The NHL vs. Everyone Else (Part 3): The Eyes Have It

When a puck or a stick meets an eye, bad things happen (see: Malhotra, Manny; Berard, Brian).  The current debate is whether visors should be made mandatory in the NHL, and whether they actually do anything.  The fact of the matter is that you can find research on almost any subject to support either side of an argument.  Ready? Go:

Visors cause more injuries!

“Oh, so visors are dangerous!”

No, not necessarily.  This was a study done in the ECHL that compared injuries in players with visors to players with no facial protection.  The study found that lacerations to the forehead and cheek were more severe in players with visors, but contusions due to collisions were more severe with no facial protection.  The researchers concluded that since high sticking caused the most facial injuries, and sticks could slip under a visor, that visors may not provide adequate protection.  Here’s the problem: Were the visors properly fitted?  How many players do you see with a loose chin strap and their helmet tilted back?  A visor only works if it is properly worn – low enough that it covers the eyes and the lower edge of the nose.  Could something still slip under it?  Yes, probably.  Is it less likely?  Obviously.  The point is that you can’t go from “Players in visors have lacerations of greater severity” to “Visors are dangerous/not helpful”.  That’s not a leap that makes sense.

Now for the other side of the argument:

Visors prevent injuries!

“Oh, so visors keep you from getting hurt!”

This study looked at NHL injuries in 2001-02, and concluded that visor use resulted in decreased eye and non-concussion head injuries, but did not affect concussion rates (I think I’ll file that last point under “Duh, really?”).

Here’s another.  This study looked at injuries in elite amateur hockey players and compared injuries in players with full facial protection, visors, and no facial protection.  Since full facial protection isn’t something the NHL will be seeing any time soon (other than what you’ll see occasionally on players healing certain facial injuries), I’ll just note that all injuries were reduced with full protection.  The study found that overall facial injury was twice as likely with no facial protection, and eye injury was 4.7 times greater.  Interestingly, the study also found that players using full and partial facial protection did not have an increase in neck injury or concussion (because I know someone was going to try to make that argument).

So there is definitely evidence that visors are protective, and one study that says players who wear them have more severe lacerations (but doesn’t reliably establish a causative link).  My conclusion: Wear a visor, save an eye.  Let’s face it – a laceration is something you can repair relatively easily – especially compared to a detached retina or a ruptured eyeball.  Every complaint about fogging or scratching or not looking cool seems petty when the alternative is losing an eye and a career.

Also, this guy has figured out how to permanently anti-fog glass and plastic surfaces.

Next time: I’ll take a look at the variety of eye injuries hockey players can get, and explain the treatments for them.  Advance warning – eye injuries are not for the squeamish.

- Jo

Helmets: The NHL vs. Everyone Else (Part 2)

Part 1 of the helmet series dealt with rules in various hockey organizations.  Part 2 will deal with the equipment itself – How it works, and why it works best when worn properly.  I’m not just talking about helmets, but about all the equipment currently in use in the NHL that protects the head and face – the helmet, visor, and mouth guard.  Let’s begin with…

The Helmet

What’s its job?

The helmet’s job is to protect the head.  Although that’s obvious, it’s not immediately obvious that there are things the helmet is good at, and things it sucks at.  Helmets are good at preventing direct injuries  – things like pucks, sticks, skate blades or the ice causing an injury to the surface of the head.  Helmets are not good at preventing indirect injuries, i.e. concussions.  The reason is the science behind how a concussion happens.

A quick trip into concussions…

A concussion refers to a brain injury causing a change in brain function.  Concussions vary in severity from very mild (feeling momentarily dazed) to severe (career ending – intractable vomiting, vision changes, permanent changes in balance, etc).  Concussions can result from a direct blow to the head, or a sudden head movement due to forces acting elsewhere (like a bodycheck on a player who doesn’t see it coming).

The brain essentially “floats” (snugly) inside the skull in cerebrospinal fluid (aka CSF, the stuff that surrounds your brain and spinal cord).  When the skull suddenly changes direction/stops/starts, the brain has to do the same.  In normal day-to-day life there’s no problem – the brain rides happily around in your skull changing direction as you do.  When there’s a sudden force applied that’s strong enough to move the head, the brain is inclined to stay where it is – remember Newton’s laws of motion? An object in motion tends to stay in motion until an external force is applied to it.

Translation: The brain wants to keep going in its original direction until something stops it.

During a hit, that inclination to keep going puts traction on the so-called “anchor point” of the brain – the midbrain – home to a lot of very important stuff, including the nucleus of the oculomotor nerve (the op center of the nerve that controls most of your eye movements).  This is where the term “rotational force” that you’ve been hearing tossed around with relation to concussions comes in.  Basically the brain is rotating on a somewhat fixed point, and when that happens you get an interruption in normal function.  The brain isn’t fond of stretching, moving, rotating, or really doing much of anything but happily riding in your skull.  Honestly, the brain is a bit of a jerk that doesn’t like to be touched, has its feelings hurt easily, and doesn’t like to be consistent about recovery.

The brain hates rotating.

It should be fairly clear now why helmets aren’t great at protecting against concussions.  They aren’t completely useless – they spread the impact across a larger area and the foam liner absorbs some of the energy, but the fact is if you hit your head hard enough your brain will move in a way that isn’t good for it.

So what’s the solution?

First, wear the helmet properly.  As we learned in part 1 of this series, the IIHF, Hockey Canada and USA Hockey require that equipment be worn “…in the manner for which it is designed”.  In fact, the IIHF goes so far as to specify how the helmet should fit: “A helmet shall be worn so that the lower edge of the helmet is not more than one finger-width above the eyebrows, and there shall only be enough room between the strap and the chin to insert one finger.” Failure to wear equipment properly results in a misconduct.

Toews, seriously?

A helmet will do a player absolutely no good against any injury if it doesn’t stay on his head.  Shane Prince of the Ottawa 67s found that out the hard way March 11th after a hit from the Niagara Ice Dogs’ Tim Billingsley resulted in his helmet flying off and the back of his head hitting the ice.

Prince got off relatively easily with a mild concussion, and is expected to return to the ice for the OHL playoffs this weekend.

Second, wear a better helmet.  Until the mid/late 90s there were still a few players in the NHL wearing the practically useless Jofa 235 (Gretzky, I’m looking at you), a helmet that was about as protective as a toque with a chinstrap.  NHL rules now vaguely state players must wear an “approved” helmet, but unlike the rest of the world, don’t specify who has to do the approval.  Regardless, sanity prevails and NHL players are keeping the fine people at Reebok, Easton and Bauer in business.

The Messier Project, which is Mark Messier in association with Cascade Sports, have come out with the M11 helmet, which they state has been proven to distribute impact forces better than traditional helmets.  In addition, they’ve shown that the M11 helmets protect better in successive impacts than traditional helmets.  The helmet also has what they call the Pro-Fit System, a ratchet at the back of the helmet that snugs it under the occiput (that big bump on the back of your head) for a more accurate fit.  What truly sets the M11 apart is the so-called Seven Technology.

Seven Technology

Instead of being padded only with foam, the helmet has several plastic units each made up of seven small interconnected plastic tubes.  These units deform under force – they flatten out and then rebound to their original form.  This absorbs and displaces the energy of the impact, meaning it’s that much less the brain has to take care of.  The Messier Project offers a great animation of how the technology works that does a far better job of explaining it than I can.

I would totally wear this.

Early iterations of this helmet were poorly reviewed because it was considered bulky, unattractive, and was poorly vented, but the M11 in its current form reviews well.  The Messier Project is currently gathering data from teams using their helmet.  They claim to have nine NHL players currently wearing their helmet, interestingly mostly Anaheim Ducks.

Third, rule changes and/or better enforcement.  Ideally the best way to avoid a concussion is to avoid getting hit in the head, or getting hit elsewhere in a way that results in sudden acceleration/deceleration of the head.  Since this is NHL hockey and I’m not stupid, I know that’s not going to happen.  Don’t get me wrong – I love hockey and I’d hate to see it diluted down to something unrecognizable.  I don’t, however, love head injuries, and I get particularly bent out of shape at avoidable head injuries.  So from a medical point of view I think it’s fair to say that wearing good equipment properly is a positive step towards at the very least reducing concussion incidence (and hopefully severity).

 

- Jo

Helmets: The NHL vs. Everyone Else (Part 1)

Part 1: Helmet Rules

Since 1979, NHL players have had to wear helmets.  Frankly, there hasn’t been much progression in their equipment policy since then.  The only thing the NHL has to say about helmets is the vaguely worded rule 9.5:

“All players of both teams shall wear a helmet of design, material and construction approved by the League at all times while participating in a game, either on the playing surface or the players’ or penalty benches.”

Okay, so what exactly is a League-approved helmet?  It’s not specified in the publicly-available NHL rules.  A very scientific process involving googling pictures of NHL players has determined that it’s basically anything CSA/ASTM certified.

Dude, seriously.  Speak English.  What’s CSA/ASTM?

The CSA (Canadian Standards Association) and the ASTM (American Society for Testing and Materials) are organizations that set standards for and do testing of hockey protective gear (among several thousand other things).  The helmet standards these organizations set cover the actual construction of the helmet (ie. it can’t be leather, although that would be an interesting look), shock absorption (sorry, Wayne — the Jofa won’t cut it), penetration (can a puck or stick get through it?), retention systems (straps), field of vision, and the markings required on the helmets (the stickers on the back that prove it’s an approved helmet).

Clearly the NHL specifies that players must wear helmets that are adequately safety tested.  The kicker is that they don’t specify how the helmets must be worn, like just about every other major hockey organization does.  When a helmet flies off, it’s likely because the player wasn’t wearing it correctly.  Properly adjusted helmet straps should keep your lid in place.

Let’s Compare Head and Face Protection Rules…

For the sake of ease, I’m going to compare the NHL, the IIHF, Hockey Canada and USA Hockey.  I won’t go into goalie requirements – that’s a different animal altogether.  I also won’t discuss adult rec leagues, as some may choose to follow Hockey Canada or USA Hockey rules, and some may not.  The collection of garbage equipment that hits the ice every Sunday in my league tells you everything you need to know.

NHL:

  • Helmet: You have to wear an approved helmet while on the ice or on the bench.  No helmet required during warmups.
  • Visor:  Permitted but not mandatory.
  • Cage: Rule 9.6 actually prohibits “…pads or protectors made of metal.” but goes on to specify that “A mask or protector of a design approved by the League may be worn by a player who has sustained a facial injury”, like the visor combo Brad Stuart of the Red Wings has been wearing after suffering a broken jaw earlier this year.
  • Mouth guard: Not required, although many players wear one.  Many players also gross me (and Johan Franzen) out by chewing on them instead of wearing them properly.

IIHF:

  • Helmet: Required in the game and in warmups.  Fit is specified: “A helmet shall be worn so that the lower edge of the helmet is not more than one finger-width above the eyebrows, and there shall only be enough room between the strap and the chin to insert one finger.”
  • Visor/cage: Full face masks or visors are recommended for all players.  Women and players under 18 are required to wear a full face mask.  Players born after 1974 must wear a visor at minimum.
  • Mouth guard: Mandatory for players under age 20.

Hockey Canada:

  • Helmet: Required in the game and in warmups, with strap securely fastened.
  • Visor/cage: Under 18 and women — Full-face protection.  Over 18 — Visor.
  • Mouth guard:  Compulsory if you’re wearing a visor.

USA Hockey:

This warms my heart: “USA Hockey strongly recommends that all players and goalkeepers in all age classifications properly wear an internal mouthpiece, a HECC approved helmet and a HECC approved full facemask for all games and practices.”  FYI, HECC is another standards organization.

  • Helmet: Required in games, warmups and practices, with strap securely fastened.
  • Visor/cage: Full-face protection is required for all players below adult level.
  • Mouth guard: Required for females 19 and under, and in all players through midget level (including high school).

This is a good time to stop and point out that the IIHF, Hockey Canada and USA Hockey require that equipment be worn “…in the manner for which is is designed” (IIHF) or the player can be given a misconduct.

The wrong way to wear a helmet. (photo: Andre Ringuette)

College Hockey (bonus section):

  • The NCAA requires full face masks and mouth guards (and helmets, obviously).
  • The CIS (Canadian Interuniversity Sport) requires a helmet and at minimum a half visor.  Mouthguards are mandatory with visors.

Obviously everyone is stricter than the NHL when it comes to face protection and equipment fit.  To an extent, head and facial protection is self-policed, in the sense that the players decide if they want to wear a visor, a mouth guard, etc.  There is absolutely no question that more protection leads to fewer injuries, and plenty of excellent research to prove it.  The question is why players who grew up in systems that require facial protection and properly-fitted equipment decide to take a step back once they’ve gone pro.  There are complaints of visibility problems, discomfort, etc., but if that’s what you grew up wearing, one would think you’d be used to it.  I’ll spare you the discussion of the visibility problems and discomfort caused by a stick or skate to the eye (see: Berard, Brian).

Next time I’ll get into the medical reasoning behind a properly-fitted, properly-worn helmet, facial protection, and mouth guards.  I’ll also discuss arguments for and against them, both reasonable and stupid.

- Jo

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