Cervical spine motion during football equipment-removal protocols: a challenge to the all-or-nothing endeavor

Abstract

Context: The National Athletic Trainers' Association position statement on acute management of the cervical spine-injured athlete recommended the all-or-nothing endeavor, which involves removing or not removing both helmet and shoulder pads, from equipment-laden American football and ice hockey athletes. However, in supporting research, investigators have not considered alternative protocols.

Objective: To measure cervical spine movement (head relative to sternum) produced when certified athletic trainers (ATs) use the all-or-nothing endeavor and to compare these findings with the movement produced using an alternative pack-and-fill protocol, which involves packing the area under and around the cervical neck and head with rolled towels.

Design: Crossover study.

Setting: Movement analysis laboratory.

Patients or other participants: Eight male collegiate football players (age = 21.4 ± 1.4 years; height = 1.87 ± 0.02 m; mass = 103.6 ± 12.5 kg).

Intervention(s): Four ATs removed equipment under 4 conditions: removal of helmet only followed by placing the head on the ground (H), removal of the helmet only followed by pack-and-fill (HP), removal of the helmet and shoulder pads followed by placing the head on the ground (HS), and removal of the helmet and shoulder pads followed by pack-and-fill (HSP). Motion capture was used to track the movement of the head with respect to the sternum during equipment removal.

Main outcome measure(s): We measured head movement relative to sternum movement (translations and rotations). We used 4 × 4 analyses of variance with repeated measures to compare discrete motion variables (changes in position and total excursions) among protocols and ATs.

Results: Protocol HP resulted in a 0.1 ± 0.6 cm rise in head position compared with a 1.4 ± 0.3 cm drop with protocol HS (P < .001). Protocol HP produced 4.9° less total angular excursion (P < .001) and 2.1 cm less total vertical excursion (P < .001) than protocol HS.

Conclusions: The pack-and-fill protocol was more effective than shoulder pad removal in minimizing cervical spine movement throughout the equipment-removal process. This study provides evidence for including the pack-and-fill protocol in future treatment recommendations when helmet removal is necessary for on-field care.

Figure 1.

Experimental setup. One athletic trainer worked as the remover, and one worked as the stabilizer. The motions of the head and torso were monitored using motion-capture technology throughout 4 different protocols.

Figure 2.

Mean changes in head relative to torso position between initiation and release. A, Cervical flexion (+) /extension (–). All pairwise protocol comparisons were different (P < .008). B, Vertical position (up [+]/down [–] relative to neutral calibration). All pairwise protocol comparisons were different (P < .008). We found no protocol-athletic-trainer interactions. Abbreviations: H, removal of the helmet only followed by placing the head on the ground; HP, removal of the helmet only followed by packing the area under and around the head with towels; HS, removal of the helmet and shoulder pads followed by placing the head on the ground; and HSP, removal of the helmet and shoulder pads followed by packing the area under and around the head.

Figure 3.

Total excursion throughout the removal process (maximum – minimum). A, Cervical flexion/extension excursions. All pairwise comparisons were different (P < .008). B, Vertical linear excursions. With the exception of the comparison between protocols H and HS, all pairwise protocol comparisons were different (P < .008). We found no protocol-athletic trainer interactions. Abbreviations: H, removal of the helmet only followed by placing the head on the ground; HP, removal of the helmet only followed by packing the area under and around the head with towels; HS, removal of the helmet and shoulder pads followed by placing the head on the ground; and HSP, removal of the helmet and shoulder pads followed by packing the area under and around the head.