Archive for the ‘Lacrosse’ Category

Commotio Cordis in Sports and New NOCSAE Standard on Chest Protectors

Looking to provide athletes the best heart protection possible

Commotio cordis is a sudden cardiac arrhythmia caused by a direct blow to the chest. It typically results from a low-velocity impact to the chest from a thrown or batted ball, puck or other object typically traveling between 20 and 50 mph. The risk increases the closer the impact is to the center of the heart.Death results when an abnormal rhythm, ventricular fibrillation, develops. However, blood circulation to the heart may also be affected.

For commotio cordis to occur, the impact has to be precisely timed to strike the heart during a 15 to 30-millisecond phase of the electrical cycle. It can cause sudden death in young baseball, softball and hockey players, as well as other athletes.

Commotio Cordis by the Numbers

  • The sport with the highest incidence of commotio cordis is baseball, followed by softball, hockey, football, soccer and lacrosse.
  • An overwhelming 95 percent of cases affect males.
  • The most frequently affected age group is 10 to 18 years.
  • Since 1995, the U.S. Commotio Cordis Registry received reports of over 225 cases. Many more unreported cases are suspected of having occurred.
  • The Registry reports a survival rate of 24 percent.

Survival Outcome

While instances of commotio cordis are rare, sadly, the death rate is 90 percent. Unfortunately, the lack of response to CPR efforts by healthy young athletes is unexplained.

History shows that responding with CPR efforts within three to five minutes is critical. Studies indicate AEDs and Risk Managementthat the chances of surviving an incident of commotio cordis are enhanced if a shock from an automated external defibrillator (AED) can be delivered promptly. Most ballparks don’t have AEDs, and those that do must have well-practiced procedures in place for the rapid use of the device. Otherwise, all is for naught.

Also, the high-profile lawsuit in New Jersey of a pitcher being struck by a batted ball that came off of an alleged “hot bat” involved commotio cordis resulting in a permanent disability to the pitcher. The metal bat manufacturer and others were sued. What is interesting to note is that commotio cordis usually occurs only when a projectile travels at a relatively slow speed, usually between 20 and 50 mph. In this case, the basis for the lawsuit was that the ball speed was too fast as a result of the alleged “hot bat.”

Protecting Against Commotio Cordis

Researchers have been looking for solutions, typically in the form of chest protectors. But statistics show that somewhere between 20 and 30 percent of commotio cordis victims collapsed while wearing chest protection of some sort. Obviously, this means that the protection athletes were given wasn’t good enough.

Educating coaches, players and parents about the importance of preventing precordial blows is critical. For example, baseball and softball players should be taught to step aside or to turn and deflect balls using the shoulder, not the chest wall.

Commotio cordis is not related to an underlying heart condition. Therefore, susceptibility cannot be predetermined by a medical screening.

Spectators, players, and staff need to be able to recognize the signs of commotio cordis and take immediate action if a player is struck in the chest and collapses.

New NOCSAE Standards in Protection

In July 2018, the National Operating Committee on Standards for Athletic Equipment (NOCSAE) set the world’s first performance standard for chest protection from commotio cordis. NOCSAE developed separate versions for baseball and lacrosse. Governing bodies of the various sports will decide whether or not they include compliance with these NOCSAE standards in their rules of play and when that goes into effect.

The Science Behind the New Standards

Together with the Louis J. Acompora Memorial Foundation, NOCSAE funded more than $1.1 million in Commotio cordis standards for chest protectorsresearch that pinpointed the cause of commotio cordis, including the critical moment of occurrence. To test impacts to the chest and heart, research engineers then developed a mechanical chest that mimics the human response of the human. All this led to NOCSAE creating the first commotio cordis-specific chest protection standard. NOCSAE looks to reduce the risk of death significantly from commotio cordis for athletes using equipment certified to this new standard.

Chest Protector Certifications By SEI

The Safety Equipment Institute (SEI) issued the first certifications for chest protectors that meet NOCSAE’s new standard. The NOCSAE criteria support a test method that produces reliable measurements to evaluate various types of chest protectors.

Chest protector manufacturers participating in SEI’s certification program must also have their facility and operations audited for quality assurance.  Additionally, all products labeled SEI and NOCSAE-certified must be recertified annually. Yes, all products have to be retested, and the manufacturing facility successfully meets all SEI quality-assurance requirements each year.  SEI serves as the world’s premier certification organization for safety and protective products.

High School Rule Change in Baseball For Catchers

The standard update for chest protectors resulted in a rule change by the Baseball Rules Committee of the National Federation of State High School Associations (NFHS). Rule 1-5-3, effective January 1, 2020, requires catchers wear chest protectors that meet the NOCSAE standard as the time of manufacture. Knowing that catchers are wearing equipment certified by the latest safety standards provides players, coaches, parents and school administrators assurance that athletes have the best heart protection possible, said Elliot Hopkins, NFHS director of sports and student services. Other youth baseball organizations will need to address whether or not they will follow the lead of NFHS.

No Guarantees of Protection and Opponents of New Standard

It’s important to note that neither NOCSAE nor SEI offer any guarantees of protection from the certified chest protectors. They clearly state that no thoracic or chest protector can prevent all cardiac injuries, and that catastrophic injury and death may occur to a wearer of a NOCSAE and SEI-certified protector.

Opponents of the new standard point out that neither NOCSAE, SEI, nor any manufacturer can say affirmatively that their product does prevent commotio cordis. Also, many question if the additional expense of compliance is worth protecting the very low number of athletes impacted by this rare condition, especially since there are no guarantees. Others wonder if the new chest protectors may cause unintended consequences such as adding an additional heat layer that may contribute to heat illness.

If you found this blog on commotio cordis to be beneficial, please check out our other sports risk management content, and other risk management blog posts.

Commotio cordis

Latest on Youth Concussions from American Academy of Pediatrics

The American Academy of Pediatrics just released an update on Sport-Related Concussions in Children and Adolescents. This 24-page report highlights the major developments in new concussion knowledge and treatment since the first report, which was published in 2010.

To follow are the points that I find to be of particular interest. Some the conclusions and actionable recommendations may be contrary to what is being disseminated by various bloggers and vendors of products related to concussions. But always remember that true science can be a very slow process and future studies may ultimately prove contrary results. If these topics are of interest, you should read the entire article for more information.

Concussions: Mechanical vs Chemical/Cellular Injury

There is no universally-accepted definition of a concussion and there are a wide range of symptoms which require individual management.

After a biomechanical injury to the brain due to either direct impact or whiplash effect, a cascade of chemical changes occur resulting in injury on a cellular level. Some of the medical terms for these are potassium efflux from neurons, increase in extracellular glutamate, upregulation of sodium-potassium ion pumps, depletion of intracellular injury reserves, and increased use of adenosine triphosphate and hyperglycolysis. All of these biochemical reactions result in decreased blood flow and increased energy demand which leads to an energy crisis.

In other words, concussions are a lot more complicated than just a bump to the head, making future research and studies necessary.

Rest After Concussions

After a concussion, an immediate reduction in physical and mental activity can be beneficial to recovery. However, prolonged restrictions of physical activities and delayed return to school can have negative effects on recovery and symptoms. A graduated return-to-play protocol should be followed under the supervision of a healthcare professional.

Reporting of Concussions Over the Past Decade

Studies indicate that the reporting of youth concussions has increased dramatically over the last decade with increases ranging from 57% to 200%. This is likely caused by the increased overall awareness of coaches, participants, and parents due to media exposure and education initiatives.

Concussions in Girls vs Boys

Female athletes are more likely to report symptoms to an authority figure than male athletes, despite Concussions in Girls soccerboth having the same knowledge.

Studies indicate that concussion rates from highest to lowest for boys are as follows: American tackle football, lacrosse, ice hockey, and wrestling. For girls: soccer, lacrosse, field hockey, and basketball.

Girls have higher concussion rates than boys in soccer and basketball.

The reasons that girls seem to be more susceptible are not entirely clear, but it has been suggested that it is due to weaker neck musculature and estrogen.

In school sports, for boys and girls combined, the following have the highest concussion rates: middle school tackle football, girls soccer, cheerleading, and girls basketball.

A study of youth tackle football for ages 8 to 12 indicates that the concussion rates are higher than in high school athletes and that 11 to 12 year olds have a nearly 2.5 increased risk as compared to 8 to 10 year olds.

Concussion incidence is higher in competition than in practice for males and females across nearly all sports.

Most Frequent Signs and Symptoms

Headache 86% to 96%
Dizziness 65% to 75%
Difficulty Concentrating 48% to 61%
Confusion 40% to 46%

Problems to Watch Out For in Post-concussion Diagnostic Tests

The most frequent sideline test used by athletic trainers is the Sport Concussion Assessment Tool (SCAT) and is available in following forms: Child SCAT 5 (ages 5 to 12) and SCAT 5 (ages 13+). These tests, which only take about 10 minutes to perform, are being constantly updated. They consist of observable signs of concussion, symptoms assessment, memory questions, neurological assessment, and balance assessment.

Symptoms can mimic pre-existing problems such as migraine, headache disorders, learning disorders, ADHD, mental health conditions, and sleep disorders. As a result, the examiner should be informed of any such condition.

Some sideline diagnostic assessment tools and checklists are not appropriate for children ages 5 to 12. Younger athletes perform worse on questions such as naming months or numbers in reverse. Concussions in youth sportsVariations are available for younger children such as the Child SCAT 5..

Tests that measure visual deficits, such as the King-Devick Test, show promise but not enough evidence from studies yet to recommend their inclusion in the SCAT.

While healthcare professionals find sideline assessment tests to be helpful, they are not to be used in isolation in diagnosing a concussion. Not enough studies exist at this time to recommend widespread use in children. Also, the value of sideline tests is minimized without a baseline test for comparison. See HitCheck for an example of an affordable sideline assessment app.

Are CAT Scans and MRIs Necessary? Which One Is Superior?

CAT scans and MRIs are critical when a severe intracranial injury or structural lesion (skull fracture or hemorrhage) is suspected, but they are not effective in diagnosing a concussion. Despite this, the use of neuroimaging increased 36% between 2006 and 2011.

Recent literature indicates that it is highly unlikely that significant intracranial hemorrhaging occurs after six hours without a deterioration in the level of consciousness. As a result, prescribing a CT without any deterioration of consciousness after six hours is unlikely to be helpful.

When neuroimaging is necessary, CT’s are more cost effective and can usually be arranged more quickly. However, children’s exposure to radiation may increase the risk of certain cancers over the long term. After the emergency period is over, MRIs are superior to CTs in detection of cerebral contusion, petechial hemorrhage, and white-matter injury.

Baseline Neurocognitive Testing

Studies conducted independently by developers of paper and online testing platforms have questioned the reliability of baseline tests from year to year. It is important for the reviewer who compares baseline to post- injury tests to understand modifiers that could alter results, such as depression, lack of sleep, failure to take ADHD medication, and athletes with musculoskeletal injuries.

The best environment for baseline and post-injury testing is a quiet, distraction-free environment, which can be very difficult to achieve for most schools and organizations.

Concerns about athlete “sandbagging” and intentionally under-performing on baseline tests are exaggerated as this can be detected.

Neurocognitive tests should not be used as the sole determining factor in return-to-play decisions.

Retirement After Multiple Concussions

The decision to retire an athlete after multiple concussions should not be tied to any specific number of concussions.

An athlete who has suffered multiple concussions should be referred to a specialist with expertise in this area for guidance.

Prevention of Concussions: What Can Be Proven By Studies

  • Mouth guards: After an initial 1954 study suggesting a connection between mouth guards and reduction of concussions, several larger studies refuted this assertion. Evidence of an advantage of custom mouth guards over non-custom remains inconclusive.
  • Helmets: Helmets were designed to reduce severe injuries such as skull fractures, subdural Football helmets and concussionshematomas, and brainstem contusion or hemorrhage. The goal of reduction of concussions has not proven to be productive. Several studies show no difference between several brands and models of helmets, both new and refurbished, in terms of severity of symptoms, frequency, and recovery time. Helmet improvements are not likely to ever be the solution to the concussion problem.
  • Aftermarket Helmet Attachments: No study has ever shown that aftermarket helmet attachments such as pads, shock absorbers, and sensors prevent or reduce the severity of concussions. The use of sensors to clinically diagnose or assess concussions cannot be supported at this time and do not have a role in decision making. See our article “Add-on Helmet Products.”
  • Other Headgear: Soccer headgear has not proven beneficial in the reduction of head-to-head or head-to-ball impact. Such headgear may actually increase the incidence of injury by encouraging more aggressive play.
  • Education: Education and awareness of concussions has proven effective in diagnosing, treating, and making return-to-play decisions. This finding is consistent with Sadler Sports Insurance injury data on concussion rates in youth baseball and football prior to 2012 and after 2012.
  • Biomarkers: Biomarkers have been investigated in playing a role in concussion evaluation. These include predisposition factors, delayed recovery, and increased catastrophic risk. These investigations are preliminary and none have advanced to use in a clinical setting.
  • Supplements: Numerous supplements have been investigated as to playing a role in preventing or in speeding up the recovery time from concussions. There are currently no studies in humans to support a benefit from supplements.
  • Neck Strengthening: Strengthening the cervical muscles and activating those muscles prior to impact has been found to reduce forces from head impact. Poor neck strength has been shown to correlate with the incidence of concussions. One study showed that each additional pound of neck strength resulted in a 5% reduction in concussions.
  • Rule Changes: Rule changes and enforcement of rules by officials may help to reduce the likelihood of concussions. Recent initiatives in youth sports look promising. These include elimination of checking in ice hockey and heading soccer in younger age groups, and reducing contact in football practice.

I hope you enjoyed my summary of this very informative article. At Sadler Sport Insurance, we have an excellent risk management library on the topic of concussion and brain injury risk management that you should check out.


 

Commotio Cordis: Proposed NOCSAE Standard for Chest Protectors

“If we can stop a bullet, we can stop a ball”

Baseball is arguably one of the safest team sports. But it’s also where we see the most incidents of commotio cordis, a sudden cardiac arrhythmia caused by a direct blow to the chest. While instances of commotio cordis are rare, one death is too many.

Heart attacks among teen athletes are quite rare, and are most often a result of an underlying physical defect. Commotio cordis has no correlation to the physical health of the victim. According to lab tests at Tufts University Medical Center, it occurs when an object traveling approximately 40 mph makes impact directly over the heart in the milliseconds between heartbeats.

Who’s at risk and why

Catchers, pitchers and infielders are most at risk for blows by high-speed balls. Lacrosse and hockey players are also susceptible to being struck by rocketed balls and pucks. Boys under the age of 15 are most at risk of commotio cordis because their chest walls are still flexible as their bones continue developing into their early 20s.

The best chance victims have for surviving commotio cordis is resuscitation by a defibrillator, a device not housed at every ballfield. And if one is available, there needs to be someone in attendance who has been trained in its proper use.

Equipment manufacturers relying on science to help reduce the risk

But researchers are coming up with another solution. Statistics show that nearly one third of commotio cordis victims collapsed while wearing chest protection of some sort, which means that the protection athletes were given wasn’t good enough.

In January, the National Operating Committee on Standards for Athletic Equipment (NOCSAE) proposed the first standard for chest protectors used in baseball and lacrosse with the intention of reducing the risk of cardiac events. To meet the standard, manufacturers have to come up with a material that will distribute the force of the blow but not affect movements of the players.

Earlier this year, Mark Link, a Tufts University Medical Center heart specialist, published results of tests run on a model made of foam and a combination of polymers that appears promising. The company that developed the material, Unequal Technologies, plans to test it’s chest protectors and heart-covering shirts against the NOCSAE standard. Other manufacturers are visiting the NOCSAE laboratories to educate themselves on the testing process so they can modify their products to comply with the standard.


Source: Lauran Neergaard. “Performance standard proposed for chest protector in baseball, softball.” www. santacruzsentinel.com. 30 May 2016.

Youth Athletes and Concussion Recovery

Too many parents following outdated medical advice

Starve a cold, feed a fever. Swimming within 30 minutes of eating causes cramps. Cracking your knuckles causes arthritis. Tilt the head back to stop a nosebleed. All outdated but once heavily relied upon advice from the medical community. Sadly, these and similarly unsubstantiated notions continue to circulate. And apparently so are incorrect ideas about concussion recovery.

Despite ongoing media attention and education efforts surrounding concussions, research shows that many parents still rely on outdated advice when monitoring their concussed children. Where once the impact of concussions was downplayed, apparently now parents are going to the opposite extreme and impeding recovery.

A national survey conducted by UCLA Health asked 569 parents how they would care for a child with concussion symptoms that persisted a week following the head injury. More than 75% said they would wake their child to check on them throughout the night and 84% said they would not permit the child to participate in any physical activity. About 65% said they prohibit use of electronic devices.

Making a healthy recovery

Frequent disruption or lack of sleep can affect memory, moods and energy levels, which are exactly what doctors use to measure concussion recovery. Once the child has been examined by a medical professional and determined to be at no further risk, sleep will help the brain recover more quickly, according to Christopher Giza, a UCLA paediatric neurologist.

And while contact sports are to be avoided until the child is fully recovered and cleared by a medical professional, mild exercise and aerobic activities such as walking and bike riding promote the healing process and overall good health.

As for electronic devices, it’s a good idea to keep kids off them during the early days of the injury. But easing them into their normal social, intellectual and physical activity is what’s best.

Most concussion patients make a full recovery, though dizziness and headaches can persist for weeks. Parents should always heed the advice of the physician monitoring the child and remember that rest and pain relievers for headaches are the best treatments in most cases.


Source: “Parents following outdated concussion tips,” www.sbs.com.au. 08 Sept. 2016.

Protecting Against Risk of Commotio Cordis

Study shows new chest protector is effective and youth athletes most at risk.

Athletic chest protectors are critical to the safety of hockey and lacrosse goalies, baseball/softball catchers, and umpires. There is a wide assortment of chest protectors on the market, most of which have proven to be less than adequate against serious injury and can give a false sense of security.

But one manufacturer’s product apparently now offers better protection from potentially fatal blows to the chest.

The Unequal Technologies HART Chest Protector have proven 95 percent effective in the prevention of Commotio cordis,  according to a study published in The Clinical Journal of Sports Medicine. Commotio cordis is a sudden disruption of the cardiac rhythm caused by a forceful impact to the chest that often results in fatal cardiac arrest.

Unequal Technologies develops protective padding for a variety of athletic of headgear, including the popular Halo headband.

Youth athletes under the age of 16 are most at risk from such incidents. About 10 to 20 cases occur annually in the U.S. More than one-third of Commotio cordis incidents occur in athletes wearing chest protectors, according to a study published in 2013. Therefore, it’s paramount that appropriate padding is properly placed.

For more information on Commotio cordis, click here.


Source: “Study Finds Unequal Technologies’ Chest Protectors To Be First To Significantly Reduce Risk Cardiac Concussions For Youth Athletes,” www.sporttechie.com. 22 April, 2016.

Youth Baseball and Eye Injuries

Looking at preventative measures

As everyone knows, baseball season is now in full swing. But what many probably don’t know is that youth athletes under the age of 14 incur more eye injuries in baseball and softball than any other sport. In rare instances, these injuries can result in permanent damage or even blindness.

Overall, there are more than 40,000 eye injuries reported each year, most occurring in baseball and basketball, followed by water and racquet sports. Balls, bats, pucks, racquets, and sticks are used in the sports that pose the highest risk for eye injuries. These sports also typically include body contact.

The leading cause of child blindness in the U.S. is injury, with most cases occurring in sports-related activities, according to the National Eye Institute. Penetration, blunt trauma and radiation are the most common causes of sports-related eye injuries. Exposure to the sun’s ultraviolet rays can result in radiation damage, which can be a particular risk when snow skiing, water skiing and participating in other water and snow sports.

Prevention measures

According to Jay Novetsky, 90% of sports-related eye injuries are preventable. Novetsky, an eye surgeon at the Vision Institute of Michigan, advocates for protective eyewear as part of every sports’ regulated safety equipment, such as safety shields, safety glasses, goggles and eye guards.

To specifically prevent injuries in baseball, batting helmets can be fitted with protective face guards and fielders can wear safety-certified sports goggles.

Many people don’t realize  that prescription glasses (and sunglasses) worn during play not only don’t offer protection, but they increase the risk of eye injury. Street eyeglasses and contacts can easily shatter upon impact and puncture the eye and surrounding areas.  Athletes who wear glasses or contacts can usually have their prescriptions matched in protective eyewear.

Return to Play

In order to return to play following an eye injury, the eye should be pain free, cause no discomfort and vision returned to normal. Release by an ophthalmologist should be required before an player with a serious eye injury returns to play. The team physician or athletic trainer should be able to determine if and when players with less serious eye injuries can return. Athletes returning to play following an eye injury should be required to wear eye protection to avoid a second injury.


Source: “Baseball Ranks #1 in Sports-related Eye Injuries for Kids.”.  www.digitaljournal.com. 14 April, 2016.