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ASTM Standard for Women's Lacrosse Helmet: Beginning of Debate About Whether Good For Game, Not End

While contact in girls' lacrosse is prohibited, concussions can and do occur. 

The two most recent studies of concussion rates among high school athletes (1,2) report concussion rates in girl's lacrosse essentially tied with girl's soccer for the highest among girl's sports, nearly as high as the concussion rate in boy's lacrosse (not statistically different in terms of rates), and almost double the rate of the girl's sport with the next highest concussion rate (basketball).  

Among all girl's sports studied, concussions represented a greater proportion of total injuries in girl's lacrosse. According to the 2012 study, concussions frequently resulted from player-equipment contact (55.9%), palyer-player contact (28.8%), and player-playing surface contact (11.9%). More specifically, the researchers found that concussions most commonly resulted from player-crosse/stick contact (41.7%), and player-ball contact (20.0%).  Clearly, then, concussions are an issue in the sport that needs to be addressed.

The question is what? Some concussion experts, including Dr. Robert Cantu (4), believe that helmets should be mandated in girls' lacrosse, as well as in field hockey, a sport in which the rules prohibit sticks above the knee but in which concussions, eye injuries, lacerations, broken noses and more also occur. 

On the other side are those who argue that, since contact to the head is illegal in girls' lacrosee, such a move is unnecessary, and could potentially turn the women's game into a collision sport. Citing a phenomenon called "risk compensation" - in which the use of protective equipment is thought to result in behavioral changes, such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates - they also fear that that making helmets mandatory could actually lead to an increase in concussion rates in the sport.

There is some evidence to suggest that such fears may be unfounded.  A study on the use of protective goggles (3), albeit in girl's field hockey and involving different protective equipment, for instance, found that their use did not increase concussion rates, despite fears that they would lead to more aggressive play and hence more concussions.  

Where does US Lacrosse, the sport's governing body, stand? Somewhere in the middle.  While Dr. Cantu argues in favor of requiring that girls and women wear a "substantial helmet" which covers the head completely but is so lightweight as not to impede side-to-side movement (4), Steve Stenersen, president and CEO of US Lacrosse, supports a modified helmet that covers the top of th head akin to a bicycle helmet, a helmet Dr. Cantu views as inadequate, based on results of tests by NOCSAE (the organization that sets safety standards for sports equipment)  that, he says, show that such helmets "tested poorly for protection against concussion-type hits." (4).  

One mother - whose daughter is still struggling to recover a year after sustaining a concussion when she was struck in the back of the head by a ball playing high school lacrosse - thinks it is "unbelievable that this is even a debate."  In a posting on a MomsTEAM forum, she argued that, "while a helmet may not save you from a concussive collision, it most certainly [would] save you from a ball to the back of the head.  Stick-to-head contact is always discussed in the women's game, [but] no one talks about the ball."

In October 2014, voting began on a proposed women's lacrosse helmet standard developed by the standard-setting group ASTM with input from US Lacrosse and based on research it funded,  research which was needed to design testing protocols and conduct the testing to yield the data and measurements used in shaping the new headgear standard.

Why a women's lacrosse helmet standard? Does the fact that one is being developed mean that the debate about whether such helmets will do more harm than good is over?

Hardly.  The new standard is likely more a function of the fact that, without an established standard in place to regulate the headgear that has come on to the market in recent years (none of which, according to US Lacrosse, has been developed based on scientific testing, and none of which the organization has endorsed), consumers are essentially "buying a pig in a poke": in other words, without a clue as to whether the product they are buying has any safety value at all. 

Whether headgear in the women's game will actually make the game safer will still be open to debate, at least until studies can be done to compare injury rates among girls and women wearing helmets and those who don't (similar to those done comparing injury rates for girls wearing goggles playing lacrosse versus those that didn't - which showed that the goggles were effective in reducing injury rates. 

So far at least, the data, says Dawn Comstock, PhD, an associate professor of Epidemiology for the Pediatric Injury Prevention, Education, and Research (PIPER) program at the Colorado School of Public Health, MomsTeam Institute Board of Advisor and a co-author of a 2014 study on injuries in high school lacrosse [5], "is quite clear - boys most commonly sustain concussions (nearly 75%) from athlete-athlete contact, the kind of mechanism we all know helmets don't always do a great job preventing - while girls most commonly sustain concussions (nearly 64%) from being struck by the ball or the stick, the kind of mechanism that helmets are actually quite good at preventing. Thus, this data clearly supports the call to put girls lacrosse players in helmets."

But, as a former college lacrosse and high school field hockey player, I have reservations about whether requiring female lacrosse and field hockey players to wear helmets will make the sports safer, or, as a result of risk compensation, actually result in more, rather than fewer, head injuries.

But the only way we will know the answer to that question is to make sure that whatever helmets female lacrosse players wear meet standards that are based on science, and have been developed after a deliberative and collaborative process by an independent organization, like ASTM, which is not funded by helmet manufacturers (unlike NOCSAE), and which does not just invite, but requires input from equipment manufacturers, product testing laboratories, researchers and governing bodies, in this case US Lacrosse.

From the numerous conversations (both on the telephone and via email) that MomsTEAM's Senior Health and Safety Editor, Lindsey Barton Straus, and I have had over the years with our friends at US Lacrosse, especially CEO, Steve Stenersen (who I started talking to way back in 1999-2000), director of health and sport safety, Bruce Griffin (who was one of the principal authors of the draft standard), and Ann Carpenetti, vice president of lacrosse operations and co-chair of the women's lacrosse headgear task group, I am confident that the draft standard is based on sound science.

Significant change

US Lacrosse is acutely aware that developing a headgear performance standard that spurs the introduction of protective equipment designed to limit peak head acceleration resulting from an impact to less than 80g of linear force without introducing additional safety hazards (such as by encouraging more stick contact to the head) is a significant challenge.

"It's our hope that developing a women's lacrosse-specific headgear standard that reflects the significant rule and culture differences between boys' and girls' lacrosse will mitigate the focal impact forces that occur from stick-to-head contact in the girl's game while maintaining the integrity of girls' lacrosse. Whether or not that results in a reduction of concussive events in girls' lacrosse is unknown, although we will certainly be studying it," said Stenersen.

At the same time, US Lacrosse has been correct to point out that protective equipment should be viewed as just one essential element in producing a safe playing experience. Months before the Florida High School Athletic Association voted in late September to mandate soft headgear for girls lacrosse for the 2015 season, Stenersen told MomsTEAM that he believed it would be "highly irresponsible" for high school associations and youth leagues to focus solely on requiring increased protective equipment if it meant ignoring what Stenersen viewed as "the most critical component to a safer, more enjoyable lacrosse experience: requiring nationally-standardized, sport-specific training for coaches and officials as a fundamental qualification to assure that the boys' and girls' lacrosse is being taught (and the rules are being enforced) correctly."

1. Marar M, McIlvain N, Fields S, Comstock R. Epidemiology of Concussions Among United States High School Athletes in 20 Sports.  Am J Sports Med 2012;40(4):747-755.

2. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011) 

3. Kriz PK, Comstock RD, Zurakowski D, Almquist JL, Collins CL, d'Hemecourt PA. Effectiveness of Protective Eyewear in Reducing Eye Injuries Among High School Field Hockey Players. Pediatrics 2012;130(6):1069-1075.

4. Cantu R, Hyman M. "Concussions and Our Kids." (Houghton Mifflin Harcourt 2012). 

5. Xiang J, Collins C, McKenzie L, R Comstock. Lacrosse Injuries Among High School Boys and Girls in the United States: Academic Years 2008-2009. Am J Sport Med. 2014. DOI: 10.1177/036354651453991 (published online July 22, 2014)