On the playing field

Study provides instruction on emergency removal of football equipment

When responding to a football player with a possible spinal cord injury, emergency personnel should consider the helmet and shoulder pads a unit and should not remove one without the other, says a study by Brown University researchers in the October issue of the Annals of Emergency Medicine.

PROVIDENCE, R.I. -- Removing the helmet or shoulder pads from a neck-injured football player before the player gets to the hospital could worsen the injury, according to a new study by several Brown University researchers. If it is necessary, remove both pieces of equipment instead of just one, they said.

Recommendations for handling a spine-injured player in the prehospital setting are published in the October issue of the Annals of Emergency Medicine, providing scientific data on a subject that has received little study.

"All personnel responsible for players during practice or on game-day need to be well-versed in this," said Mark A. Palumbo, a study author and assistant professor of orthopaedics in the Brown University School of Medicine. "The time to learn is not on the football field."

Past studies demonstrate that up to 25 percent of injuries occur after a traumatic event - during transport or the early stages of management - although the rate is likely lower in the well-controlled setting of a football game, wrote the researchers. There is currently no universally accepted protocol for the emergency removal of the protective gear worn by football players.

Working in the lab, researchers simulated injuries in the region of the spine most common to football injuries. While there was no relative change in the position of the spinal cord under conditions that simulated an athlete wearing either full gear or no gear at all, wearing one piece or the other changed its position in a way that could exacerbate neurologic damage, researchers said.

A football player's head will fall backward if the helmet is removed when pads remain, or fall forward if the pads are removed when the helmet remains. Either scenario violates the basic principle that a spine-injured person should be immobilized, said Palumbo.

On the field, a player's equipment should only be removed if there is a medical emergency. The ideal situation is to wait until arrival at a medical facility and have a team of at least two or three people remove the equipment, according to the researchers.

In emergencies, methods such as cutting off the face guard to get access to the airway or cutting open the shoulder pads to get access to the chest may be options that would also allow the equipment to remain on the athlete, Palumbo said.

Cervical spinal cord trauma during organized football competition is rare. Data from 1977 to 1989 showed the rate of permanent spinal cord injury to be 1.65 per 100,000 among college players and .62 per 100,000 among junior and senior high school football players, according to the study.

Because of the rarity, past recommendations regarding emergency handling of a player's equipment have been based on suppositions carried over from experience with helmeted motorcycle accident victims and anecdotal experience, researchers said. Emergency medical technicians may be trained - or bound by local protocol - to remove the football helmet, while sports medicine experts may advise against it except under limited circumstances. The researchers are now in the process of writing a manual with recommendations for coaches, sports medicine doctors and emergency medical technicians.

Palumbo conducted the study with doctors Jonathan A. Gastel, Michael J. Hulstyn, Paul D. Fadale, and Phillip Lucas from the Department of Orthopaedics, divisions of sports medicine and spine surgery in the Brown University School of Medicine.

The findings are limited to football players. Although the general principles might pertain to other sports where similar equipment is worn, recommendations from this study apply only to football, Palumbo said.