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Lacrosse Helmet Facemask Removal Timeliness and Preference Rating Using a Cordless Screw Driver, FMX, and Two-tool Approach

2015; Volume: 7; Issue: 1 Linguagem: Inglês

10.3928/19425864-20150121-03

1942-5872

Katherine A. Frick, Thomas G. Bowman, Patricia A. Aronson,

Medical Imaging and Analysis

Original Research freeLacrosse Helmet Facemask Removal Timeliness and Preference Rating Using a Cordless Screw Driver, FMX, and Two-tool Approach Katherine A. Frick, MS, ATC, LAT, , , MS, ATC, LAT Thomas G. Bowman, PhD, ATC, , and , PhD, ATC Patricia Aronson, PhD, ATC, , PhD, ATC Katherine A. Frick, MS, ATC, LAT , Thomas G. Bowman, PhD, ATC , and Patricia Aronson, PhD, ATC Athletic Training & Sports Health Care, 2015;7(1):5–13Published Online:January 21, 2015https://doi.org/10.3928/19425864-20150121-03Cited by:3PDFAbstract ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail SectionsMoreAbstractIf a cervical spine injury is suspected in a helmeted athlete, facemask removal may be required to secure an airway. Expedient and careful facemask removal increases the chance of survival and reduces hypoxic damage. This study compares the speed of three methods of facemask removal between athletic training students (n = 10) and athletic trainers (n = 10) on a lacrosse helmet. Time and satisfaction of facemask removal using a cordless screw driver (CSD), FMXtractor 2 (Sports Medicine Concepts, Inc., Livonia, NY), and two-tool approach were measured. A factorial multivariate analysis of variance revealed a main effect for method of removal (multivariate F4,106 = 14.77, P < .001). Time (F2,54 = 15.27, P < .001) and satisfaction (F2,54 = 38.35, P < .001) differed between the removal methods. The CSD was the fastest and most preferred method to remove a facemask from a new men's lacrosse helmet. The authors recommend using a CSD first when attempting facemask removal on a new lacrosse helmet. [Athletic Training & Sports Health Care. 2015;7(1):5–13.]IntroductionA catastrophic injury is a deformation of the cervical spine that can be associated with potential or definite damage to the spinal cord.1 Emergency management techniques of potential catastrophic injuries differ slightly when working with an athlete who wears protective equipment such as a helmet and shoulder pads. In the case of potential catastrophic injury or cervical spine injury in a helmeted collision sport such as football and ice hockey, removal of the facemask from the helmet is a critical and lifesaving procedure that all athletic trainers must be able to perform efficiently.2 Although some have argued for facemask removal when a cervical spine injury is suspected in a patient wearing a lacrosse helmet and shoulder pads,3 a consensus on how to care for the potentially catastrophically injured lacrosse athlete has yet to be reached.4 When dealing with a cervical spine injury, securing neutral cervical alignment and allowing quick access to the airway is paramount for the injured athlete, which may require helmet removal. An improperly fitted or adjusted helmet will impede the ability to gain proper control, alignment, and immobilization of the cervical spine.4At this time, research has not come to a definite conclusion on the most effective way of establishing an airway while maintaining proper cervical alignment due to the fit and size of lacrosse helmets. Current research is beginning to explore the risks and benefits of facemask removal or entire helmet removal for a lacrosse athlete who has sustained a cervical spine injury.3,5–8 Although it has been found that lacrosse helmet facemask removal can occur within a reasonable amount of time when using a cordless screwdriver (CSD),5,8 the space for the spinal cord is not significantly different between helmeted and non-helmeted athletes6 and cervical spine motion is limited the most when the lacrosse helmet is removed,7 suggesting that helmet removal may be more appropriate. However, it remains unknown how much cervical motion occurs during helmet and facemask removal tasks.All emergency health care providers should be familiar with the helmets that athletes wear and the best way to remove the facemask should an emergency occur. It has been determined that procedures used to secure an airway, such as facemask removal, to allow for examination of the athlete and also to perform cardiopulmonary resuscitation and use an automatic external defibrillator if needed must occur within 4 minutes of the injury.9,10 Taking longer than the allotted 4 minutes to provide lifesaving care dramatically increases the possibility of irreversible physical and/or brain damage or even death.4 Effective emergency health care providers should be able to complete facemask removal in 30 to 60 seconds with any method and helmet they use.2,11Due to the popularity of and the number of participants in football, the majority of facemask removal research has been conducted on football helmets.12–16 Many tools, such as the FMXtractor 2 (FMX; Sports Medicine Concepts, Inc., Rochester, NY), Trainer's Angel (TA; Trainer's Angel, Riverside, CA), CSD, anvil pruner, and PVC pipe cutter, have been used for football helmet facemask removal.13,14,16,17 The variety of tools can be used in numerous ways, alone or in combination. Studies have found removal tools, such as cordless and manual screwdrivers, to be more favorable and produce less torque on the athlete's head and cervical spine area.5,13,18 Despite often being heavily favored, it has been noted that relying completely on a removal tool could end in failure due to the oxidation or corrosion of the fixtures.10,19 In this situation, a cutting tool can be used to complete facemask removal by compromising the loop straps securing the facemask in place when the screws cannot be removed.4,12,20The popularity of men's lacrosse is steadily increasing, resulting in an increased number of participants.21 The collegiate men's game had nearly 11,000 participants during the 2011–2012 academic year across all three divisions compared to slightly more than 4,000 during the 1981–1982 season.21 In men's lacrosse, from 1996 to 2012 there were 14 instances that the use of cardiopulmonary resuscitation and an automatic external defibrillator were necessary for the care of a catastrophic incident during play.18,19 Due to the prompt medical care and use of an automatic external defibrillator, 7 of the individuals in these instances survived.22,23 These extreme circumstances are critical to note for every emergency health care provider.Removal of the facemask in lacrosse catastrophic injuries must be quick and efficient; however, little research has been conducted on facemask removal of a men's lacrosse helmet. Although similar at first glance, the lacrosse and football helmet are different in structure, durability, models, and materials.24 The removal instrumentation is often the same for football and lacrosse helmets, but the actual technique is different due to the helmet construction and loop strap location. One study found the use of a CSD to be the fastest and easiest method to remove a lacrosse facemask.5 However, a two-tool approach (TTA) was not included and only athletic trainers participated. We believe it is important to also study athletic training students because they may be required to assist in emergency protocol. Therefore, the purpose of this study was to compare lacrosse helmet facemask removal time and satisfaction for the Cascade CPX lacrosse helmet (Cascade Lacrosse, Liverpool, NY) among athletic trainers and athletic training students. Our hypothesis was that the CSD would be the fastest method and receive the highest satisfaction scores, similar to previous research studying lacrosse5 and football10,13,14,19 facemask removal procedures.MethodsParticipantsTen athletic trainers and ten athletic training students volunteered to participate in this study. Each participant was required to have provided athletic training services to either football or men's lacrosse for at least 1 month within the 5 years prior to participation. All of the athletic training students attended a Commission on Accreditation of Athletic Training Education accredited Athletic Training Program at a school in the National Athletic Trainers' Association District 3, whereas the athletic trainers were educated at various schools but were licensed in his or her state and employed in National Athletic Trainers' Association District 3. We set no other specific exclusion or inclusion factors. Demographics of the participants can be seen in Table 1.Table 1 Participant Demographic InformationGROUPNO.SEXDOMINANT HANDYEAR IN ATP/CERTIFICATION YEARS (MEAN ± SD)Athletic trainer10M = 4, F = 6R = 8, L = 211.75 ± 8.02Athletic training student10M = 3, F = 7R = 8, L = 22.40 ± 0.52ATP = athletic training program; SD = standard deviation; M = male; F = female; R = right; L = leftWe settled on our sample size based on a power analysis of previous research examining the differences between the CSD and FMX when performing facemask removal in football helmets.25InstrumentationWe used two tools in this research design in a combination of three different methods. The CSD (Ryobi model HP41LK 4 volt lithium ion; Ryobi Technologies, Inc., Anderson, SC) and the FMX, as seen in Figure 1, were both used on two separate trials, and then both tools were used in a TTA. We chose to use these tools because the CSD has been found to be the quickest and easiest tool for facemask removal with both football10,13,14,19 and lacrosse5 helmets. However, screw removal failure has been found in both football12,13,18,26 and lacrosse8 helmets, requiring a cutting tool to complete the task. The researcher and participants used the same FMX throughout all of the trials as the cutting tool for the loop straps and the participants used one battery-operated rechargeable lithium CSD with the included Phillips screwdriver bit throughout all of the trials. We sharpened the FMX after every 15 removal trials as per the manufacturer's guidelines and charged the CSD prior to each data collection session.Figure 1. The FMXtractor 2 (Sports Medicine Concepts, Inc., Livonia, NY) and the cordless screwdriver (Ryobi 4 volt lithium ion; Techtronic Industries, Anderson, SC).A total of three new Cascade CPX helmets were used for all of the trials. Between each participant, the researcher replaced all loop straps and used a Torque Ratchet Screw Driver (A-50; Apco Mossberg Co., Attleboro, MA) to set the screws to a standardized 3 in/lbs of torque before each trial.15,27 We recorded time with a standard digital stopwatch (Sportline; EB Sport Group, Yonkers, NY) for all completed trials.Testing ProceduresEach participant volunteered to meet the lead researcher at a research laboratory or athletic training clinic with ample space. Participants signed an informed consent agreement on arrival and we then read each participant a copy of the removal techniques given by the manufacturer of the Cascade CPX.28 Our use of the Cascade CPX (Figure 2) is due to the common use of this specific helmet in many levels of play in lacrosse29 at the time of data collection. After the removal techniques instructions had been given, the participants were read standard directions written by the researcher explaining the methodology and testing procedures. The lead researcher was present in all trials and available to answer any participant questions. The participants then were allowed up to 15 minutes to familiarize themselves with the helmet and tools. The researcher required each participant to use the FMX to cut one loop strap and to use the CSD to unscrew one screw as practice. The researcher fitted the helmet properly to a volunteer to simulate an actual athlete in the supine position on a field. The participant then took the position of a worst-case scenario in which the athletic trainer removing the facemask would be positioned superior to the athlete using both knees to provide stabilization.12,13,16Figure 2. The Cascade CPX men's lacrosse helmet (Cascade Lacrosse, Liverpool, NY).Method 1 used only the CSD, which required removing three different screws on the helmet. The three screws that were removed were the two side screws holding the facemask and chin guard onto the helmet and the top screw fixing the facemask to the visor of the helmet. With this removal technique, the cage of the facemask and the chinguard were removed from the helmet as a unit.Method 2 used only the FMX. The participant cut all five loop straps securing the facemask to the helmet shell and chinguard. The five loop straps consist of the two side loop straps, the two lower loop straps connecting the facemask to the chinguard, and also the bifurcated loop strap that holds the cage of the facemask to the visor of the helmet. The bottom two loop straps connecting the facemask to the chinguard are secured by pop rivets when manufactured. We drilled out these pop rivets and replaced them with a screw and T-nut combination to allow us to replace these loop straps following the cutting trials.Method 3 removed the facemask using the TTA. This method used both tools and consisted of cutting the two side loop straps, cutting the two lower loop straps, and then completing the facemask removal by removing the top screw at the visor of the helmet using the CSD. We included this procedure because in our experience the bifurcated loop strap under the visor is difficult to cut due to its position and most participants had difficulty cutting the visor loop strap during pilot testing. We thought this location substantially hindered the use of the FMX for lacrosse helmet facemask removal and wondered if the TTA would perform better than using only a CSD or the FMX. Further, due to the location, the top screws have been found to be less likely to fail during facemask removal18,26 because of corrosion as they do not incur the same level of water exposure from sweat or the athletes drinking.Each participant completed all three facemask removal methods during one session in a counterbalanced order to minimize the effect of learning on the time necessary to complete each trial.We began timing when the participant picked up the tool for the particular trial and stopped timing once the facemask had been completely removed. The order of the removal method trials was counterbalanced for each of the participants prior to the testing session to control for the possible effects of fatigue and to remove time dependency on experience with the tools. During pilot testing, we noticed that most participants needed a substantial amount of time for completing facemask removal. Therefore, we established no time limit for this experiment to allow for an accurate representation of the time required for lacrosse helmet facemask removal without a high number of failures due to going longer than a time limit. Each trial was fully completed when the facemask had been completely removed from the helmet. After the completion of each trial, the participant orally rated satisfaction with the given facemask removal method on a scale of 1 to 10, with 1 being completely dissatisfied and 10 being completely satisfied. The participants rested for 5 minutes between each data collection trial. After each trial we used replacement loop straps from the manufacturer to repair the helmet for the next trial and re-torqued each of the screws to our previously set 3 in/lbs of torque.15,27Statistical AnalysisWe completed statistical analysis using IBM SPSS Statistics version 21.0 for Windows (IBM Inc., Armonk, NY). To compare the times of the three different methods of facemask removal (CSD, FMX, and TTA) and the satisfaction scores among the two groups (athletic training students and athletic trainers), we used a 2 × 3 factorial multivariate analysis of variance (MANOVA) with follow-up analyses of variances (ANOVAs) and Tukey post-hoc tests to identify where significant differences occurred between removal methods. We chose to use a MANOVA due to the strong negative correlation between the two dependent variables, time and preference (r = −.785, P < .001). For statistical significance, we set the alpha level at P < .05 a priori.ResultsWe completed 60 trials (three removal methods with 20 participants) in this study. Each participant fully completed each of the three removal techniques and was successful 100% of the time (ie, the facemasks were removed from the helmets in all trials). Although the participants successfully removed all of the facemasks for the current study, nine trials took longer than 4 minutes. Previous research commonly uses 3 or 4 minutes as a maximum time due to the hypoxic damage and cellular death that occurs in that amount of time without adequate breathing and proper perfusion.3,4,9,27 We found a significant main effect for removal tool (F4,106 = 14.77, P < .001, η2 =0.59, 1-β = 1.00). We failed to find a significant interaction between removal tool and group (F4,106 = 1.38, P = .51, η2 = 0.06, 1-β = .26) and no significance was found for the main effect of group (F2,53 = 1.38, P = .26, η2 = 0.05, 1-β = .28).TimeThe results for time can be found in Figure 3. We followed up the significant main effect with ANOVAs for time. The factorial model results indicated facemask removal time was influenced by the method of removal, (F2,54 = 15.27, P < .001, ω2 = .32, 1-β = .99). Tukey post-hoc testing revealed a significant difference between CSD (38.83 ± 11.49 seconds) and TTA (167.82 ± 103.96 seconds) (P = .001) and between CSD and FMX (207.92 ± 143.20 seconds) (P < .001), but no significant difference between TTA and FMX (P = .43). Conversely, the specific group the participant was in (athletic trainer or athletic training student) did not affect facemask removal time (F1,54 = 1.99, P = .16, ω2 = .01, 1-β = .28), and the interaction between removal method and group was also not significant (F2,54 = 1.22, P = .30, ω2 = .02, 1-β = .26).Figure 3. Facemask removal times. *Cordless screwdriver (CSD) significantly faster than two-tool approach (TTA) and FMXtractor 2 (FMX) (Sports Medicine Concepts, Inc., Livonia, NY) (P ≤ .001). AT = athletic trainers; ATS = athletic training studentsSatisfactionThe results for satisfaction can be found in Figure 4. The factorial model results indicated there was a significant tool satisfaction difference among participants, (F2,54 = 38.35, P < .001, ω2 = .56, 1-β = 1.00). Tukey post-hoc testing indicated a significant difference between the satisfaction of the CSD (9.20 ± 0.52) and the FMX (4.85 ± 1.93) (P < .001) and between the CSD and the TTA (6.05 ± 1.90) (P < .001). There was no significant difference between the FMX and the TTA (P = .06). The CSD was the tool given the highest satisfaction score by 95% (19 of 20) of participants. However, the specific group that the participant was in (athletic trainer or athletic training student) did not affect removal satisfaction (F1,54 = .06, P = .81, ω2 = .01, 1-β = .06). Further, the interaction between facemask removal satisfaction and participant group was not significant (F2,54 = .36, P = .70, ω2 = .01, 1-β = .11).Figure 4. Satisfaction of removal method *Cordless screwdriver (CSD) significantly higher satisfaction rating than two-tool approach (TTA) and FMXtractor 2 (FMX) (Sports Medicine Concepts, Inc., Livonia, NY) (P < .001). AT = athletic trainers; ATS = athletic training studentsDiscussionTimeThe purpose of this study was to compare the speed of three methods of removing the facemask of a Cascade CPX lacrosse helmet. All trials were completed successfully; all facemasks were completely removed from the helmet. For this study, no time limit was set, in contrast to other studies that kept a 3- or 4-minute maximum because that is when hypoxic cellular death begins to occur in the brain.3,4,9,27 Groupings of trial times can be seen in Table 2. Similar to previous research with football10,13,14,19 and lacrosse,5 the results gathered in this study indicated that participants performed facemask removal the fastest with the CSD removal method. The times obtained in the current study (Figure 3) using lacrosse helmets are similar to previous work that recorded facemask removal with the CSD on football helmets,13–15,19 but slightly higher than times reported with lacrosse helmets.5 Our research results also agreed with previous work on football10,13,19 and lacrosse5 facemask removal because the CSD was favored over the other two methods of facemask removal (Figure 4).Table 2 Trials Lasting > 3 MinutesGROUP3–4 MIN4–5 MIN5+ MINAthletic trainersFMX = 1FMX = 1FMX = 1TTA = 2TTA = 1TTA = 0CSD = 0CSD = 0CSD = 0Athletic training studentsFMX = 3FMX = 1FMX = 2TTA = 1TTA = 1TTA = 2CSD = 0CSD = 0CSD = 0FMX = FMXtractor 2 (Sports Medicine Concepts, Inc., Rochester, NY; TTA = two-tool approach; CSD = cordless screwdriverVarious reasons may be attributed to the speed and satisfaction of the CSD over the other two removal methods. The CSD allows facemask removal with fewer steps than the other two removal methods used. Only three steps must be performed before the facemask can be completely removed when using a screw removal procedure. These three steps are removing one screw on each side and one screw in the visor of the helmet. This is in comparison to the FMX having five steps (or five loop straps to cut) and the TTA having five steps (four loops straps to cut and one screw to remove).Grip or hand strength may also influence the use of the FMX by having to squeeze the tool manually shut, whereas grip strength is not likely to be a factor in use of the CSD. Research has attempted to draw a correlation between sex or grip strength and the effectiveness of cutting through loop straps, but these attempts have not been successful when studying football facemask removal.10 However, research on lacrosse facemask removal has found a correlation between grip strength scores and facemask removal time for cutting tools but not the CSD.5The similarity between the steps required for facemask removal when using the FMX and TTA is a likely reason the times between these two methods were not statistically different. Although we thought using a CSD instead of a cutting tool at the visor location would improve facemask removal times, that was not the case.Placement of the loop straps on the helmet can cause an unusual cutting angle when using the FMX on a lacrosse helmet. This cumbersome angle was occasionally a problem for participants throughout the current study. A combination of this uncomfortable cutting angle, in addition to inadequate grip strength, may cause a severe difference not only in the time but also the comfort level of using the tool. Perhaps the use of a different cutting tool, such as a pruner with a thicker blade, or different helmet designs could improve the ability to compromise the loop straps. The natural familiarity of the tool may also be brought into scrutiny. The FMX is slightly different from most tools that many individuals commonly use. The CSD is a familiar tool for many and is often considered a household object. The common use and comfort of this tool could possibly also influence the satisfaction of the tool.SatisfactionThere was a significant difference found between the satisfaction scores of the removal methods. Although participants were not informed of the removal time until after the completion of all three trials, we suspect that removal method satisfaction was influenced by how the participants felt they did with each method and the time that corresponded with the participants' performance. The significance found between time of facemask removal and satisfaction of removal method in this study contrasted previous research on football helmets.16 This previous study illustrated that no difference was indicated among time and satisfaction with tools such as the anvil pruner, FMX, PVC pipe cutter, and Trainer's Angel.16 We believe these differences exist because we used a removal tool, whereas the previous study only examined cutting tools. However, our findings are similar to lacrosse literature, which found the CSD was faster and easier to use than the FMX and Trainer's Angel but similar to a pruner.5The satisfaction of the current study may have been due to the familiarity of the tools, the time the participants perceived that it took to complete the task, or the ease of the task in general. Many of the participants commented on the difficulty of the cutting tool compared to the use of the removal tool. The cutting tools used for facemask removal must be at a proper angle to completely cut through a loop strap securing the facemask to the helmet shell on a helmet. Participants often had to make several attempts in cutting the plastic loop straps, whereas in using the CSD they did so with perceived relative ease. It is likely that the current study found higher levels of satisfaction when using a CSD as a removal tool rather than the FMX or another cutting tool due to the familiarity and ease of the tool.Group DifferencesIn this study we also investigated possible differences for facemask removal time and satisfaction between the different groups (athletic trainers and athletic training students). We found no differences between athletic trainers and athletic training students for time on any of the three removal methods. This is consistent with previous work that found no significant difference between football facemask removal times of specific groups (athletic training students, athletic trainers, and emergency medical technicians).14,27 One previous study suggested that no differences were found between certified athletic trainers and athletic training students because both groups were required to watch a video demonstration of the methods prior to participation and because two new forms of facemask removal (Quick Release Mechanism and the Pocket Mask Insertion) were being tested on football helmets.27 Comparable to the current study, neither certified athletic trainers nor athletic training students had extensive previous training in facemask removal specifically for men's lacrosse helmets. Lack of prior formal education and experience may have led to the absence of differences between the groups in previous work27 and in our study.Previous work emphasizes that facemask removal must be completed and interventions must be administered within a 4-minute window of the occurrence of catastrophic injury and that the actual act of facemask removal should be performed in 30 to 60 seconds.2,9,11 Although the few seconds of difference between facemask removal methods in the current study between the groups and across removal methods may not be statistically significant, these seconds have the clinical possibility of saving an athlete's life. During life-threatening catastrophic instances, every second counts when administering care. In the 60 trials that were conducted, only 25 fell within or below the recommended 30- to 60-second time frame.Fifteen of the trials that adhered to the time recommendations were completed by athletic trainers, and only 10 of the trials that were within the time recommendation were completed by athletic training students. In the current study, 3 of the 30 trials completed by athletic trainers took more than 4 minutes. All of the trials that took more than 3 minutes used either the TTA or the FMX removal methods. Of the 30 trials completed by athletic training students, 6 trials took more than 4 minutes. Similar to the athletic trainer trials, all of the trials lasting more than 3 minutes used either the TTA or the FMX removal method. We believe these findings warrant additional research to identify the most efficient training and practice methods to improve student proficiency at facemask removal.Limitations and Future DirectionsLimitations of this study included the setting in which the data were collected. The laboratory setting is a controlled environment, protected from severe weather and difficult temperatures such as extreme heat or cold. The helmets were also in optimal condition because they were unused.The state of mind that the participants were in may also have influenced the performance and the data collected. The knowledge that the "athlete" was merely a model and not truly facing potentially life-threatening complications could have affected the performance of the participant who completed the facemask removal trials because the participants were in a less stressful scenario than they would be in if they were to be in a live setting.For the practicality of the experiment, the bottom two loop straps that are typically held in place by pop rivets were drilled out and replaced with a screw and T-nut combination, allowing us to replace the cut loop straps. These altered helmets were only used in the cutting trials of the FMX and the combination method, but this alteration of the helmet still may have affected the normal cutting of the loop strap even though every effort was made to keep the altered helmets as similar to the original helmets as possible. These alterations may have changed the tension the pop rivets put on the loop straps or the precise angle in which they are affixed to the helmet.We also provided our participants with only 15 minutes to practice prior to the first trial. Allowing more time for familiarity or allowing full practice trials prior to the start of data collection may have produced different results.Future research should study different brands and types of helmets. Various other methods of facemask removal have been researched with other helmeted sports such as football and ice hockey. The use of an oscillating tool should also be explored in facemask removal. These tools work by allowing rapid back and forth movement creating friction and ultimately cutting through the material. The angle of the oscillating tool often allows for precise control over the cutting and does not create torque or large amounts of force on the object being cut. Despite the absence of research illustrating benefits or dangers of using the tool, some health care providers have turned to such tools