Comparison of Preseason and Postseason ImPACT Scores in NCAA College Soccer Players

1. Comparison of Preseason and Postseason ImPACT Scores in NCAA College Soccer Players Demetri Menegos, D.O.April 16, 2010 Sports Medicine Fellow Atlantic Health--Overlook Mount Sinai School of Medicine

2. Background • College Soccer players suffer repetitive impact to the head throughout their season through heading of a soccer ball • Both in practice and in games they must strike the ball with their head from defensive and offensive positions • This exposes them to multiple impacts to the head throughout their season • Depending on position some players will head the ball more than others

3. Background • How repetitive heading of a ball throughout a season may affect a player's performance on Neuropsychological testing is unclear • There is much ongoing debate as to the effect of heading a ball on a soccer player's long term health • It has been suggested that soccer players should wear protective head gear, especially at the youth level to protect a player from developing Neurocognitive dysfunction secondary to heading

4. Headgear in Soccer • Mainly marketed to Youth Soccer players under the age of 12, where the occurrence of heading is significantly decreased, as compared to higher levels of play • Many of the headers at this level occur off the bounce • Studies have shown that the peak force of impact from a soccer ball was reduced by 112% or 400 N • Clinical Efficacy remains to be seen

5. Specifications of the Ball • Law 2 of the game, as per FIFA's Laws of the Game, states : • Circumference : 27-28 in. (68-70 cm) • Weight : 14-16 oz. (410-450 grams) • Pressure : 8.5-15.6 psi (59-108 kPa)

6. Mechanics of Impact • The highest velocity balls a player might head voluntarily are as follows : • Goalkeeper's Punt : 70km/h or 43 mph • Goalkeeper's Dropkick : 85 km/h or 53 mph • Goal Kick : 85 km/h or 53 mph • Shot towards goal from a striking position : 119 km/h or 74 mph

7. Mechanics of Impact • A ball traveling at between 65 km/h and 120 km/h : • Hits a solid object for 10.23 milliseconds • Force of 850N to 1200 N • Acceleration of 30 to 55 g forces

8. Mechanics of Impact • Head can withstand greater linear forces than those created by properly heading a soccer ball • Purposeful heading is largely linear • Most head injury occurs from rotational forces, as in boxing • A blow of the ball to the side of the head in an unprepared player, or via improper or bad heading technique, can lead to rotational impact • Can be coupled with Transverse Rotation in an unprepared player

9. Mechanics of Impact : In Comparison • Football : Impacts last for 250 to 300 milliseconds at g forces ranging from 150 to 450 g • Boxing : Impact duration lasts from 14 to 18 milliseconds • 6000 N • G forces of 100 g

10. Mechanics of Heading • Heading the ball appropriately is a difficult technique and certainly tough to master as an effective threat at the college or professional level • Most coaching books that describe teaching progression don't even mention heading until 12 years of age or older • Active technique • Ball is to be contacted on the forehead at or near the hairline

11. Mechanics of Heading • The trunk is hyperextended and the chin tucked in slightly to the chest • The more trunk extension, the faster the forward velocity of the trunk and the greater the impact on the ball • Arms are usually extended for balance and protection • Exercise in precision timing

12. Mechanics of Heading • Flexing the hips, brings the trunk and head towards the ball • Arms are pulled back • Contracting the neck muscles fixes the head, making a firm surface for contact • Effectively increasing the mass of the contact surface, F=ma • To contact the ball at the top of a jump, the trunk must be flexed to transfer force to the ball

13. Mechanics of Heading • Proper heading technique is the athlete's best defense against injury from heading a soccer ball • Younger athlete may be at risk because of smaller size, less muscular development and less skillful heading technique

14. Mechanics of Heading • Coaches should instruct players to head the ball just below the hairline on the frontal bone • The thickest part of the cranium • Simultaneously isometrically contracting the neck musculature • To counteract the force of the ball, the player should apply a counterforce, generated by moving the trunk into flexion

15. Mechanics of Heading • The athlete becomes a single rigid unit that lowers the risk of injury, by decreasing the linear and rotational accelerations on the head • Forces generated by the ball are dispersed across the player's body

16. Mechanics of Heading

17. Frequency of Heading • Not a lot of data to document the frequency of heading • The average amount of headers per game in the English Premier League is stated to be six to seven per game

18. Incidence of Concussion in Soccer • According to a study of concussions in soccer players by Dick, Putukian, Agel, Evans, and Marshall (2007) • 67.7% of reported concussions were due to player contact • 18.3% were associated with contacting the ball • 13.4% with contacting the playing surface

19. Incidence of Concussion in Soccer • In a Canadian study on concussions in University Football and Soccer players by Delaney, Lacroix, Leclerc and Johnston (2002) • 70.4% of Football players had suffered concussion symptoms within the previous year • 62.7% of Soccer players had suffered concussion symptoms • 23.4% of Football players and 19.8% of concussed soccer players realized they had suffered a concussion

20. Incidence of Concussion in Soccer • Goalkeepers were the most commonly affected position

21. Concerns : Soccer and Head Injury • Head injuries account for 4 to 20% of all injuries in soccer • In a study involving US National Team players, the findings suggested that any evidence of encephalopathy in soccer players relates more to acute head injuries received playing soccer than from repetitive heading (Jordan, 1996) • In an Italian retrospective study involving professional players from the top three Italian divisions, there was a 20-fold increased incidence of ALS as compared to the general population (Vanacore and Belli, 2005)

22. Hypothesis • No difference exists between Preseason and Postseason Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores when NCAA College Soccer players sustain subconcussive microtrauma from forceful, repetitive contact activity through heading a ball from defensive and offensive positions

23. Purpose • The purpose of this study is to evaluate the effect of heading on performance in Neuropsychological testing • To this effect Preseason and Postseason ImPACT testing would be used to evaluate for Neuropsychological dysfunction in NCAA Division III US College Soccer players

24. Methods • Men's Soccer players from a large Division III University were recruited to participate in the study • Athletes were ImPACT tested at the beginning of their NCAA Division III Soccer season • They were ImPACT tested again at the very end of their NCAA Division III Soccer Season • The season had a length of twenty games • The regular season lasted for two months

25. Methods • Players suffering a concussion at any point during the season were excluded from the study • 13 Soccer players completed Preseason and Postseason ImPACT testing without having suffered a Concussion during the season • Four players suffered a concussion over the course of the season • Five players didn't complete the Postseason ImPACT

26. Methods • A Statistician was employed as part of the study to run the study data • A repeated measures analysis of variance was used to compare the scores at the two time intervals • Preseason and Postseason ImPACT scores were evaluated for statistical significance

27. Results • No statistically significant decreases were found in overall ImPACT scores when comparison was made between Preseason and Postseason ImPACT scores • Symptom scores, Visual and Verbal Memory Composite Scores were compared for statistical significance • No significant decrease was noted between Preseason and Postseason scores (p<0.05)

28. Results • There was no significant decrease in Visual or Verbal Memory Composite scores (p<0.05) • P values were calculated to be : • Visual Memory Composite : p=0.01 • Verbal Memory Composite : p=0.04

29. Results • Total Symptom Score remained stable between Preseason and Postseason (p<0.05) • Total Symptom Score : p=0.04 • Reaction Time Composite scores showed a wide spectrum of scores with a p=0.389

30. Discussion • Total Symptom Scores, Memory Composite Verbal Scores and Memory Composite Visual Scores on ImPACT testing were unchanged (p<0.05) between Preseason and Postseason • These findings fall in line with a College Football study evaluating ImPACT scores in athletes at similar intervals by Adamson, Pink and Sweet, 2007 • ImPACT scores were not significantly altered in non-concussed football players

31. Discussion • No statistically significant decreases were found in overall ImPACT scores in any of the domains or composites of the tests

32. Conclusions • ImPACT scores are not significantly altered by a season of repetitive microtrauma due to heading of a soccer ball in collegiate athletes who did not sustain a concussion

33. Conclusion • This is a small scale Pilot study evaluating the effects of repetitive subconcussive microtrauma due to heading of a ball in NCAA College Soccer players on Neuropsychological ImPACT testing • The study should be performed on a larger scale to evaluate the effects of heading on an athlete's Neurocognitive functioning • This includes a larger sample size in terms of participating athletes

34. Conclusion • More Importantly : • It must be considered that the NCAA College Soccer season in the respective study had a duration of two months and twenty official competitive matches

35. Conclusion • The College Soccer season is significantly shorter than the International Soccer Season • The Professional Soccer Season in the majority of professional leagues around the world can last up to eleven months when including Preseason and Postseason matches • Professional Soccer players may play upwards of 75 matches a year when Club and International commitments are taken into account

36. Conclusion • It would be prudent to extrapolate the study on a professional level • Testing professional soccer players via ImPACT testing Preseason, Midseason and Postseason • Ideally, Soccer players would be ImPACT tested at the beginning of the traditional Preseason at the beginning of July, Midseason and at the end of the traditional season at the end of May

37. Clinical Significance • ImPACT scores should be correlated with clinical findings to evaluate an athlete for the occurrence of a Post-concussive event

38. Bibliography • Jordan BD. Acute and chronic brain injury in United States national team soccer players. Am J Sports Med 1996;24:704-5. • Belli S, Vanacore N. Proportionate mortality of Italian soccer players: Is Amyotrophic Lateral Sclerosis an occupational disease. European Journal of Epidemiology 2005;20,3:237-242. • Dick, R., Putukian, M., Agel, J., Evans, T. A., & Marshall, S. W. (2007). Descriptive epidemiology of collegiate women’s soccer injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2002–2003. Journal of Athletic Training, 42(2), 278–285. • Broglio, S. P., Ju, Y., Broglio, M. D., & Sell, T. C. (2003). The efficacy of soccer headgear. Journal of Athletic Training, 38(3), 220–224.

39. Bibliography • Kirkendall, D. T., & Garrett, E., Jr. (2001). Heading in soccer: Integral skill or grounds for cognitive dysfunction? Journal of Athletic Training, 36(3), 328–333. • Delaney JS, Lacroix VJ, Leclerc S, Johnston KM (2002). Concussions among university football and soccer players. Clin J Sport Med. 2002 Nov;12(6):331-8. • Putukian M, Echemendia R, Mackin S. The acute neuropsychological effects of heading in soccer. Clin J Sports Med 2000;10:104-9. • Miller JR, Adamson GJ, Pink MM, Sweet JC (2007). Comparison of preseason, midseason, and postseason neurocognitive scores in uninjured collegiate football players. Am J Sports Med. 2007 Aug;35(8):1284-8.

40. Thank You! • Michele Gilsenan, D.O. • Peter Barry, D.O. • Michael Beams, D.O. • Nick Belasco, D.O • Tim Sensor, ATC • Kean University Soccer