average of 3003.4 rad/s2. For the left side, peak linear accelerations ranged from 11.4 g to 49.4 g with an average of 27.2 g. Peak angular accelerations ranged from 762.1 rad/s2 to 4509.8 rad/s2 with an average of 2586.6 rad/s2 for the left side. The back of the head had the fewest header impacts with 6. These impacts were also low in linear acceleration with a range of 4.9 g to 19.0 g averaging 11.9 g. Angular acceleration values were also low with a range of 444.8 rad/s2 to 927.0 rad/s2 and an average of 723.2 rad/s2.

124

Figure 6.5: HIC values for headers by location with mTBI tolerance level HIC values for the header impacts were generally low for all locations. The right side had the highest HIC values with an average of 38.1 (Table 6.1) and a peak value of 154.1 (Figure 6.5). The left side followed with an average HIC of 27.36 and a peak of 79.40. Although the front location had the most impacts, the HIC values remained low with an average of 7.7 and a peak of 24.0. The top and back of the head had very low HIC values with averages of 9.5 and 2.6 respectively (Table 6.1).

125 Table 6.1: Average results for headers by location Peak Linear Peak Angular General Location L Side R Side Top Front Back Acceleration (g) 27.2 28.1 19.5 17.4 11.9 Acceleration (rad/s2) 2586.6 3003.4 1851.8 1657.5 723.2 HIC 15 27.4 38.1 9.5 7.7 2.6 36.7 51.2 15.5 13.6 5.1 GSI

The impacts that each individual player saw during each scrimmage was also investigated. The maximum number of header impacts a single player

experienced in a scrimmage was four with players 3 and 18 both having that total (Figures 6.6, 6.7). In addition to these header impacts, player 18 also had a non header impact, a collision with the goal post, which was above the angular acceleration 25 % threshold for injury (Figure 6.12). Players 5 and 19 were the only two players that had header impacts with angular accelerations exceeding head injury tolerance limits (Zhang, et al., 2004). Both of these players had multiple impacts during their scrimmages, not just the single tolerance exceeding blow (Figures 6.6 6.7).

126

Figure 6.6: Linear head acceleration for all header impacts for individual players

Figure 6.7: Angular head acceleration for all header impacts for individual players In addition to the header impacts, there were also various other impacts. There were 21 non-header impacts recorded (Table 6.2). These included

collision with the goal, player collisions, player falls, and unintentional ball to head impacts (Table 6.2). The majority of players participating had only one nonheader event occurring during their scrimmage and many had no occurrences.

127 Three players, however, had multiple instances. These were players 12, 13, and 29 (Table 6.2). Player 12 also had multiple header events during their All impacts to player 12 were well under the

scrimmage (Figures 6.6, 6.7). current tolerance limits for mTBI.

128 Table 6.2: Description of non header impacts and the player that impacted
Peak Linear Acceleration Player Description (g) 23.7 20.4 15.1 7.7 11.1 10.7 12 18 32.2 11.6 16 24 27.1 25.7 18.5 5 56.7 18.9 18.9 15 Peak Angular Acceleration (rad/s2) 3739.3 1749.9 1332.3 628.5 881.8 811.3 828.4 823.6 1090.7 1247.1 1315 2831.8 5179.5 2847 753.6 497.5 2910.3 987 1982.3 899.9 HIC 15 13.7 5.4 6.4 0.5 1.0 1.7 1.9 4.1 25.4 4.0 6.7 15.4 16.5 17.3 8.7 0.2 GSI 17.9 11.4 8.1 1.2 1.6 2.2 2.8 7.2 31.6 7.5 10.9 31.7 20.4 20.8 10.3 0.3

5 Player fell 7 Unintentional ball to head 9 Player fell 12 Player fell 12 Player fell 13 Player collision 13 Player collision 14 Player hit ground 15 Ball hit back of head 17 Player collision 19 Player fell 21 Player collision 22 Collision with goalpost 24 Player collision 26 Player fell 27 Player hit ground 28 Player collision 29 Player collision 29 Player collision 29 Unintentional ball to head

90.8 114.7 2.9 8.7 1.9 5.4 10.3 2.7

129 The majority of the non-header impacts took place to the front and to the top of the head, with six impacts each (Figures 6.8, 6.9). None of the impacts at either of these locations reached any of the threshold levels for either linear or angular acceleration. Following these two locations, five impacts occurred to the left side. Of these five impacts, one had an angular head acceleration (5179.5 rad/s2) that exceeded the 25 % risk of injury tolerance level. This was the only non-header impact to exceed any of the previously established tolerance levels. The right side of the head and the back of the head had limited non-header impacts with two and one respectively.

Figure 6.8: Linear head acceleration for all non header impacts by location

130

Figure 6.9: Angular head acceleration for all non header impacts by location HIC was also evaluated by location of the impact for the non-header impacts (Figure 6.10). The highest HIC value for non-header events was 90.8 and occurred to the top of the head. This value is not considered to be at an injurious level as it is well under the tolerance level of 250 established for mTBI.

Figure 6.10: HIC for all non header impacts by location The highest peak linear acceleration of 56.7 g, to player 28, was found to

131 occur from a player collision (Figure 6.11). This was the only impact that player 28 experienced that was high enough to trigger the HIT system. With a

corresponding angular acceleration of 2910.3 rad/s2, it is unlikely that injury would occur as none of these values reach any of the injury tolerances currently established for mTBI. A separate incident, a collision with the goal, resulted in the peak angular acceleration of 5179.5 rad/s2 which occurred to player 22 (Figure 6.12). In

addition to this non-header impact, player 22 had four header impacts during their scrimmage. Although none of the header impacts exceeded tolerance

values for linear head acceleration, one of the headers had an angular acceleration of 4509.1 rad/s2. This nearly exceeds the tolerance level proposed by Zhang et al. (2004) and could increase the risk of additional impacts.

Figure 6.11: Linear head acceleration for all non header impacts for individual players

132

Angular Head Acceleration

9000 8000 7000 6000 5000 4000 3000 2000 1000 0 0 2 4 6 8
Angular Acceleration (rad/s2 )

p = 0.80 p = 0.50 p = 0.25

10 12 14 16 18 20 22 24 26 28 Player

Figure 6.12: Angular head acceleration for all non header impacts for individual players 6.4 Discussion There have not been any previous studies recording on-field

measurements of head acceleration during soccer play. Therefore, the current study cannot be compared to previous on-field data collections. It can, however, be compared to previous laboratory studies. The maximum linear and angular accelerations found in the current study greatly exceed those found by Naunheim et al. (2003). In the laboratory study, Naunheim et al. (2003) did not have linear or angular accelerations exceeding 199 m/s2 and 1.46 krad/s2 in contrast to a maximum linear acceleration of 617 m/s2 and a maximum angular acceleration of 8.87 krad/s2 determined in the on-field study. This is a 418 m/s2 difference in the maximum linear accelerations seen between the two studies and a 7.41 krad/s2 difference in the angular acceleration measurements. The current study also exceeds the acceleration measurements determined by Shewchenko et al. (2005). Shewchenko et al. (2005) determined

133 that the average peak linear acceleration over the different heading scenarios participants performed to not exceed 194 m/s2 which was found to be much lower than the peak average linear acceleration of 276 m/s2 from the current study. A peak average angular acceleration of 2.41 krad/s2 was found for the laboratory study in contrast to the 3.00 krad/s2 found in the current on-field study. These values are much more similar to the on-field collections than the study performed by Naunheim et al. (2003). This is due to the use of averages as opposed to maximums and it does not take into account worst case scenarios. Additionally the laboratory studies looked only at a redirection directly back towards where the ball came from. This reduces the amount of angular

acceleration that participants will experience and only represents a small portion of the type of headers players experienced during actual play. Data were compared to mTBI head injury tolerance values proposed previously (Ommaya, et al., 2002, Pellman, et al., 2003, Zhang, et al., 2004). None of the impacts, heading events or otherwise, exceeded the 66 g threshold which was the 25% risk of injury tolerance level (Zhang, et al., 2004) or the HIC value of 250 (Pellman, et al., 2003). Based on these observations, it seems as though the linear acceleration contribution of heading is not causing head injury based on a single impacts. Angular accelerations, however, did exceed the suggested limits. Three angular acceleration measurements for heading events (4509.8 rad/s2, 5298.3 rad/s2, 8869.1 rad/s2) exceeded the 4500 rad/s2 limit which has been suggested as the limit required to produce concussion in adults (Ommaya, et al., 2002). Of

134 these three impacts, one also exceeded the 25% risk of injury threshold of 4600 rad/s2 and one exceeded the 7900 rad/s2 limit which correlates to an 80% risk of head injury (Zhang, et al., 2004). In addition to the three heading events

exceeding the 4500 rad/s2 concussion injury tolerance level, an impact caused by a collision with the goal resulted in an angular acceleration of 5179 rad/s2 which also exceeds the 25 % risk of injury value proposed by Zhang et al. (2004). Although single impacts exceeded the suggested mTBI tolerance levels, there was no stoppage of play during any of the scrimmages due to injury. Funk et al. (2007) suggest a 10 % risk of injury with a linear acceleration of 165 g, a HIC of 400, and a peak angular acceleration of 9000 rad/s2 to produce mTBI. These values are much higher and indicate a lower risk of injury at the values seen in the current study. Tolerance values required to induce mTBI could be higher than Zhang et al. (2004) as suggested (Funk, et al., 2007), or the lack of stoppage of play could be due to other causes. This could be due to the fact that they fell within the percentage of the population that would not be injured at the suggested tolerances, or it is possible that these tolerance levels are not representative of the types of impacts that occur during soccer heading. It is also possible that angular acceleration alone is not the best predictor of injury in soccer heading impacts. Since these were the only values that exceeding injury tolerances, it is possible that these values alone are not representative of injury causation. The high levels observed could be due to a limitation of the instrumentation itself, but it when looking at the validation of the HITS higher

135 level impacts had a much better correlation than the lower level impacts. This indicates that the system responds accurately at the impact level at which injury is presumed to occur. However, data seem to indicate that angular acceleration during heading events could potentially pose a problem; especially as single impacts are exceeding 80% risk of injury tolerances. Additionally, all heading impacts with angular accelerations exceeding suggested limits took place to either the right or left side of the head. This indicates an unusual heading

method or inaccurate technique. When impacts took place to the front or top of the head, no limits were exceeded. This further emphasizes the importance of teaching proper technique. All of the suggested tolerance levels which current data were compared to were developed for single impact events. Many of the players in the current study experienced multiple impacts, not all of which were header impacts. All of the players who experienced tolerance exceeding impacts had other impacts as well. Player 22 actually experienced two of the four impacts that had angular accelerations above the recommended tolerance levels, one a header and one a collision with a goalpost. In addition to those two impacts, player 22 also had three other headers that fell below recommendations. Based on standard

tolerance levels it is challenging to determine if the combination of all of those impacts in a single scrimmage increases the likelihood of injury. Further

research is necessary to determine if the level of multiple impacts has an effect on mTBI probability. Additionally, further research is needed to determine if

136 symptoms are occurring after scrimmages where head accelerations are known. This could provide a possible correlation. Some limitations of the current study include the limited study population. The study was limited to a single age group and to female soccer players. Further research would be necessary to determine if differences exist in head acceleration based on age or gender. Additionally, the current study investigated soccer scrimmages and not actual games. This is due to the challenge of getting players to wear equipment that is not required during competition. Higher head accelerations may be seen during a more competitive, and likely more aggressive, game scenario.

137 CHAPTER 7 CONCLUSIONS AND FUTURE RECOMMENDATIONS 7.1 Conclusions Soccer is one of the most popular sports throughout the world. With a recent increase in youth players in the United States, an increase in injuries has also been reported. In addition to the unintentional head impacts that occur during soccer play, similar to those of other sporting activities, soccer players also intentional use their head to redirect the soccer ball, an act known as heading. The effect of these intentional impacts has been studied, the majority of research being conducted on adults, with conflicting outcomes. The risks to children are potentially greater due to their size versus the force being applied by the ball. It has been reported that ball mass, impact velocity, and size of the individual all contribute to the potential for injury. The importance of proper technique may be especially true in the youth population, since their skill level has not been well developed to control their head motion when heading the ball. Although previous research has been conducted to determine the effects of repetitive heading in soccer, the results are very controversial. Conflicting results have been observed in studies throughout the history of soccer heading research. Many of these previous studies have had significant challenges within the methodology, including the lack of controls or using improper control groups and many have not taken into account other outside factors that could be contributing to results. In order to determine the effects of the repetitive

138 subconcussive head impacts associated with heading, an in-depth analysis of the biomechanics of heading needed to be performed. The current study investigated the effect of the intentional head impacts that occur during soccer play. Initial steps were taken to determine the frequency and severity of heading episodes in the field using both field observation and to determine the possibility of head injury caused by impact with the ball only. The NEISS database was used to determine injury occurrence from ball to head only impacts. Ball only injuries comprised 15.9% of total head injuries. These injuries were not necessarily caused by heading the soccer ball, as some of the impacts were due to unintentional ball to head impact, but many of the cases were described as heading related. It is, however, challenging to determine a total number of participants due to the inclusion of organized and non-organized soccer injuries. These data indicate that heading alone can result in injuries severe enough to require medical attention. However, the current study most likely underestimates both total injuries and ball to head injuries because many less severe injuries would not be included. This is an inherent problem with using the NEISS database to estimate injuries. Therefore, the current study

represents the more severe cases, and is potentially an underestimate of the total injury occurrences. After establishing that youth soccer players have reported to the Emergency Department complaining of injuries that occurred from impact with the ball only, an analysis of the biomechanics of heading in youth soccer needed to be performed. In order to assess the biomechanics of heading in youth soccer, a

139 laboratory study was performed to determine head and back angles and neck muscle activation during a variety of heading tasks. Heading tasks were also included that had players modify there traditional technique in order to compare linear head acceleration and to see if any of the tasks were effective in reducing head acceleration. between players. It was found that heading techniques are quite variable An overall inconsistency was found for head flexion, torso

flexion, and head rotation. It was also noted that this variability existed in EMG data as well. This is very similar to what has been previously observed in adult players. This is most likely due to the many possible heading scenarios.

Therefore, players do not use muscle memory to perform the task in the same manor every time, but instead learn to adjust to whatever scenario occurs. This provides unlimited possibilities for heading scenarios and would most likely result in additional variation in results. The current study only looked at redirection directly at the source of the ball launch. If additional scenarios were introduced to provide redirection in other ways, additional distinctions would be made. Comparisons between genders or between heading tasks were

challenging to make. Based on the results of the current study, it indicates that differences are not related these variables, but that the differences occur between each player. This also made making a comparison with the adult

players unproductive as any difference would most likely have nothing to do with age, but with the players being different and the scenarios being slightly different. Although attempts have been made to determine head acceleration during soccer heading events, a system for on field data collection had not been

140 previously available. This system was created for use in soccer research, but had to be validated prior to use. A validation was conducted using various

scenarios that typically occur in soccer play. The results show that the new soccer HITS system correlates well with the standard measurement system of the HIII 3-2-2-2 accelerometer system. Although the system requires the use of a headband, it provides a much needed method to measure head acceleration in soccer players during normal play. It allows for accurate measurements to be taken which could potentially lead to an injury threshold specific to certain soccer impacts. Additionally, this system will allow a comparison between different

types of impacts that occur during soccer play. Once validation occurred of the HITS head acceleration system, this system was implemented in soccer scrimmages to determine actual on-field head acceleration. The current study found both linear and angular head

accelerations that exceeded the acceleration measurements determined previously in laboratory studies. This could be due to the fact that laboratory studies using players have to use a ball impact speed that is on the low end of what would be seen in the field. Additionally the laboratory studies looked only at a redirection directly back towards where the ball came from. This reduces the amount of angular acceleration that participants will experience and only represents a small portion of the type of headers players experienced during actual play. Data were compared to mTBI head injury tolerance values proposed previously, and none of the impacts exceeded the injury tolerance levels for

141 linear head acceleration or HIC. Based on these observations, it seems as

though the linear acceleration contribution of heading is not causing head injury based on a single impacts. There were, however, impacts that exceeded

suggested values for angular head acceleration. Although single impacts exceeded the suggested mTBI tolerance levels, there was no stoppage of scrimmage play due to injury. This could be due to the fact that they fell within the percentage of the population that would not be injured at the suggested tolerances, or it is possible that these tolerance levels are not representative of the types of impacts that occur during soccer heading. It is also possible that angular acceleration alone is not the best predictor of injury in soccer heading impacts. Additionally, all heading impacts with angular accelerations exceeding suggested limits took place to either the right or left side of the head. This indicates an unusual heading method or inaccurate technique. When impacts took place to the front or top of the head, no limits were exceeded. This further emphasizes the importance of teaching proper technique. 7.2 Future Recommendations One of the major challenges in the current study was comparing head acceleration measurements to injury tolerance levels that were established for single impacts of a different nature than those that occur during soccer play. It would be of interest in future research to determine a threshold for multiple impacts. This would be of specific interest in the sporting community where many players are at risk for multiple low level impacts.

142 One of the first steps to determining this threshold occurred in the current study, where a greater knowledge of what occurs during soccer heading events was gained. It is, however, necessary to further investigate the head

acceleration values that are obtained in other populations. The current study lacks any on-field data collection during soccer scrimmages involving male players. Additionally, different age groups should be investigated to determine if there is an difference as players age. Although it would be of interest to

determine head acceleration in younger players, it is unlikely that there would be enough heading events to warrant this investigation. Soccer scrimmages and not actual games were investigated due to the challenge of getting players to wear equipment that is not required during competition. Higher head accelerations may be seen during a more competitive, and likely more aggressive, game scenario. Future studies would be required to determine if these differences actually occur. In addition to these on-field measurements, further research should be performed in the area of soccer biomechanics within the laboratory setting. The current study, along with previous studies, only looked at redirection directly at the source of the ball launch. If additional scenarios were introduced to provide redirection in other ways, additional variation would most likely be noted. It

would be of interest to determine if head acceleration changes with the addition of alternate redirection scenarios.

143

APPENDIX A HIC APPROVALS

144

145

146

147

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160 ABSTRACT EVALUATION OF REPETITIVE HEADING IN YOUTH SOCCER BY ERIN HANLON December 2009 Advisor: Cynthia Bir, Ph.D. Major: Biomedical Engineering Degree: Doctor of Philosophy The specific aims of this project were: 1) to determine the incidence of head injury in youth soccer related only to head to ball impacts using the National Electronic Injury Surveillance System database; 2) determine the frequency of heading in youth soccer based on age, gender, and skill level; 3) validate a novel headband system to measure head impact frequency during soccer play; 4) measure the biomechanical response of youth soccer players during heading events using the Functional Assessment of Biomechanics motion capture system and; 5) measure head impact frequency and severity using the Head Impact Telemetry System (HITS). A total of 62,021.55 soccer head injuries were

estimated to occur from 2002 to 2007 in the United States with 15.9 % of these injuries being caused by impact with the ball only. When observing the

frequency of heading occurrences, males had significantly more headers/minute and total headers than females, but females incurred 59.64% of the injuries that were caused by impact with the ball only. A novel head acceleration

measurement system, HITS, was found to provide a much needed method to

161 measure head acceleration in soccer players during normal play. It allows for accurate measurements to be taken which could potentially lead to an injury threshold specific to certain soccer impacts. The system was used in during soccer scrimmages and measured head acceleration during impact events that took place during these scrimmages. None of the impacts, heading or otherwise, exceeded the tolerance levels for mild traumatic brain injury (mTBI) that were previously established for linear head acceleration. Angular accelerations for three heading events and one non heading even, however, did exceed the suggested limits. Based on these observations, it seems as though the linear acceleration contribution of heading is not causing head injury based on a single impacts. Angular acceleration has potential problem and should be investigated further in conjunction with determining tolerance values for multiple impacts.

162 BIOGRAPHICAL STATEMENT ERIN HANLON PLACE OF BIRTH: Georgetown, OH, USA EDUCATION: 2009 2006 2004 Ph.D MS BS Biomedical Engineering Biomedical Engineering Biomedical Engineering Wayne State University Wayne State University Wright State University

ACADEMIC EXPERIENCE: 2005 to date 2007 to 2009 2005 Graduate Research Assistant Mentor, Freshman Engineering Graduate Student Assistant Wayne State University Wayne State University Wayne State University

SELECTED PUBLICATIONS: Hanlon, E., Bir, C. (2009). Validation of a Wireless Head Acceleration Measurement System for Use in Soccer Play. Journal of Applied Biomechanics. Accepted with Revisions. Hanlon, E., Bir, C. (2009). Real Time Measurement of Head Acceleration During Youth Soccer Play. Poster Presentation at the Summer Bioengineering Conference, June 2009, Lake Tahoe, California. Hanlon, E., Bir, C. (2008). A Model to Determine the Effect of Multiple Subconcussive Impacts in the Rat. Podium Presentation at the American Society of Biomechanics Annual Conference, August 2008, Ann Arbor, Michigan. Hanlon, E., Bir, C. (2007). The Determination of Heading Frequency in Youth Soccer. Podium Presentation at the American Society of Biomechanics Annual Conference, August 2007, Palo Alto, California.