Of all the injury risks in football, head injuries are the most concerning. Football helmets have been touted for their ability to protect players from head injuries. Many brands market their laboratory studies for concussion prevention in football.

But what are the true benefits of football helmets in preventing concussion? What is the main purpose of helmets? And how is innovation expanding helmet function? Is there other equipment that can help prevent concussions?

This article will discuss the pros and cons of football helmets and other equipment for concussion prevention:

• Original Purpose of Football Helmets
• Causes of Concussion
• Objective View on Current Helmets
• Innovation in Football Helmets
• Importance of Facemask Design in Concussion Prevention
• Benefits of Mouthguards for Concussion Prevention
• Other Equipment for Concussion Prevention

Original Purpose of Football Helmets

Helmets are used in many professions like construction and military to prevent direct impacts to the head. They are also used in a variety of sports such as skiing/snowboarding, biking, baseball, hockey, and football. Their main purpose is to protect external structures such as the skull and facial bones.

Helmets can prevent direct impact to the head and face from falling debris, tools, the ground, a ball or puck, or another person. Without the helmet, these impacts may cause broken bones, cut skin, dental injuries, and catastrophic brain injuries. In this way, helmets effectively protect against moderate to severe head trauma.¹

In 1943, helmets became mandatory in football to prevent severe head injuries.² In the early 1900’s, football was a dangerous game with significantly more head and neck trauma, hospitalizations, and even deaths. Introducing the football helmet helped to make the game safer for players.

The football helmet started as a leather piece of material with no facemask. Over the years, this became a hard shell with minimal padding and a lightly reinforced mask to cover part of the face. Then, heavier helmets with a harder shell and more facial protection were added.

During this time, concussions were not a concern as many did not know what they were or even their consequences. Getting one’s ‘bell rung’ and ‘seeing stars’ was just a part of the game. These helmets protected players from moderate and severe head trauma, but what did they do for concussion prevention? We first need to discuss what causes a concussion.

Causes of Concussion

According to the American Association of Neurological Surgeons (AANS), a concussion is a “clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status or level of consciousness, that results from mechanical force or trauma.”³ This definition emphasizes that the alteration in brain function is temporary and is caused by a mechanical force.

The mechanical force can be directly to the head or neck area or to the body resulting in forceful movement of the head and neck. However, one force may cause a concussion in one individual on one day, but the same force to the same person may not provoke a concussion the next day.

The discrepancy here is how great the individual’s head moves after suffering the blow. If one person gets hit in the head very hard, but the head does not move, a concussion will likely not occur. On the other hand, if the same person’s head rotates quickly in any or multiple directions, the person is more likely to sustain a concussion.

The brain sits suspended in a liquid within the skull called cerebrospinal fluid. Because it is not fixed to the skull, it is allowed to move freely and slosh in multiple directions. When the head quickly rotates, or accelerates, upon receiving a mechanical force, the brain also moves but at different speeds and directions. This causes the brain to rotate on top of the brainstem and spinal cord and bounce into the inside walls of the skull.

It is not the mechanical force, but rather the rotational acceleration of the head, and subsequently, the brain that causes a concussion.⁴

Objective View on Current Helmets

There is no current evidence that a specific type or brand of football helmet can prevent a concussion. This should make sense based on their inherent structure.

All current football helmets contain a similar structure: hard plastic shell, interior foam padding, and facemask. It lacks any component designed to prevent rotation of the head and neck. Hence, current football helmets cannot prevent concussions.

Instead, they are designed for comfort, style, and blunt force protection.

Comfort is important because the players must want to wear a helmet that is properly fitted to them. While helmets do not prevent head rotation, evidence shows that players who are not properly wearing their helmets are more likely to have worse symptoms and longer recovery following a concussion.⁵

Style is necessary because players want to look good. They want a specific facemask to make them look tough. However, a lightly reinforced facemask may be best.

Of course, blunt force protection is the ultimate reason to wear a helmet in football. The protective hard shell with substantial padding covering the skull and jaw bones is essential to prevent skull fractures. The facemask is necessary to prevent facial fractures and lost teeth.

While current football helmets are vital to prevent moderate and severe head trauma, they are not effective at preventing concussions. To accomplish this, helmets would need to decrease rotational acceleration of the head upon impact.

Innovation of Football Helmets

New helmet innovations are trying to effectively decrease head accelerations. In 2021, the National Football League created a Helmet Challenge that offered $3 million to companies to help stimulate development of new helmets that could outperform the current model regarding concussions. Three teams—Kollide, Impressio and Xenith—received the grant funding.⁶

Kollide has made a unique mesh-like inner lining containing 95 3D-printed pads that can help redirect the energy from initial impact across the entire helmet liner. With this redirection of energy, there would be a smaller direct force to the head in which the player can stop head and neck movement.

Impressio has created a liquid crystal elastomer that resembles the shock absorption of cartilage in the body. They have now inserted this substance within a 3D-printed lattice-like rubber into helmets. This material is also trying to decrease the direct force so that the player can activate neck muscles to prevent head acceleration.

Xenith, who has been making helmets and football equipment for over 10 years, has created a variable stiffness shell that is softer in some areas to bend and disperse energy. The inside contains a lattice-like structure as well along with unique Rheon Labs material that is soft and flexible at low speeds and stiffens up with higher impacts.

These new technologies all have a similar goal with their new football helmets. They want to reduce the impact to and acceleration of the head upon impact.⁷ This will ideally prevent excessive brain movement, twisting and turning, to decrease risk of concussions.

I think these technologies are great for advancing helmets in football and other sports. However, I am not convinced that improving helmet design will significantly prevent sports-related concussions in the future.

Importance of Facemask Design in Concussion Prevention

One factor that is important to consider when choosing a football helmet is the facemask. Most kids like to look cool in their helmet either with a specific facemask or visor. Certain facemasks can greatly restrict one’s peripheral vision, which may increase risk of concussion. A wider peripheral vision can help prevent concussions by improving a player’s ability to see, anticipate, and react to oncoming hits.⁸

If a facemask or visor restricts peripheral vision and decreases the player’s reaction time, it may increase one’s risk of concussion. Two studies measured reaction times of college football players using standardized equipment.^9,10

One found that wearing a helmet and helmet with a clear visor both significantly impaired reaction times to peripheral visual stimuli.⁹ So wearing a helmet in general will decrease peripheral vision. For this reason, training peripheral vision and reaction time while wearing a helmet may be beneficial in concussion prevention.

The second study expanded this by testing different types of facemasks and visors.¹⁰ They also found that wearing a helmet significantly impaired peripheral vision reaction time, but the heavy- and extra-heavy-reinforced facemasks were worse than the light- and medium-reinforced facemasks especially in the outermost and lower peripheral visual fields. Additionally, the smoke- and mirror-tinted visors worsened the peripheral vision reaction times compared to the helmet only.

Player should choose helmets with lighter-reinforced facemasks without a tinted visor, even though this helmet may not look as cool. The National Federation of State High School Associations (NFHS) prevents football players from wearing tinted visors during games, but some like to wear them during practices. This act should be stopped for all ages.

Furthermore, helmet manufactures should be researching and utilizing more facemask prototypes that allow for a wider peripheral vision. These should not only help with performance but may also help concussion prevention in football.

Benefits of Mouthguards for Concussion Prevention

Mouthguards are mandatory at almost every level of football. They have benefits in preventing injuries especially those related to the mouth. Mouthguards can prevent biting one’s tongue and cracking teeth especially if players clench their teeth upon contact. They may also help prevent concussions.

One review article states that six of eight studies report decreased concussion risk when wearing a mouthguard verses no mouthguard in basketball, hockey, and rugby.¹¹ This is good evidence in these sports.

Mouthguards are required in most levels of football, so their effects are more difficult to study. Football studies primarily look at the difference between custom and standard mouthguards. Two of five studies found benefits of reducing concussion risk in high school football players with custom mouthguards.¹¹ So custom mouthguards may be beneficial, but clearly the studies have mixed results.

Mouthguards may decrease concussions by absorbing and redistributing impact to the jaw that would otherwise be transmitted to the brain. This mechanism is plausible, but the brain will still likely be rotating within the skull upon head impact.

I suspect that a benefit of mouthguards is clenching one’s jaw into some rubber material. Because some jaw muscles are connected to the neck, there will subsequently be neck muscle contraction as well. Proper neck muscles activation can prevent head acceleration upon impact. This will decrease brain movement to lower concussion risk.

Other Equipment for Concussion Prevention

It would be nice if there was a way to cushion the brain. For instance, the woodpecker has a unique hyoid bone and tongue that wraps around the brain to act as an internal shock absorber while pecking a tree.¹²

Humans only have cerebrospinal fluid (CSF) surrounding the brain, but this fluid is not dense enough to prevent excessive sloshing. One way to increase the fluid pressure so it can act as a cushion would be to decrease the outflow of CSF through veins leaving the brain. This may be partially accomplished by tightening neck muscles attached to the hyoid bone, which compresses the internal jugular vein.¹³

The Q-Collar by Q30 Innovations is designed in this fashion. The collar wraps around the neck and puts mild compression on the internal jugular vein on each side. This compression prevents some blood flow from leaving the skull leading to increased CSF volume. Keeping more fluid volume in a closed container results in increased intracranial pressure. This pressure exerts more force on the brain, which in theory, prevents excessive brain movement and sloshing upon impact.

Q30 Innovations have over a decade of animal and human studies on their website. The preclinical data on rats are convincing. And human trials on football, hockey, and soccer players also demonstrate potential.

They show mitigation of functional and structural brain changes that can normally occur with a contact sport season. Wearing the collar also prevented reduction in working memory scores from pre- to post-season. These are promising for preventing subconcussive head trauma, but the Q Collar has not been studied regarding concussion prevention.

Summary

The main purpose of football helmets are to prevent moderate and severe head trauma like fractures and bleeds. There is no evidence for football helmets in concussion prevention. However, properly-fitted helmets may help prevent severe symptoms following a concussion. Helmet innovations are seeking to improve efficacy in preventing concussions, but it will never be the sole solution.

Other equipment may help prevent rotational acceleration of the head and excessive brain movement that are necessary for concussion. Mouthguards show some benefit in concussion prevention, maybe by tightening jaw and neck muscles. New technologies like the Q Collar seem to decrease the effects of subconcussive head trauma by cushioning the brain.

When selecting a helmet, it is important to find one that offers a wide range of vision without a tinted visor. This is important for increasing peripheral vision and reaction time, which may help concussion prevention in football.

Football helmets are necessary, but we will see there are many other ways to improve concussion prevention in football!

References

1. Sone JY, Kondziolka D, Huang JH, Samadani U. Helmet efficacy against concussion and traumatic brain injury: a review. J Neurosurg. 2017;126(3):768-781.
2. Chronology of Professional Football. Pro Football Hall of Fame. Accessed January 23, 2022. https://www.profootballhof.com/football-history/chronology-of-professional-football/
3. Agarwal N, Thakkar R, Than K. American Association of Neurological Surgeons. Updated 2021. Accessed March 6, 2022. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Concussion
4. Holbourn AHS, Edin MA, Oxfd PD (1943) Mechanics of head injuries. Lancet 242(6277):438–441.
5. Greenhill DA, Navo P, Zhao H, Torg J, Comstock RD, Boden BP. Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players. Sports Health. 2016;8(3):238-243.
6. McMichael, C. 3 next-gen helmet designs that could curb concussions in the NFL. Digital Trends. February 16, 2022. Accessed December 31, 2022. https://www.digitaltrends.com/news/nfl-helmet-challenge-winners-technology/
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8. Kung SM, Suksreephaisan TK, Perry BG, Palmer BR, Page RA. The Effects of Anticipation and Visual and Sensory Performance on Concussion Risk in Sport: A Review. Sports Med Open. 2020;6(1):54.
9. Miller RA, Rogers RR, Williams TD, et al. Effects of Protective American Football Headgear on Peripheral Vision Reaction Time and Visual Target Detection in Division I NCAA Football Players. Sports (Basel). 2019;7(9):213.
10. Ballmann CG, Covington AC, Miller RA, Rogers RR. Protective Football Headgear and Peripheral Visuomotor Ability in NCAA Football Athletes: The Role of Facemasks and Visors. J Funct Morphol Kinesiol. 2021;6(2):34.
11. Emery CA, Black AM, Kolstad A, et al. What strategies can be used to effectively reduce the risk of concussion in sport? A systematic review. Br J Sports Med. 2017;51(12):978-984.
12. Wang L, Lu S, Liu X, et al. Biomechanism of impact resistance in the woodpecker’s head and its application. Sci China Life Sci. 2013;56(8):715-719.
13. Barpujari A, Pierre K, Dodd W, et al. Lessons from NATURE: methods for traumatic brain injury prevention. Arch Clin Toxicol (Middlet). 2021;3(1):34-41.