Sep 12, 2017Survey the Field
Hey Mike, ever wonder why woodpeckers can beat their heads against trees all day and never get brain injuries? Ever wonder why bighorn sheep can headbutt over and over again without giving themselves head injuries? We have a theory to explain these phenomena, and we want to study it. Would you like your school to be the first to test it on the field?”
These questions, posed to me in the summer of 2014 by Gregory Myer, PhD, FACSM, CSCS*D, Director of Research and the Human Performance Laboratory for the Division of Sports Medicine at Cincinnati Children’s Hospital Medical Center, were akin to asking me: “Mike, you’re dying of thirst in the desert — would you like something to drink?” My response? Heck, yes!
Dr. Myer was talking about testing the Q-Collar. Developed by the Connecticut-based company Q30 Innovations, it looks like a very thick collar that only encircles 75 percent of the neck. Its job is to put light pressure on the jugular vein. Like putting a kink in a garden hose, this increases the intracranial blood volume (not pressure) in the skull. The idea is that creating this backflow of fluid could decrease the “slosh effect” that contributes to some sports-related concussions. (It’s believed that a similar mechanism keeps woodpeckers and bighorn sheep free from head injuries.)
Dr. Myer wanted to test the Q-Collar at my school — St. Xavier High School in Cincinnati, an all boys’ Jesuit high school — and eventually publish the results in a scientific journal. I was all-in.
This being my first foray into conducting research at St. Xavier, I quickly learned there are a lot of steps between agreeing to be in a study and seeing the printed journal article. Multiple people are involved, the data collection process can be a grind, and it can add quite a bit of work for the athletic trainer. But now that we have crossed the finish line, I can see that the experience was well worth it.
WHY WE PARTICIPATED
The main reason I agreed to take part in the Q-Collar study is because I think the biggest issues facing athletic trainers in the future will be related to preventing and treating head injuries. Until recently, my medical staff and I could only be reactive when it came to concussions. Other than making sure helmets were reconditioned yearly, working on neck strengthening for our teams, teaching proper tackling techniques, and monitoring and eliminating unnecessary contact during practices and games, we weren’t sure what else we could do for prevention.
[The players] were somewhat apprehensive about wearing the collar and were concerned it wouldn’t feel natural. To help with this, we explained that the collar would be fitted into a non-invasive laceration sleeve, which would keep it stable during play and protect it.
So when Dr. Myer asked if we wanted to participate in a potentially revolutionary investigation into head trauma, I was eager to find out how we could be involved. However, I had one condition — there had to be unquestionable research behind the Q-Collar. I am a gigantic skeptic when it comes to trying out new products because there are a lot of snake oil salesmen out there telling unsuspecting parents, coaches, doctors, athletic trainers, and athletes: “This device will solve all of your concussion problems!” or “This piece of equipment will decrease concussion risk by 30 percent!” I think it’s important to see evidence that a product works before putting all of your faith in it.
Fortunately, Dr. Myer assured me the Q-Collar was backed by several years’ worth of research. It was shown to protect the brain from significant trauma and didn’t inflict any side effects on the athletes or animals that were tested. The only cons I could see to taking part in the study were the potential that the Q-Collar might not work and the added time demands the investigation would place on my staff and me, neither of which seemed like significant enough reasons to say no. At that point, participating in the study was looking more and more like a no-brainer (awful pun intended).
The clincher was getting St. Xavier’s administration on board. In my 11 years at this school, I have built up enough trust with our administration that if I bring something to them, and I believe it could benefit our community, they are almost always supportive. So I presented the study to them as a potential way for St. Xavier to be on the frontlines of addressing the concussion epidemic and show our parents, athletes, coaches, alumni, and future students that we take head injuries seriously.
Convinced, my administration and Athletic Director John Sullivan signed on to the first-ever on-the-field study of the Q-Collar. We started with the varsity ice hockey team in the winter of 2014-15.
ON THE ICE
To get volunteers for the study, we held a preseason meeting for hockey players and their parents where we explained the research on the Q-Collar. We then outlined the basic structure for the investigation, which would involve student-athletes wearing the Q-Collar on their necks and having accelerometers in their helmets to track all collisions sustained throughout the 2014-15 season.
Each participant would also undergo preseason, midseason, and postseason MRIs, electroencephalography (EEG), vision testing, neurocognitive testing, and neck ultrasounds. These would help the researchers better understand how the brain functions while wearing the Q-Collar and how the brain changes over the course of a season with all of the collisions associated with playing hockey.
We had to do some selling to get the players on board, as it is not easy to convince high schoolers to change their routines. They were somewhat apprehensive about wearing the collar and were concerned it wouldn’t feel natural. To help with this, we explained that the collar would be fitted into a non-invasive laceration sleeve, which would keep it stable during play and protect it.
The coaches were sold on the study once we reassured them that it wouldn’t interfere with their ability to coach or add any hassle to their routines. The fact that St. Xavier Assistant Athletic Trainer Ken Rushford, ATC, CSCS, or I would be present at every single practice and game was another significant selling point, as we typically didn’t attend off-site practices and away games for hockey. For the coaches, the potential benefits far outweighed any perceived annoyance of being a part of something extra.
In all, 14 of the 17 varsity hockey players signed up to participate. The research team wanted a crossover study design, so they planned for seven players to wear collars and accelerometers from the beginning of the season to the midway point. Then, the other seven athletes would take over wearing the devices. If athletes wore the collars and accelerometers for their part of the season and completed every test and imaging, they would be financially compensated by the researchers.
Once the study got underway, Ken or I made sure the collars and accelerometers were turned on for every practice and game and recorded daily whether athletes wore their collars, whether they were sick, and whether they had any injury or other issue. After practices and games, we turned off all the accelerometers, collected them, and uploaded them to the cloud for the Cincinnati Children’s researchers to analyze.
All seven members of the first intervention group were great about wearing the Q-Collar, but we hit a bump in the road midway through the study when we attempted to switch to the second group of seven players. You can change research up on mice or pigs mid-experiment, but when human subjects have their routines changed halfway through the season, they might elect to discontinue participation. As a result, only three or four players from the second group wore the collars on an even semi-regular basis, which was absolutely their right to not participate. No research with minors would ever be allowed to occur if it was mandatory. In retrospect, the study should have continued throughout the season with just the first group wearing the collars.
Although fewer players wore the Q-Collar during the second half of the season, all 14 student-athletes underwent each phase of testing and imaging. We got some great information from their scans. The Cincinnati Children’s research team also obtained some exceptional and ground-breaking information from all of the data.
Overall, the hockey players really liked the fact that they were on the ground floor of what could be a fairly extraordinary advance in head injury prevention, and they loved being a part of the study. Certainly, the tedium of checking the collars and accelerometers every day started to wear on them over time, but the collar eventually became simply another piece of equipment to put on, added to the literal dozens they already wore.
The results of the ice hockey study were published in the June 2016 edition of Frontiers in Neurology. They were extremely promising in that they showed the Q-Collar preserved brain structural and functional integrity over the course of the season. We were on to something big.
TO THE GRIDIRON
Getting a taste for research with the St. Xavier ice hockey team made us want to continue this study with the logical next step. We looked toward the great white whale when it comes to head injuries in sport: football.
It did not take much convincing to get our St. Xavier football coaches and athletic administration on board for another Q-Collar study after seeing the results of the hockey investigation. Our Head Football Coach, Steve Specht, is very involved with USA Football and its Heads Up initiatives to help decrease head injuries in football at all levels, and he was interested from the beginning. Just as with ice hockey, a big selling point for the football coaches was that the study would not impact any portion of their practices or games. My staff and I — not the coaches — would handle all of the extra work.
To inform football players and parents of the research, we had another preseason meeting. We offered participation in the study to 30 athletes at first, and 20 of them decided to join. After that, we added a few more players to make the group more robust, increasing the final number to 32. This group consisted mostly of starters and second-team players from both the offense and defense. A few players who were chosen had a history of head injury, so they were particularly excited to be a part of the research.
St. Xavier became the first football team to wear the Q-Collar on the field of play in fall 2015. Similar to the hockey players, the football athletes wore the collars and accelerometers for every practice and game and underwent pre- and postseason MRIs, EEGs, vision tests, and neurocognitive testing. But unlike the hockey investigation, this was not a crossover study, so we did not switch participants midseason or do midseason testing.
Every day, my staff and I tracked whether the athletes wore the collars, were sick, or were injured and didn’t participate. A group of 31 football players from nearby Moeller High School were the control group, meaning they did not wear the collars but wore the accelerometers and received the same pre- and postseason testing.
Over the course of the season, two St. Xavier players chose to stop wearing the collars, and two were lost for the season with significant injuries. However, the other 28 athletes had almost 100 percent usage rate in helmeted practices and games. Like in hockey, the players said the collar became just another piece of equipment. The first season of football research was a success across the board.
We were excited to do an additional football study of the Q-Collar in the 2016 season, including 10 athletes who participated in 2015 and wanted to do it again. There were various reasons for doing another study — we had the chance to get two years’ of data on athletes, we were interested in the changes that might happen from year to year, and we were curious to see what information we might glean from four testing dates for each individual.
For the 2016 season, Dr. Myer and Q30 initiated and ran the study, following the same testing and monitoring protocols as before. The football team ended up winning the Ohio Division I state title in December of 2016, which was the icing on the cake of a tremendous research partnership and injury prevention initiative. It was certainly one of the most memorable, intense, and surreal seasons I’ve ever been a part of.
With more than 60 football players imaged, tracked, and tested over two seasons, the Cincinnati Children’s SPORT Center, led by Dr. Myer and his team of Kim Barber Foss, MS, LAT, ATC, Staci Thomas, MS, and Chris DiCesare, MD, were able to analyze a plethora of data. Their results were published in the June 2016 edition of the British Journal of Sports Medicine.
In regards to brain integrity over the course of two football seasons, there were some incredible findings that showed a lot of promise for protecting and preserving brain structural and functional integrity, very similar to the hockey study. The hypothesis that the Q-Collar may work to prevent brain injury is still being tested in various settings, including female and non-contact sports, but from what we have seen, we are optimistic.
An unexpected — but fascinating — result related to pre- and post-injury brain scans. Athletes from both St. Xavier and Moeller tore their ACLs during the 2015 season, and it was incredible to see that their brains looked different before and after the tears. There may be much more to research on this front, but it is unique to have pre- and post-ACL tear MRIs for multiple athletes.
REFLECTIONS & ADVICE
Now that our role in the Q-Collar studies is just about done, if a high school athletic trainer were to ask me, “Should I get involved in research?” I would first say evaluate your resources. You have to factor in the added time and personnel commitment that comes with being part of an investigation.
For example, as I mentioned earlier, Ken or I had to be present at every practice and game when the Q-Collar was being tested. Providing this level of coverage proved to be a bit of a challenge with ice hockey because our hockey team does not practice on campus. It was also tricky to balance traveling to away games for ice hockey without neglecting our other sports. We adjusted by prioritizing and switching our schedules around to make everything work, but this might be difficult for sports medicine programs with limited personnel. Football wasn’t as difficult since we were already covering every practice and game, anyway.
Further, we had to make sure athletes had their accelerometers turned on and off every day, and then we had to collect and upload all of them individually. Each one only took about 10 to 15 seconds, but doing this 32 times at the end of each football practice and game got old fairly quickly. It might not seem like it, but this is quite a bit of legwork to keep up with on a daily basis.
Fortunately, I had Ken, four team physicians, two athletic training students from the University of Cincinnati and Xavier University, four strength coaches, and a staff of 10 student managers to help support our day-to-day research needs, not to mention the team of research professionals at Cincinnati Children’s. However, if you are the sole athletic trainer at your school and don’t have much of a support system, it can be challenging to add more responsibilities on top of your already busy day.
Beyond the time and personnel required to take part in a study, you have to be prepared for the grind of research work. Testing the Q-Collar was my first real experience with the minutiae of research, and it was, well, boring at times. Although I knew it was necessary, the day-to-day monotony of checking all the boxes, turning the accelerometers on and off, and uploading them was incredibly tedious. The plus side is that this experience has made us much more appreciative of what conducting a study really entails.
So, if you factor in all the potential obstacles that can come with participating in a study, and it still makes sense for you, go for it! If there’s a chance you can make an impact beyond your sphere of influence, nothing should stop you from exploring that possibility. You never know what kind of ripple effects you could have. We already wear a ton of hats as athletic trainers, including healer, therapist, motivator, and educator. Why not add researcher?
This article first appeared in the July/August 2017 issue of Training & Conditioning.