In a back room of a lab at the University of Ottawa is a cabinet full of heads.
The “headforms” come in beige, blue and charcoal hues, and they’re built to take a beating. This is the Neurotrauma Impact Science Laboratory, where devices are designed to ram the heads from all directions; to drop them onto different surfaces resembling turf or roadways; to send them flying sideways into a propped-up futon (the wall was taking too much abuse).
Accelerometers inside the headforms help scientists to make a computer model of each hit, which can show how force is transmitted through the head from hits of different speed, duration and angle. That helps them calculate the types of strain that can lead to head injuries – and how to prevent them.
But this lab is also part of a larger debate about just how far science has come in understanding concussions – and what companies who make protective gear are allowed to say about their ability to limit the risk in contact sports.
Last year, the federal Competition Bureau penalized Reebok-CCM Hockey Inc. for advertising its Resistance hockey helmet in a way that the regulator said “created the impression that the helmet would protect players from head injuries such as concussions.” The product website at the time said the helmet could “reduce rotational acceleration of the head during an impact.” CCM agreed to change marketing and packaging materials in response to the decision. The Bureau had reached a similar agreement with CCM rival Bauer Hockey Corp. the previous year.
Sales of hockey equipment in Canada fell to $400-million last year – an 8-per-cent decline from the year before – according to numbers provided to the Canadian Sporting Goods Association by Ipsos Reid. Helmets represented just 3 per cent of those sales.
The regulator’s focus on hockey helmets is a result of consumers’ growing awareness of concussions.
In the past five years, emergency-room visits for sport-related brain injuries in Ontario and Alberta have increased 78 per cent for children under the age of 9, and 45 per cent for 10- to 17-year olds, according to the Canadian Institute for Health Information, and 94 per cent of visits were concussion-related.
Businesses are trying to respond to those concerns with more investment in protection technology. Bauer says that roughly 4 per cent of its revenue is put back into research and development.
But this climate also means there are sometimes competing interests between regulators, which enforce marketing claims, and those who believe some leeway is necessary for companies to advertise new technologies that they invest heavily to develop.
The decisions have come at a time of increasing scrutiny over marketing claims, in general, in North America: The U.S. Federal Trade Commission has ordered the makers of POM Wonderful to stop making unproven health claims about its products. Last year, Coca-Cola Co. said it would change the labels on its Vitaminwater products to settle a lawsuit.
“We’re seeing the early signs of increased regulation,” said Alan Middleton, a marketing professor at York University’s Schulich School of Business. Research has found that only roughly 15 per cent of purchases are based on a customer’s thorough research. For the rest, Prof. Middleton explained, advertising has to describe the features of a product in order to get the message across.
“If they are using words that are very cautious” in order to avoid regulatory hassles, he said, “they may not resonate with consumers.”
While it’s crucial that the regulator police marketers to avoid snake-oil sales tactics, the CCM and Bauer cases were not so cut-and-dried: Neither said outright that their helmets prevented concussions, but claimed instead that they could mitigate the risks of some rotational impacts. The Bureau took the view that the implied message about concussion protection was enough for it to step in.
The research that informed the design of CCM’s Resistance hockey helmet came out of the lab at the University of Ottawa. The man who runs it – a globally respected scientist in the field of neurological trauma research – believes that decisions such as this could be discouraging innovation.
“It drives me nuts when people say helmets don’t do anything for concussion. … You can’t prevent concussion. No. But you can certainly mitigate risk,” said Blaine Hoshizaki, director of the lab and professor in the Faculty of Health Sciences at the University of Ottawa.
Prof. Hoshizaki supports regulators’ scrutiny into marketing claims. But when it comes to advertising around rotational hits – which are most commonly associated with concussions – he says the science is clear.
“We’re doing all this research, thousands and thousands of data sets, to understand this,” he said. “I don’t understand why they’re so aggressive against manufacturers. … This is where people should be inventing.”
As awareness around concussion dangers has expanded, so have people’s concerns about the safety of sports participation – especially for their children – and how to reasonably control for risk.
Canada’s Competition Act requires advertising claims about product performance to be based on “adequate and proper” testing. (The Competition Bureau declined requests for interviews for this article, and would not speak to how assessments are conducted in these cases, referring questions to the summary of the legislation on its website.)
When the CCM decision came out, spokesperson Phil Norris said the Bureau acted on the marketing claims because “the science behind concussions in sports is still in its infancy.”
Most people agree that caution is warranted – the question is just how much caution?
“If there are successes, you want them portrayed with the proper amount of enthusiasm, but not pretending that we’ve got a cure,” said Shawn Marshall, a physician and medical director of the acquired brain injury rehabilitation program at the Ottawa Hospital Rehabilitation Centre, and a professor at the University of Ottawa’s Brain and Mind Research Institute. Dr. Marshall calls Prof. Hoshizaki “the expert” in the field of brain-trauma research. And he has concerns about balance when it comes to advances in technology. “We’re still trying to learn why does one person have a concussion and another person does not, when things look very similar? There’s a lot we don’t know.”
Paul Echlin, a doctor who specializes in sport-related traumatic brain injury, agrees that the science has progressed, but fundamentally disagrees that companies should be allowed to advertise products for mitigating concussion risk.
“The games have to be changed, dramatically, fundamentally, to stop hitting the head so often. People want to have external cures. … There is none,” Dr. Echlin said. “You cannot put falsehoods out to the public that you can continue to play these games, your children can continue to get hit, and somehow they’ll be protected by a better helmet.”
Standards for helmet safety certification were developed starting in the early 1970s, and have mostly focused on preventing traumatic brain injuries such as skull fractures – not concussions.
“We’ve been working on this rotational problem, and trying to figure out how to add a test of rotational acceleration to our standard … for the past several years,” said Pat Bishop, a technical committee member at the CSA Group (formerly the Canadian Standards Association). “It’s fraught with a whole lot of difficulty.”
On the other hand, to say the science is in its “infancy” is in some ways unhelpful, since all scientific knowledge is constantly changing as research progresses.
“The [‘infancy’] accusation could be levelled against any branch of science,” said Donald Redelmeier, a professor of medicine at the University of Toronto and physician at Canada’s largest trauma centre, at Sunnybrook Health Science Centre. “I can see why the Competition Bureau has to walk a tight line. … But the lack of finding does not necessarily prove the finding of a lack. It depends on where the balance of evidence is.”
Prof. Hoshizaki says that published research proves that rotational forces can be diminished in some cases.
Even consumer advocates may cautiously agree. Recently, Consumer Reports tested two bicycle helmets with liners that allow the helmet to move on the head during impact to absorb rotational forces. The testers found that the helmets reduced rotational forces by as much as 43 per cent compared with models without that type of liner. The publication cautioned that because the “impact threshold” of rotational forces that lead to a concussion isn’t definitive, it could not say that the liner had been proven to reduce injury risk. But it concluded: “Even if the extra benefit isn’t definitive … [it] might be worth the extra cost.”
Extra cost is a factor: Companies say it’s fair to charge more to recoup investments on technology that improves performance. However, CCM says that a system of fluid-filled liners it developed – based on Prof. Hoshizaki’s invention, which gives the helmet a layer that encourages rotational movement of the helmet separate from the head – is sold at multiple price points.
“Helmets, previously, were just a die-cut foam that absorbed energy, which worked very well,” said Laura Gibson of CCM Hockey. “… [The new liner] allows us to handle multiple types of impacts. … Everyone is aware that we don’t know everything, that we’re learning all the time.” The company has recently extended its agreement to work with Prof. Hoshizaki’s lab for another three years.
Bauer’s helmet has a basket that is slightly separate from the liner to similarly encourage movement of the helmet for rotational hits. However, it is now careful how it advertises such features.
“We’re cautious [to say] that a helmet can protect against a wide range of hits in hockey, instead of calling out specific types of hits,” said Craig Desjardins, vice-president of product for Bauer Hockey. “… If we can talk to our consumers in a way that resonates better with them, that allows us to better educate them on a product benefit, that will ultimately be a win for the industry and for consumers.”
Bauer is also working with a company called Q30 Sports Science on a type of compression collar for the neck, which is designed to increase blood volume in the skull and that its developers say reduces the “compliant space” that allows the brain to slosh around more.
The funding for this kind of development mostly comes from industry.
“Corporate funding is necessary, because the Government of Canada is in no position to pay for all the research that needs to be done,” Dr. Redelmeier said.
Prof. Hoshizaki’s lab accepts funding from companies, but remains independent by publishing its research in peer-reviewed journals – regardless of whether findings benefit its benefactors.
Walking around the lab, he asks a graduate student to pull up an animated re-enactment on a computer. A small yellow figure stands on a green background that looks like a primitive MS Paint drawing of a field. The figure, made up of a series of circles that mimic real body movement, topples backward, placing its elbows behind it on landing. Its head snaps back.
Reconstructions are based on athletes’ accounts, hospital reports and video footage of hits and falls. The animated reconstruction of those accounts shows where and how a head was hit. The impact can then be replicated in real life, using one of the headforms. Information from hits to the headforms goes back into the computer, where a model of a brain shows exactly how the energy moved through the head and what parts of the brain were affected. The lab has conducted hundreds of these recreations to help understand the effect of multitudes of different kinds of impacts.
“Can we decrease that trauma? Yes we can, and the helmets today do it,” Prof. Hoshizaki said. “Do they do the best job they can? Probably not. People are just beginning to understand the relationship between trauma and the whole spectrum of disease. As we begin to understand that … we do see, significantly, a decrease in strain on brain tissue with better technology.”
But Prof. Hoshizaki also believes equipment is not enough: The rules of sports need to change to decrease the number of hits to the head.
The problem with marketing claims is that the promise of better equipment could make people feel safer than they are, even as the game remains the same. What parent would not shell out more money for a helmet that better protects their child? But should people be asked to pay a premium when – even if some rotational force can be absorbed – the cure for a concussion does not lie in equipment?
“With protective equipment, the psychology of sport is that you feel protected and it might actually change your behaviour,” Dr. Marshall said.
The culture of sport may well need to change. According to three 2014 studies of 730 U.S. college football players, for every concussion diagnosed in a player, there were 21 smaller hits they did not report to medical staff and six hits that the players thought may have led to a concussion, but also did not report. That is another reason for caution in advertising claims.
“People want to keep selling products and say we can do the same thing, play the same game,” Dr. Echlin said. “That’s just wrong.”
Concussions and helmets
A concussion is an injury to the brain that can cause headaches, nausea, dizziness, and in roughly one in ten cases, blackouts. A direct hit to the head can cause a traumatic brain injury such as a skull fracture – and helmets are mostly constructed to deal with those types of direct impacts. A concussion, on the other hand, usually results from a hit that causes the brain to move around inside the skull.
Researchers have been working to understand the science of concussions for decades. Early tests into brain trauma occurred in the 1940s, using gelatin as a substitute for brain tissue to understand how the organ reacted to impact. Later tests using cadavers helped to establish the Wayne State Tolerance Curve, which defined when skull fractures were likely to occur based on a combination of the speed of acceleration and how long it lasted.
But understanding the causes of concussions has been a work in progress. Since the 1960s, scientists have established that “rotational” impacts, where the head is made to rotate, are a contributing factor in concussions in addition to linear (or straight-on) impacts measured in the Wayne State Curve.
Just more than 10 years ago, that understanding progressed significantly with the research of Bennet Omalu (of Concussion film fame.) Dr. Omalu found tau protein deposits in the brain of a dead football player, showing that the player had suffered from chronic traumatic encephalopathy or CTE.
It was stark evidence that the culture of athletes shaking off a bell-ringer, in high-impact sports such as football and hockey, is dangerous: These hits to the head contribute to long-term damage to the brain. People who are subjected to repeated concussions may be in danger of developing CTE, though the type of concussion and the number that would increase that danger is not as well understood.
More recently, scientists have come to understand that linear acceleration, rotational acceleration, the duration of an impact and the location of impact on the head all play a role in determining concussion risk.