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Is Protective Equipment Useful in Preventing Concussion? a Systematic Review of the Literature B W Benson,1 G M Hamilton,1 W H Meeuwisse,1 P Mccrory,2 J Dvorak3

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Is Protective Equipment Useful in Preventing Concussion? a Systematic Review of the Literature B W Benson,1 G M Hamilton,1 W H Meeuwisse,1 P Mccrory,2 J Dvorak3 Downloaded from bjsm.bmj.com on December 6, 2011 - Published by group.bmj.com Supplement Is protective equipment useful in preventing concussion? A systematic review of the literature B W Benson,1 G M Hamilton,1 W H Meeuwisse,1 P McCrory,2 J Dvorak3 1 Sport Medicine Centre, Faculty ABSTRACT 1960s and 1970s, mouthguard use was mandated of Kinesiology, and Department Objective: To determine if there is evidence that by several US and Canadian organised sports of Community Health Sciences, equipment use reduces sport concussion risk and/or including football, ice hockey, lacrosse, field hockey Faculty of Medicine, University of Calgary, Calgary, Alberta, severity. and boxing. The premise for mandating use was Canada; 2 Centre for Health, Data sources: 12 electronic databases were searched not only to decrease dental injury rates, but also Exercise & Sports Medicine, using a combination of Medical Subject Headings and text reduce players’ risk of concussion.7–15 The benefits University of Melbourne, 3 words to identify relevant articles. of mouthguard use in protecting athletes from Parkville, Australia; F-MARC, 7–9 16–23 FIFA Medical Assessment and Review methods: Specific inclusion and exclusion dental injury is supported in the literature, Research Center, Schulthess criteria were used to select studies for review. Data however, controversy exists as to whether mouth- Clinic, Zurich, Switzerland extracted included design, study population, exposure/ guard use can reduce athletes’ risk of concussive outcome measures and results. The quality of evidence head injuries.24–26 Face shields attached to helmets Correspondence to: Dr B Benson, Sport Medicine was assessed based on epidemiologic criteria regarding are another piece of equipment that has been Centre, University of Calgary, internal and external validity (ie, strength of design, hypothesised to decrease the frequency of con- 2500 University Drive NW, sample size/power calculation, selection bias, misclassi- cussive head injuries in sport. During the l970s, full Calgary, Alberta, Canada, T2N facial protection was mandated by all organised 1N4; [email protected] fication bias, control of potential confounding and effect modification). youth ice hockey associations worldwide.27 These rules, combined with the improvement of face Accepted 6 February 2009 Results: In total, 51 studies were selected for review. A comparison between studies was difficult due to the shield standards, have been shown to reduce the 8–15 28–31 variability in research designs, definition of concussion, frequency of facial, dental and eye injuries. mouthguard/helmet/headgear/face shield types, mea- To date, we are not aware of any studies that surements used to assess exposure and outcomes, and have systematically reviewed the evidence on the variety of sports assessed. The majority of studies were effects of all types of equipment use on concussion observational, with 23 analytical epidemiologic designs prevention. The objective of this manuscript is to related to the subject area. Selection bias was a concern systematically review the literature and determine in the reviewed studies, as was the lack of measurement if there is scientific evidence that mouthguard, and control for potentially confounding variables. helmet/headgear and face shield use, compared Conclusions: There is evidence that helmet use reduces with non-use, reduces sport-related concussion head injury risk in skiing, snowboarding and bicycling, but rates and/or severity of injury among male and the effect on concussion risk is inconclusive. No strong female athletes of all ages and levels of competi- evidence exists for the use of mouthguards or face shields tion. Study limitations will be discussed and to reduce concussion risk. Evidence is provided to suggest specific recommendations will be made for future that full facial protection in ice hockey may reduce research. concussion severity, as measured by time loss from competition. METHODS Data sources Twelve electronic databases were searched using a Concussion, defined as a ‘‘complex pathophysiolo- combination of Medical Subject Headings and text gical process affecting the brain, induced by words by means of ‘‘wild cards’’ and Boolean 1 traumatic biomechanical forces’’, is one of the operators to identify potentially relevant English most common and potentially dangerous types of and non-English articles. The search strategies injuries sustained in collision sports.2–5 Specific risk administered were as follows: factors are poorly delineated and rarely studied 1. mouthguard$ OR (mouth guard$) OR (mouth which makes primary prevention a difficult task as protect$) OR (gum shield) [all fields] AND (con- there is little evidence to base preventive strategies. cussion$ OR (brain injur$) OR (head injur$) OR Equipment use such as properly fitted and injur$) [all fields]; maintained helmets/headgear, mouthguards and 2. (helmet$ OR headgear$ OR (head protect$)) face shields are commonly purported concussion [all fields] AND (concussion$ OR (brain injur$) OR prevention strategies. Their use in some sports is (head injur$) OR injur$) [all fields] AND sport$; obligatory (eg, football, lacrosse, ice hockey), 3. ((face shield$) OR visor$ OR (face protect$)) whereas in others they are optional (eg, rugby, [all fields] AND (concussion$ OR (brain injur$) OR soccer). The benefits of helmet use has been (head injur$) OR injur$) [all fields] AND sport$. established with empirical evidence in some sports For mouthguard articles, the Science Citation that do not require its use (ie, bicycling),6 but there Index Expanded (1900–2008), Social Sciences is much debate on the use of headgear in other Citation Index (1956–2008) and Arts & sports (ie, rugby, soccer, rodeo, skiing, snowboard- Humanities Citation Index (1975–2008) databases ing, Australian rules football, etc). During the (ISI Web of Science, 1900–Sept 2008) were also i56 Br J Sports Med 2009;43(Suppl I):i56–i67. doi:10.1136/bjsm.2009.058271 Downloaded from bjsm.bmj.com on December 6, 2011 - Published by group.bmj.com Supplement searched by entering a commonly referenced original study,13 of all concussions sustained among 2470 football players from revealing 43 citations. Furthermore, the bibliographies of the 21 Alabama high schools over three consecutive seasons (1984– selected articles were hand-searched to identify additional 6) were sustained by players who did not wear mouthguards articles not revealed by the above search strategies. (p = 0.001).32 The remaining three descriptive observational studies were case series or reports. The case report suggested a Study selection protective effect on repeat concussion over one season in a The following inclusion criteria were used to select relevant rugby player who wore a custom-fitted, triple-laminated, 36 studies: (1) original data; (2) case report, case series, cross- pressure moulded mouthguard. One case series revealed no sectional, case control, cohort, quasi-experimental or experi- post concussion differences in neurocognitive deficits (via mental study designs; (3) published peer-reviewed abstracts; (4) ImPACT) between mouthguard users and non-users at the 37 outcome includes a measure of concussion sustained in sport or time of first follow-up assessment (mean 3 days), while the biomechanical study of concussion; (5) studied concussions other case series reported no concussions sustained by one associated with mouthguard, helmet/headgear or face shield University football team over one season for players who wore 38 use; (6) exposure included some measurement of mouthguard, custom-fitted mouthguards. helmet/headgear or face shield use; (7) male or female subjects; Five prospective cohort studies were conducted to assess the (8) all ages; (9) all levels of competition; (10) all types of sports association between mouthguard use (vs non-use) and concus- (contact and non-contact); (11) all languages; and (12) peer- sion rates. One study provided evidence to suggest a protective reviewed and non-peer reviewed reports. Exclusion criteria were effect of mouthguard use on concussion severity (measured by 39 as follows: (1) review articles; (2) commentaries; (3) letters to time loss from unrestricted participation), three studies found 19 40 41 the editor; (4) no measure of mouthguard, helmet/headgear or no significant difference in concussion rates, and one study face shield exposure; and (5) studies exclusively examining head examined concussion rates between football players wearing injuries other than concussion associated with mouthguard, custom versus non-custom mouthguards and thus did not 26 helmet or face shield use. The titles and abstracts of the examine risk differences between users and non-users. The one identified citations were screened by two reviewers to identify cohort study suggesting a protective effect on concussion all potentially relevant articles. If there was insufficient severity did not measure individual mouthguard exposure and 39 information available (eg, no abstract), the full papers were therefore could not provide a measure of relative risk. The fifth reviewed. Potentially relevant articles were obtained and the prospective cohort was a large study of 1033 professional ice methods section reviewed to identify studies that met the pre- hockey players revealing that the risk of concussion was not determined inclusion criteria. significantly different between players wearing mouthguards versus no mouthguards (relative risk: 1.42, 95% CI: 0.90 to 2.25),
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