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Dr Richard Bonser DR ian de vere

DM3306 MAJOR PROJECT

The Concussion Diagnosis Process in Amateur Rugby

Tom ADCOCK 1006472 Brunel University Industrial Design & Technology BA


Contents

1.1 Abstract 1 2 Project Definition 2.1 Concussion: The Invisible Injury 5 2.2 The Concussion Crisis 7 2.3 Concussion in the NFL 9 2.4 Concussion in Rugby 11 2.5 Case Studies 13 2.6 Preliminary Design Brief 15 2.7 Design Approach 17 3 The Opportunity 3.1 Meeting the RFU 21 3.2 Patent Review 25 3.3 Parallel Products 27 3.4 Developed Design Brief 29 4 The Experience 4.1 The Current Diagnosis Experience 33 4.2 The Importance of Measuring Impact 35 4.3 Experience Development 37 4.4 The Developed Diagnosis Experience 39 5 The Product 5.1 Electronic Functionality Prototyping 43 5.2 Coding PPP1 45 5.3 Developing PPP1 47 5.4 Game Testing: PPP1 49 5.5 PPP1: The Deliverable 51 5.6 Aesthetic Prototype Development 53 5.7 IRB Regulations 55 5.8 PDS Limitations 57 5.9 Anthropometric Considerations 59 5.10 Locating the Components 61 5.11 Padding/Protecting the Components 63 5.12 Material Investigation - Fabric 65 5.13 Concept Development 67 5.14 Manufacturing PPP2 71 5.15 Game Testing: PPP2 73 5.16 PPP2: The Deliverable 75


6 The End of the Major Project 6.1 Final Design Proposal 79 6.2 Deliverables 81 6.3 Personal Evaluation 83 6.4 External Evaluation 85 7 Future Possibilities 7.1 Commercial Potential 89 7.2 Future Development 91 Glossary 95 References 99 Acknowledgements 107 Appendix A1 Industrial Review Evening 111 A2 Product Design Specification 113 A3 Graduated Return To Play (GRTP) 115 A4 Pitch-side Concussion Assessment (PSCA) 117 A5 Ethical Approval 119 A6 Code 121


1.1 Abstract This report gives an overview of the design and development of a product which aims to improve the current experience of diagnosing concussion in rugby, primarily focusing on rugby union (*herein referred to as ‘rugby’) at a grass-roots level. A three stage design process has been employed; researching the opportunity, re-thinking the concussion diagnosis experience and then designing a product to facilitate the improved diagnosis experience. Extensive research into the injury, its causes and the current concussion diagnosis protocols

was collated in order to develop a full ‘diagnosis experience’ for amateur rugby. To facilitate this, a product was developed which enables the user to quantify the severity of collisions and asses forces imparted on their head during a match or training situation; thereby removing the element of subjectivity in the diagnosis of concussion. Prototyping has been split between functional/ electronic prototyping (using the Arduino platform) and visual/aesthetic prototyping (using fabrics and protective foam) to produce two headwear prototypes. A full glossary is available at the end of this report.

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2. PROJECT DEFINITION

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Figure 1 - Concussion is a minor traumatic brain injury caused by a sharp jarring or impact to the head or upper body which forces the brain to collide with the inside of the skull.

Figure 2 - The image on the left is the brain of a healthy 65 year old man. The image below is magnified to show individual cells. The image on the right is the brain of a former NFL player who died at the age of 45. The dark matter is accumulated tau protein, now thought to be the cause of dementia.


2.1 CONCUSSION: THE INVISIBLE INJURY 2.1.1 What is a Concussion? “A concussion is a form of minor traumatic brain injury which may be caused by a sharp jarring or impact to the head, face, neck or upper body which forces the brain to collide with the inside of the skull” (Medline Plus, 2013). Severe concussion can be indicated by a loss of consciousness; however, many concussions do not result in the loss of consciousness which causes great difficulty in diagnosis. Not being ‘knocked out’ does not mean you are not concussed.

to, anger, suicidal behaviour, ‘Parkinsonism’ (symptoms similar to that of Parkinson’s disease) and in some cases the early onset of dementia (Gavett, Stern and McKee, 2011).

2.1.2 The Dangers of Concussion Concussion is often described as “the invisible injury” (Concussion: The Invisible Injury, 2013) in view of the fact that, unlike most sports injuries, the damage cannot be seen by eye. In addition to this, with the exception of ‘normal’ side affects such as headaches (which can easily be blamed on something else), the injury is mostly painless in recovery (Medline Plus, 2013). This not only leaves medical teams in the difficult position of assessing cognitive symptoms to gauge the extent of the injury, but also prevents an athlete from honest self-diagnosis and subsequent self-removal from future games. An athlete would never continue to play with a sprained ankle when the injury is visible and painful; but many would continue to play with invisible, painless concussions. In the short term, “concussion typically results in the rapid onset of short-lived impairment of neurological function” (McCrory et al, 2013), generally including short-term memory loss, depression, confusion and headaches (Medline Plus, 2013). In the long term, it is becoming increasingly evident that multiple concussions without recovery can lead to a condition called Chronic Traumatic Encephalopathy; a “neurodegenerative disease which occurs years or decades following the recovery from acute or post-acute affects of head trauma” (Gavett, Stern and McKee, 2011). Signs and symptoms of CTE include, but are not limited

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2.2 THE CONCUSSION CRISIS In the summer of 2013, following the NFL lawsuit (See ‘2.3 Concussion In The NFL’), concussion was unavoidable in the media. Heightened awareness meant the injury was everywhere with more and more horrifying stories each day. Following this, the ‘Mail On Sunday’ began a campaign, calling out for rugby’s governing bodies to act and rugby clubs to educate their players of the dangers of concussive injuries. All of this media hype helped to raise awareness of the injury - but offers no real solutions to the problem. The majority of diagnosis protocols put in place were shot down as being ineffective (Rugby365, 2013), and even those which received praise could not work in the amateur game due to the lack of medical staff available. The concussion problem has recently come to a crisis point - diagnosis protocols are not working and more and more players are being injured; with many high profile stories of players being forced to retire due to concussive injury. The rugby world is at tipping point; something needs to be done before participation levels drop and the sport suffers irreparable damage. With the rugby world cup coming to England in 2015, the sport should be thriving. Unfortunately, due to the horror stories in the media, this just isn’t happening. With the press pushing rugby to react and do something proactive to conquer the concussion crisis and medical protocols failing to perform adequately - good design could be the solution to rugby’s problem.

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In 2013, the NFL reached a settlement of:

$765,000,000 AFTER BEING SUED BY:

4,500 american footballers

=

1/4 of all of the players who have played in the NFL

ON THE GROUNDS THAT:

“The long term dangers of concussion have been concealed and injured players had returned to action too quickly” ...Rugby is a sport with a problem


2.3 CONCUSSION IN THE NFL 2.3.1 THE NFL LAWSUIT In 2013, the National Football League (NFL) reached a settlement of $765 million after being sued by more than 4,500 ex-American footballers on the grounds that the “long term dangers of concussion have been concealed and injured players had returned to action too quickly” (Cleary, 2013). The affect of this lawsuit has been felt at all levels of sport, not only in the professional game. Since the settlement, participation rates have dropped significantly in the youth game - “a sign that the concussion crisis that began in the NFL is having a dramatic impact at the lowest rungs of the sport” (Fainaru and Fainaru-Wade, 2013). Parents are no longer encouraging their children to play American football, instead encouraging ‘safer’ noncontact sports.

One of the ways in which the NFL has been seen to react to the concussion crisis is through improved diagnosis practices; allowing for players to be correctly diagnosed and removed from subsequent games. A number of American sportswear manufacturers now produce devices to assist the diagnosis of concussion (See ‘3.3 Parallel Products’), which have been very successful in the removal of injured players from the field. However, at the time of writing, nothing suited for this task in rugby is available. In summary, the design opportunity is clear: improve the concussion diagnosis process, ensuring injured players can be easily “recognised and removed”, aligning with the RFU educational campaign (see 2.4 Concussion In Rugby).

2.3.2 How is this affecting rugby? The NFL was the unfortunate recipient of the inevitable backlash following increased knowledge of concussion and its dangers. American football was used as an example and rugby must now react before it faces a similar litigation issue. Since it gained professional status in 1995 the sport has gone from strength to strength. However, in order to keep this rise up, it is important that rugby’s governing bodies quench the fire of concussion before the problem worsens. More important for the future of rugby, perhaps, is the issue of participation. When a sport is deemed ‘unsafe’ by parents, participation levels drop at the junior level of the game - which will have devastating effects in the future. The passion in team sports of any kind (particularly contact sports like rugby) instil good values in young people, as well as the obvious health benefits of exercise; so these sports should be encouraged! Concussion is causing an unnecessary air of ‘danger’ around the rugby and safe ways to play must be found.

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E S A C D HEA DON’T BE A

N O I S S U C N O C R O F K C E STOP! CH RECOGNISE REMOVE RECOVER RETURN

know the symptoms and signs of concussion.

any player you suspect has got a concussion IMMEDIATELY. Arrange for further assessment by. a health care professional fully give players time to recoverr injury. as you would with any othe ep-wise all players must follow a st(GRTP) Graduated Return to Play gby/sport until and must not go back to rudo so by a doctor. they have been cleared to

em out! Recognise, Remove and if in doubt, sit th

RFU.com/Headcase


2.4 CONCUSSION IN RUGBY Rugby’s reaction to the concussion crisis has largely been an approach based on education - which is one of the most important factors in ensuring the sport can be played safely and fewer concussions go undiagnosed. In the professional game, a number of diagnosis protocols are now running, or on trial - the main one being the Pitch-Side Concussion Assessment, (PSCA). This allows players to leave the pitch for 5 minutes and undergo a trimodal evaluation of injury comprising of a cognitive assessment, symptom assessment and a balance assessment; intended to reveal concussion on the pitch-side (IRB, 2013). If at any time during the process a medical professional suspects concussion; the player is removed from play and must not return. On the whole, the PSCA has been successful in removing players from the field following a potentially concussive impact, but there have also been a number of stories of players who are clearly concussed returning to play - after being assessed by their own team’s medical staff.

However, this is where problems begin to arise. Rugby players are a notoriously macho bunch, with intense loyalty towards their teammates. They are quite literally prepared to put their body on the line for the team; regardless of the consequences. Rugby players love their sport and team, and will do anything to participate as long as possible. Sport scientists call this attitude ‘deviant overconformity’ (Peyton, 2009) and it is one of the largest problems rugby’s governing bodies face when conquering the concussion crisis. Rugby players, as a demographic, are typically resistant to admitting injury - a task made even easier when the injury is invisible. Combine this with the fact most amateur rugby players spend the evening following a game in the club bar and it is all too easy to shift the blame of that headache the morning after a match! Good design can ensure this decision to ‘ignore’ the injury is taken out of the players hands. By presenting the player with solid evidence of a concussion the injury would become much harder for a player to ignore.

The real problem with concussion lies in the amateur game. The lack of medical professionals present at matches, in addition to a general lack of education around good concussion practice renders this the real target demographic for an improved concussion diagnosis experience. In an attempt to educate and improve practices in the amateur game, the RFU have launched the ‘Headcase Campaign’ to promote a ‘recognise and remove’ attitude towards concussion - ensuring players know how to recognise a concussion and can subsequently remove themselves from the risk of further injury (RFU, 2013). This campaign, spread largely through posters and visits to rugby schools and clubs, hopes to educate players not only of the correct diagnosis techniques, but also the correct mindset towards the injury - that the risks simply aren’t worth playing for.

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Figure 3 - Ben Robinson died after collapsing unconscious during a school rugby match. His death was the first confirmed case of ‘second impact syndrome’ in the UK. His mother describes his death as a tragic example of “rugby’s dirty secret”.

Figure 4 - Nic Berry was forced to retire in 2012 following a series of concussions with increasing severity. The decision was made by one of the world’s leading neurologists - who refused to sign Nic off as medically fit to play rugby.


2.5 CASE STUDIES Until very recently, the dangers of concussion in contact sport were not widely acknowledged, and the majority of rugby players took a particularly blasé attitude to the injury. However, with the increased awareness of the dangers, a number of diagnosis protocols have now been established in the professional game with some success. It is now the turn of the players to ‘catch up’ and correct their attitude towards the injury. 2.5.1 Case Study - Ben Robinson Ben Robinson, 14 years old, collapsed unconscious in the final minute of a school rugby match after sustaining concussion earlier on in the game. Ben was rushed to hospital where he was later pronounced dead. This was the first confirmed case of ‘second impact syndrome’ in the UK (Peters, 2013b). Second impact syndrome is a relatively unknown condition which is thought to be caused by multiple concussions; although there is currently no firm evidence of this. However, it is possible that Ben’s death could have been prevented if his first concussion was correctly recognised and he was removed from play. Ben’s father, Peter Robinson, has highlighted the worry at the grass-roots level of the sport - “At a professional level they have the protocol and they have the professional staff to take care of the players...I’m talking about schools and club level needing to recognise and remove players from the field of play” (Peters, 2013b).

leading neurologists, who refused to sign Nic off as medically fit to continue to play rugby (Peters, 2013a). It can be said with certainty that Nic is host to the many of the symptoms of concussion, as he has been heard to say “I’d be panicking all the time. I’d get home and couldn’t remember if I’d done or said something inappropriate ... I’d get up in the morning and forget where I’d put my keys or wallet the night before” (Peters, 2013a). Nic believes rugby’s attitude to concussion

“We used to treat concussion as a joke... now I worry about getting dementia” Lewis moody, former England international (now a concussion awareness campaigner)

is progressing, with research being carried out, but admits his wife does worry for the future “The scary thing is the dementia side of it and not knowing how far the damage has actually gone” (Peters, 2013a).

2.5.2 Case Study - Nic Berry Nic Berry is a former Australian and London Wasps rugby player who was forced to retire in 2012 due to a series of concussions with increasing severity. Nic suffered 9 concussions in the 2011-2012 season and took the entire off-season without playing contact sport to allow his brain to recover, before returning in the first game of the next season only to be concussed again. The decision to retire was then taken out of Nic’s hands by Professor Peter Hamlyn, one of the world’s

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2.6 PRELIMINARY DESIGN BRIEF

“Refine the process of diagnosing concussion in amateur rugby�

The preliminary design brief was deliberately kept very broad, so as to ensure the project could be approached with an open mind. This allowed the development of a complete concussion diagnosis experience (including a product to facilitate this), rather than a more narrow-minded entirely product design approach to the problem. The

design brief was later refined following the research phase, when a better understanding of the problem has been gained and the potential solutions have been uncovered. Working in this way ensures the problem is faced with a thorough and iterative design process, exploring all possible solutions before selecting a concept to develop.

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STAGE 1. OPPORTUNITY

+

STAGE 2. EXPERIENCE

=

STAGE 3. PRODUCT


2.7 Design Approach

With such a broad preliminary design brief and a short time frame to complete the project, a new design process was developed to ensure the problem could be approached logically, maximising productivity. It was established early in the project that the solution to the concussion problem could not be found simply through product design. When designing a new product, with so few recognisable reference points to the average player, the result must be flawlessly integrated into the sport. A human-centred approach must be taken; considering the needs of those playing rugby, taking care to ensure the final solution is safe and practical to use. STAGE 1. OPPORTUNITY The first phase of the design process ‘goes broad’ on the issue in hand; studying every aspect of ‘the concussion crisis’ and identifying key design opportunities to take forward. ‘Opportunity’

encapsulates research and a complete analysis of the problem in hand, culminating in a developed, refined design brief with a number of clear deliverables outlined.

STAGE 2. EXPERIENCE The experience phase is focused on gaining an understanding for the environment in which a product may be used. This ensures a user-centred design is developed, with the final concussion

experience a practical, realistic solution which can be easily incorporated with no affect on the integrity of the sport or how it is played, instead continuing to play the same but with safe practices.

STAGE 3. PRODUCT The final design phase is product development. This phase consolidates all of the knowledge gained from ‘opportunity’ and ‘experience’ and uses it to generate a product concept, designed to help

facilitate the new concussion diagnosis experience developed in ‘experience’. Combining the three design phases allows for a fully considered solution to the issue in hand.

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3. THE opportunity

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Figure 5 - Twickenham Stadium, London. The ‘Home of English Rugby’ and the location of the RFU headquarters - and the meeting with Dr Mike England.


3.1 MEETING THE RFU On November 11th 2013, a meeting was held with Dr Mike England at the Rugby Football Union (RFU) HQ in Twickenham Stadium. The purpose of this meeting was to discuss the context of concussion in rugby - how it is affecting the sport, current diagnosis protocols and the design opportunities arising. This meeting was also used as an opportunity to discuss and develop the initial user experience (See ‘4.3 Experience Development’). Dr Mike England works for the RFU which is the UK’s governing rugby body. Here, he is the medical advisor for game development, therefore his research on concussion has been extensive and he can often be seen discussing the issue with the media. Mike also helped to develop the current PSCA concussion assessment protocol in use in the elite game (see ‘4.1 The Current Diagnosis Experience’). 3.1.1 Key Discussion summary: The Context - Concussion is a real problem for those at the top of the rugby game. - There are now a number of successful practices in place for diagnosing at the professional level, but these take time to be adapted and filter down to the amateur game. - Any product designed which will genuinely assist the diagnosis of concussion will be very useful; whether in realistic game situations or as a research tool will depend on its development. 3.1.2 Key Discussion summary: Current Diagnosis - It must be stressed that the PSCA process is only one part of a complex concussion assessment and a player is given lots of opportunities to ‘fail’ this assessment. - The PSCA is currently only on trial at the elite level of the game and a number of elements of it may be modified after the trial. - To carry out a PSCA a qualified medical

professional must be on hand; therefore it is unlikely the protocol will filter down to the grass roots level in its current form; and so should not be included in the user ‘experience’ of any developed concept. - The RFU ‘Headcase’ campaign is the current awareness campaign, which focuses mainly on awareness, education and the promotion of the ‘recognise and remove’ mindset in regard to concussion. On this note, the main issue the RFU face with grass-roots rugby is education; ensuring players (especially younger players) understand it is not worth the risk of sustaining multiple concussions and should follow the ‘recognise and remove’ protocol. - It is possible to self diagnose, but there are a number of issues; people (particularly men) have a culture of convincing themselves a problem is ‘something else’ - which is particularly easy to do with the “invisible injury”. There is also the issue of self-honesty and overcoming the ‘macho’ rugby culture of denying that they are hurt. 3.1.3 Key Discussion summary: design opportunity - Current gum shields and scrum caps available do not do anything to prevent concussion. - There is a worry that existing head guards/scrum caps encourage risk taking behaviour on the field. - Dr England has his concerns about sensor technology as a whole, suggesting it is difficult to design a ‘helmet’ which moves exactly the same as the head; therefore the impact forces can be exaggerated/absorbed by this extra movement in the headwear. - An element of ‘custom-fitting’ could help to combat the issue of a sensor moving independently to the head and giving false data. - Any hard sensor can cause damage to the user and care must be taken. When you attach an object to a rugby player; you cause risk to the individual as well as other players. This risk must be considered.

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Figure 6 - The room in which the meeting was held, overlooking the pitch where the Rugby World Cup Final will be played in 2015!


3.1 MEETING THE RFU - Any sensor technology must be multi-directional and assess rotational force as well as direct impact. - There is a concern of ‘competitive impacts’ when attaching sensors to players; alerts of impact should be discrete to combat the risk of an opposing team player deliberately trying to remove a player from the field of play with a large impact, which could injure both players. - On this note, designers must be aware of “legislation for idiots” when designing for such a wide range of people and understand that there is likely to be someone playing rugby who will attempt to deliberately try to set off sensors which could cause severe injury. - He agrees there is a need to develop sensor technology which enables the study of impact; it particularly could have value as a research tool. - In his opinion, sensor technology is only of use in a game situation if it is accurate and works with realistic thresholds. 3.1.4 Summary Meeting Dr Mike England really revealed (for the first time in this project) the difficulty of designing something which is so greatly needed - but risks a potentially incorrect diagnosis. However, the need for such a project is clearly defined and the opportunities for a product within the diagnosis process are clear.

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“Concussion proof helmets are a pipe dream... design should focus on areas other than prevention�

Fastcodesign


3.2 PATENT REVIEW A thorough patent search was conducted in the early stages of the project to identify any similar/ parallel technologies I should be aware of when designing a product to assist the diagnosis of concussion in amateur rugby. Two patent databases were reviewed - The “Intellectual Property Office” (www.ipo.gov.uk) and the “United States Patent and Trademark Office” (www.uspto.gov). These two databases list all of the UK/US patents. The search revealed very few patented products intended to assist the diagnosis of concussion. However, two interesting solutions to ‘the concussion in sport problem’ were revealed: 3.2.1 Concussion Warning Apparatus Pub No: us2011/0144539 a1 Pub date: june 16, 2011 inventor: Norman ken ouchi (US) Abstract: This patent protects an invention which is used to detect possible concussions through blunt forces to the head. Areas of the head are covered in an indicating sheet (similar in design to ‘bubble wrap’) which can later be examined for indications of a blow (popped ‘pods’ in the material) which may have caused a concussion. Analysis: This patent protects a useful way to make the ‘invisible injury’ visible through ‘bruising’ of the indicating sheet. However this single-use application is impractical for the multi-impact nature of contact sports.

Abstract: A protective helmet insert for reducing the possibility of a concussion through shock absorption. The shock absorbing section of the helmet possesses a substantially constant resistive deformation force characteristic for reducing the peak G-force applied to the head during an impact. Analysis: Defeating concussion through shock absorption is a complex and extremely difficult task. The amount of material needed to effectively reduce the possibility of a concussion would far exceed a practical helmet size for use in sport. 3.2.3 Summary Surprisingly, the patent search revealed very few protected inventions. This could be partly due to the very recent increased understanding of the injury and many more patents can be expected in the coming years. Those inventions which are protected largely seem to be focused on preventing concussion completely, rather than finding a safe way to play the sport and diagnose the injury. In an article written about concussion in the NFL for FastCompany in 2013, Mark Wilson Writes “We’re expecting a mere 1.5 inches of foam and candy shell to decelerate a player’s head gently enough to prevent their brain from bouncing around inside their skull and causing poorly understood, but permanent and devastating injury” (Wilson, 2013). Rugby headwear can’t even be as thick as 1.5 inches. This sums up the design opportunity in a nutshell - attempting to prevent a concussion is nigh on impossible. The opportunity is to design a product which allows a player to safely diagnose their concussion and remove themselves from further risks.

3.2.2 PROTECTIVE HELMET AND INSERT WITH CONCUSSION REDUCTION FEATURES PUB NO: US2013/0254978 a1 PUB DATE: OCTOBER 3, 2013 INVENTOR: DAniel & Rodney McINNIS (US)

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Figure 7 - The Reebok CheckLight; an LED based system to assist the diagnosis of concussion in American Football.

Figure 8 - Adidas MiCoach speed_cell. Although not a concussion-related device; the idea of monitoring sports through wearable technology is present.

Figure 9 - Riddell InSite head impact monitoring unit; designed to alert when significant or multiple impacts are sustained by a player during an American football match. This helmet insert wirelessly transmits impact data to an ‘alert unit’ on the sideline of the pitch, where the coaching staff can act accordingly.


3.3 PARALLEL PRODUCTS 3.3.1 Riddell InSite (Figure 9) The Riddell InSite is a head impact monitoring unit designed to alert the coaching staff when significantly severe or multiple impacts are sustained by a player. This helmet insert quantifies the impact and analyses it before wirelessly transmitting it to the ‘alert unit’ on the sideline of the pitch, where the coaching staff can act accordingly (Ungerleider, 2013). This helmet insert costs around $350 (not including the actual helmet): which doesn’t align with the budget of the grass-roots level of American Football, therefore is seldom used by any players who aren’t playing at the elite level of the sport. In addition, the helmet does not allow you to customise impact thresholds to each player’s height, weight or susceptibility to a concussion (Ungerleider, 2013) - surely a player should be able to lower the impact threshold if the helmet has previously failed to detect a concussion in use? For those at the elite level of the sport, this helmet would prove useful - however those at this level of sport often already have a medical team on-site to diagnose and monitor any potential concussive injuries. It should also be noticed that the sheer size of the components in use here would not align with Rugby, however American Footballers wear a helmet to with space for these components. 3.3.2 Reebok Checklight (figure 7) The Reebok Checklight is another helmet insert; aimed primarily at American Footballers although they suggest it could be applied to any sport with the risk of impact. This insert has two LEDs which glow yellow following a moderate impact, and red following a more severe impact (Welch, 2013). Again there is no customisation of the thresholds or even a definition of a ‘severe’ impact. The benefit of the ‘skull cap’ design is the tight fit which means the sensor will move in true accordance with the head. However, the fact that the product lights up following a severe impact would promote ‘competitive impacts’; meaning the opposition

team may deliberately try to ‘light up’ the Checklight, knowing the player could be removed from play. 3.3.3 Adidas MiCoach Speed_Cell (Figure 8) Although not an impact sensor, the Adidas MiCoach is a good parallel product to observe. This device (a small insert which can fit inside a boot or running shoe) tracks and analyses the ‘performance’ of the user; recording key data such as speed, acceleration, distance etc. This data can then be transferred to an iPhone application where the user can monitor progress and performance (Adidas, 2013). The system of reviewing performance is something which could be applied to rugby concussion management - allowing a rugby player to build up an ‘impact profile’ which can be monitored after a game and the risk of concussion analysed. 3.3.4 Summary The NFL is clearly ahead of rugby in terms of using wearable technology to assess impacts to monitor concussion; aspects of some of these products are a useful source of inspiration and could be translated into rugby. The experience surrounding products like the Adidas MiCoach is exactly what needs to be replicated in the concussion management experience. A player should be able to monitor their injury in the same way they can already monitor their performance.

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3.4 DEVELOPED DESIGN BRIEF Brief To develop a concussion diagnosis experience for club rugby. This will involve the development of a product or garment concept which can quantify the severity of collisions a rugby player is subjected to during a match, detecting the possibility of a concussion. Market The product or garment will be designed with the amateur rugby player in mind (grass-roots level). However, there should be an awareness that it may be used at all levels of the sport. Outcomes/Objectives The design of the diagnosis experience should be a result of research into current rugby concussion procedures combined with knowledge of best practices to reduce consecutive concussions in sport and techniques to prevent player deviant over-conformity. The product or garment should be able alert the user of the possibility of a concussion by measuring the severity of impacts the user is subjected to during a match. The design of the product or garment will take into account all possible scenarios of use, maximising comfort, safety and usability at each stage. Deliverables The final delivery will be a considered design approach to the problem outlined above, and will include the following: 1. Diagnosis Experience A graphic representation storyboarding the diagnosis experience (involving the product/garment) will be produced alongside the product/garment. This will explain in simple terms how the product should be used as well as educating users of correct ‘recognise and remove’ and return to play procedures. 2. Product/Garment The product/garment will be proved through two prototypes: I) Proof of principle prototypes - to prove technical features II) Aesthetic prototypes - to represent visual features. These will both be developed based on user and expert feedback throughout the design process. *Product design specification can be seen in the appendix of this report.

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4. THE EXPERIENCE

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= Professional Rugby Player = Amateur Rugby Player = Design opportunity


4.1 THE CURRENT DIAGNOSIS EXPERIENCE 4.1.1 Diagnosis in professional rugby Since the increased media attention, alongside the NFL lawsuit, rugby’s governing bodies have been quick to react in the professional game: with some successful protocols now in place to assist the diagnosis of concussion. THE Pitchside concussion assessment The Pitch-Side Concussion Assessment (PSCA) is nearing the end of its trial in professional rugby. On the whole, it has been successful in removing players from the field following a potentially concussive impact. The PSCA works by removing a player suspected of a concussion from the field of play for 5 minutes, in which time the suspected player undergoes a ‘trimodal’ evaluation comprising of a cognitive assessment, symptom assessment and a balance assessment (See ‘Appendix - Pitch Side Concussion Assessment’). If at any time during the process the medical care professional suspects a concussion, the player is removed from play and must not return to play before undergoing a GRTP programme. It is recognised by the IRB that “concussion is one of the most complex injuries in sports medicine to diagnose” (IRB PSCA Procedures & Definitions, 2013) and so it must be stressed that the PSCA is a tool only to be used in situations of doubt. Therefore, the PSCA should not replace clinical judgement when a player is obviously concussed. If a medical care professional does not suspect concussion, the player may return to play; but will continue to be observed for symptoms throughout the match. It should be noted that the PSCA is currently only available in professional rugby, where experienced and trained medical care professionals are on hand - which is why it is unlikely that any form of PSCA will be introduced to the amateur game.

the recovery period may be longer in children and adolescents” (McCrory et al, 2013). Considering this, it is important to follow strict ‘recognise and remove’ procedures. The first stage is to recognise that a player has been concussed; currently a task clouded with an athlete’s deviant over-conformity and the subjectivity of assessing an athlete’s symptoms (see 4.2 The importance of recording impact force). Once this has been achieved, the player must not play contact sport until they complete a GRTP programme, which is a minimum 21 day process comprising of 6 stages (See Appendix - Graduated Return To Play); each gradually exposing an athlete to higher levels of exercise and impact (McCrory et al, 2013). The importance of this stage, in both recognising and removal, should not be underestimated, as this controlled exposure to subsequent impacts can mean the difference between a healthy adult life or a life shrouded by the effects of CTE. 5.1.2 Diagnosis in amateur rugby The design opportunity comes in the diagnosis of concussion in amateur rugby - which is much more difficult than the professional game. In amateur rugby, assessment tools like the PSCA are impossible to perform accurately and safely, as there is seldom a medical professional available. However, it is important that all players are undertaking the GRTP process if they have a concussive injury. To ensure this; we need amateur rugby players to follow a proactive concussion management routine - which will become the core of “the developed diagnosis experience” (See ‘4.4 The Developed Diagnosis Experience).

Graduated return to play “The majority (80-90%) of concussions resolve in a short (7-10 day) period [provided the person does not sustain further concussions] although

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4.2 THE IMPORTANCE OF MEASURING IMPACT Until very recently, the idea of a ‘concussion management programme’ in sport has been an alien concept. Since the increase in media attention bought about added research into the injury - rugby has started to realise that completely avoiding concussion in rugby is an impossibility; it would probably be much easier to change the rules of the sport!

injury much harder to ignore. By seeking medical attention and undergoing a professional diagnosis, this player can now be sure of any potential injury and take the correct GRTP procedure which their professional counterparts already take.

In order to keep the integrity of the game alive, it is important to instead look for ways to play the sport safely. This is where concussion management programmes come into play. By monitoring a player’s concussions, ensuring the correct GRTP process is undertaken following a concussive injury - it is possible to safely return to play over time with minimal long-term damage to the brain. Professional players now have a team of medical staff meticulously analysing every move of each player on the field - removing them from danger at the slightest sign of a concussion. This is simply not possible at the amateur level of the game which means everyone playing at the grass-roots level of the sport is under an immense amount of danger; often without knowledge of the risks. So how will measuring impact help? It is a proactive method to manage the potentially concussive impacts a brain is exposed to during each match. By wearing a device which measures impacts to the head/brain, a player is taking a conscious step towards concussion management. This player can now be informed of any dangerous impacts which could potentially cause concussive injuries. This player now has concrete evidence they should seek a medical professional - a decision which was previously left as a subjective personal analysis. This evidence will make the invisible

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4.3 EXPERIENCE development EXPERIENCE 1

4.3.1 Experience 1 Experience 1 was developed as a starting point to introduce some level of concussion management into amateur rugby. This diagnosis experience gives the player real-time concussion alerts; allowing them to be removed from play and assessed - which relies on the PSCA being available in the amateur game. This experience was reviewed by Dr Mike England at the RFU headquarters (See ‘3.1 Meeting The RFU’), and design professionals at the Industrial Review Evening (See ‘Appendix - Industrial Review Evening’). Discussions with Dr Mike England revealed that the PSCA is unlikely to be introduced into the amateur game and so it should not be included in the developed diagnosis experience.

EXPERIENCE 2 1

Player gets tackled. A ‘device’ measures the impact; recording the number and severity of each impact in the game.

3

If a medical professional can see evidence of a concussion, the player can undergo a graduated return to play (GRTP) scheme.

2

After the game, the player can review the impacts he/she has endured during the match. If there are severe impacts, the player is advised to seek a medical professional.

4

After completing the full GRTP, with no further signs of concussive injury - the player can return to playing full rugby.

1

Player gets tackled. A ‘device’ measures the impact; if there is a possibility of a concussion, the player is alerted.

3

Player will undergo a developed version of a ‘pitch side concussion assessment’. This includes a standardised assessment of cognition, a balance assessment and a symptoms and signs assessment.

2

The player should leave the pitch for 5 minutes with a temporary replacement (under new 2013 season ‘brain bin’ ruling)

4

A) If the assessment is passed; the player can play on with caution. B) If the assessment is failed, the player must be substituted and undergo a graduated return to play (GRTP) scheme.

4.3.2 Experience 2 During the meeting with Dr Mike England (See ‘3.1 Meeting The RFU’) it became clear that the PSCA will not be available in the amateur game due to the lack of medical professionals available. Therefore, the experience was developed to allow players to self-diagnose without the need for a trained medical professional. This experience also removes the possibility of ‘competitive impacts’ - where opposing players purposely try to set off sensors to remove a player. By analysing impacts after a game to check for concussion - a player is able to be proactive in their concussion management and follow a GRTP process following a concussion. This experience was the ‘working prototype’ to develop the product; and was later refined after the product design phase was completed to create the ‘developed diagnosis experience’ (See ‘4.4 The Developed Diagnosis Experience’).

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DIAGNOSING CONCUSSION IN AMATEUR RUGBY

1

86G

2 MATCH REVIEW

114G

AVERAGE FORCE

TIME

STAGE 1 - GAMEPLAY

Throughout game, players wear headwear containing impact recording sensor technology. This headwear will measure and record each impact in the game above a threshold pre-defined by the player (set by age/weight/concussive injury history).

3

STAGE 3 - DIAGNOSIS

If a medical professional can see evidence of a concussion, the player will undergo a graduated return to play (GRTP) scheme.

STAGE 2 - REVIEW

After the game, each player can review his/her ‘impact profile’ via a mobile app. The impacts they endured during the match are presented visually; if there are severe impacts, the player is advised to seek a medical professional.

4

STAGE 4 - RETURN TO PLAY

After completing a full GRTP, with no further signs of concussive injury - the player can return to playing full rugby.


4.4 THE DEVELOPED DIAGNOSIS EXPERIENCE The final diagnosis experience was developed following the product design phase of this project (See ‘5 - The Product’). This new concussion diagnosis experience uses the product to remove the element of subjectivity in diagnosis from the hands of the player. By visually presenting the player with clear impact data; they cannot be in-denial about the possibility of a concussion. This proactive step towards effective concussion management is exactly what is necessary in the amateur game - where the majority of concussive injuries currently go undiagnosed.

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5. THE PRODUCT

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5.1 electronic functionality PROTOTYPING 5.1.1 The Arduino The Arduino platform is an open-source computing system based around a simple input/ output (I/O) board. In addition to the board, Arduino uses a computer based software program which allows the user to program commands to the board using a simplified programming language, which is based on C (Banzi, 2009). For this project, the Arduino was used as ‘the brains’ of the product - processing data from sensors, converting it to a G-force reading and presenting it to the user. 5.1.2 Component selection For this application, the arduino needs to read the g-force applied to the head in each impact (above a threshold) - and present it to the user. For the initial prototypes this information is presented via an LCD screen, however in the finalised product, this would be wirelessly transmitted to a smartphone application (See ‘7.2 Future Development’). To source the correct sensors for this application research was carried out into similar projects - one such example is that of a martial arts enthusiast who affixed accelerometers to a punch bag in order to read the force of his punches (Beineman, 2010). For this project he used “ADXL193” single axis accelerometers with a +/-250g analog output (Beineman, 2010). Following this; contact was made with ‘Sparkfun Electronics’ (www.sparkfun. com) - an electronic hobbyists shop based in Colorado, USA, to discuss these accelerometers and their application. Discussions revealed that these accelerometers would perform exactly as required - they can read huge impacts, as we know rugby tackles can exceed 100G (GuineaPigs, 2007), and they were small enough to be easily incorporated into a wearable product. A number of these accelerometers were purchased for prototype development, in addition to a analog enabled LCD

screen (again from sparkfun electronics) which is used to present the impact data. 5.1.2 prototype development Initial prototyping was focused around learning to use the Arduino platform - with a number of simple programming tasks. Learning and applying a new programming language in a few months is no easy feat! Following this, some real steps could begin to be taken towards the real focused intention of this project. Reading Impacts Initially using only a single accelerometer, the first prototypes were focused on reading a signal from the sensor and converting it to a g-force. These accelerometers work through resistance to the voltage. Taking 1/2 of the supply voltage as ‘rest’ (0G) - then offering more or less resistance in each direction on the axis in accordance with the severity of the impact. With a 5v supply voltage, the accelerometer reads a rest voltage of 2.48v (approx); which changes with the impact. How can this change be calculated as a g-force? Zero G = 1/2 of supply voltage = 2.48v We know from the data sheet supplied with the accelerometers that 1G = 0.008 volts. Therefore: 1G

= 2.488v (2.48v + 0.008v)

100G = 3.28v (2.48v + 0.8v) We can use the shift in voltage to calculate the g-force (in the positive direction on the axis) by incorporating a mathematical equation into the code:

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5.2 coding PPP1 This equation takes the voltage reading from the impact, then subtracts the ‘rest’ voltage before dividing the remainder by 0.008 to calculate the g-force of the remaining voltage; therefore the g-force of the impact. 5.2.1 Setting Thresholds In order to make this reading useful however; it needs limitations. Recording every slight movement in a match would result in thousands of unnecessary readings - it is important to set thresholds.

To incorporate these extra accelerometers into the code, it had to be written to read the impact across all axis and then gauge which direction/ accelerometer the highest force is applied to. Therefore, the following addition was made to ensure each accelerometer is checked in the event of an impact (See ‘Appendix - Code’ for full code and annotations):

For the working prototypes, I used the ‘if statement’ to act as this threshold:

This code takes the voltage to G force calculation and asks the arduino - “Is the impact greater than 80g? If it is, print ‘G force = IMPACT’. If it isn’t, do nothing”. This threshold limits exactly what kind of impact the user can see - and could be easily adjusted in the final product; according to age, weight and susceptibility to concussion. In a more simple sense, it also works to stop all of the unnecessary readings the user does not need.

This section of code reads the impact voltage from each accelerometer, converts them all to a g-force and then uses the ‘if statement’ to gauge which g-force is the largest.

5.2.2 Multi-Directional Readings The next stage in the product’s functional development was to achieve multi-directional impact sensitivity. It is essential the device can measure the force imparted in a tackle from any angle. To achieve this, 4 accelerometers were used, located across the head to cover all directions (See 5.10 Locating The components); this ensures the impact is read across each axis.

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Figure 10 - Flow chart of the decision process made by the Arduino when in use. This diagram was used to code functionality into PPP1.


5.3 DEVELOPING PPP1 5.3.1 Reading the peak force The accelerometers sample an impact reading extremely fast - which means that during an impact the final reading which is greater than 30g (which is printed to the LCD screen), will not be the largest force in that ‘impact event’. Here, code was written to take the ‘peak’ g-force from each ‘impact event’ and print that to the LCD screen, rather than the most recent impact. To do this, a number of variables within the code were given names to enable differentiation between the ‘types of force’ being managed by the arduino:

was simply produced by stitching the sensors to a standard scrum cap; like those already widely available. The cables from the sensors could then be ran underneath a player’s shirt for testing, leading to the arduino (protected in foam casing) in the player’s pocket.

g_force = any impact registered by an accelerometer max_force = the highest force in an ‘impact event’ max_overall_force = the biggest impact in a session/ game In addition to this, the ‘boolean’ command was used. This is a simple two-way ‘switch’ in the code, used here to define an ‘event’ of an impact. Put simply, after an impact, the arduino keeps reading the accelerometer until the reading stops ascending - and then prints the ‘peak’ of the impact force to the LCD screen. In addition to this, the largest impact during a session will be printed and kept on the LCD screen until the Arduino is reset. The code loops continuously in use - constantly checking the accelerometers for new impacts above the threshold. The flow chart of decisions made by the Arduino can be seen in Figure 10. *Full code breakdown with annotations is available in the appendices of this report 5.3.2 Making PPP1 PPP1 is a ‘works-like’ prototype, intended to function as the designed product should, but without necessarily considering the aesthetic qualities of the design. For this reason, PPP1

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5.4 Game tESTING: PPP1 5.4.1 Game testing Scope & Purpose Having received ethical approval to test the functionality of the prototype; two players were selected to assist the development in a mocktraining situation. During this session, a number of gameplay scenarios were set up - including tackling (both attacking and defensive), rucking (attacking and defensive) and competing for a high ball. After each scenario, the LCD screen was checked for peak impacts and the result noted. This allowed working impact thresholds to be set for the future iterations.

5.4.3 Time RESTRICTIONS Following testing of PPP1, it was decided that functional development should to be put on hold in order to develop the aesthetic prototype. This project had stringent time restrictions and this decision ensured a rounded solution could be presented at the major project deadline - where functional development could then be continued (See ‘7.2 Future Development’).

5.4.2 Setting impact thresholds During each of the gameplay scenarios, the peak g-force recorded was noted - in order the gauge an idea of the ‘average’ impact force. During testing, g-forces of between 30-70G were common, with a maximum recorded force of 87G during a rucking exercise, when the test subject was knocked in the head by a stray boot. Post-testing the test subject took a concussion diagnosis from the club doctor and revealed no signs of concussion - however this kind of impact did warrant an assessment. Following testing, the data was analysed and compared to data taken from a University of Michigan study (Bailey, 2011). The following (working) thresholds were then decided upon: Minimum read (to cancel out running/movements other than tackles) = 20G Green threshold (the player should be warned to stay vigilant of concussion symptoms) = 50 - 90G Amber Threshold (the player will be advised to be assessed for concussion symptoms by a medical professional) = 90 - 120G Red Threshold (the player will be advised not to play rugby of any kind until they have been assessed for symptoms by a medical professional) = 120G +

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5.5 PPP1 - THE DELIVERABLE

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5.6 aesthetic prototype development After electronic functionality had proven the principle, the visual/aesthetic ‘vessel’ for the impact sensitive technology could be considered. 5.6.2 Why headwear? Initial ideation sessions pondered over the location of the technology on the body. Mouthguards, and the ear canal were all speculated as potential areas for the technology initially, however, it was decided that it would be unreasonable to assume the technology could be replicated small enough to be located here. The head is the most obvious (and comfortable) choice for any concussion related product and following discussions at the Industrial Review Evening (See Appendix - Industrial Review Evening) and with Mike England at the RFU (See ‘3.1 Meeting The RFU’) it became clear that the product should be a headwear garment. Another benefit is that a large number of rugby players already wear a scrumcap/headband of some kind so introducing the product as headwear would not require a shift in rugby culture.

- The next main flaw with scrum caps is their overbearing nature. Wearing a scrum cap can be very uncomfortable; Tight chin straps rub on facial hair whilst full side panels restrict peripheral vision - something wholly undesirable when playing a fast paced contact sport. - Stylistically, existing rugby headwear is tightfitting with its form based around its padding pattern. The garments usually have a single or two colour design (available in a range of colours) to match or contrast with the rugby kits. 5.6.3 Summary It became clear at this point that any new headwear designed must not instil any false confidence in its protective qualities or be too overbearing in its size and must offer a more practical, comfortable garment. However it must also still protect the ears in a scrum - an area where existing scrum caps perform well.

5.6.2 Current headwear investigation As a starting point for the aesthetic development, existing rugby headwear was analysed both by the designer and also non-designing rugby players in the focus group. This revealed a number of fatal flaws with the current headwear available for rugby players - scrum caps and bandage headbands: - Although the scrum cap is intended to protect the ears during a scrum, a number of players actually believe they protect the head during a match; which has lead to players in all positions wearing them - even those who play no part in the scrum. Even those players who know that the scrum cap does not protect the head will often admit that they wear a scrum hat for that added ‘false confidence’ in its protection; which is obviously a very dangerous mindset. This means people are taking unnecessary risks with the illusion of protection.

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105°

105°

25°

HEAD

Figure 11 - The headgear should provide peripheral vision clearance of at least 105° on either side.

Figure 12 - Provide visual clearance of 25° vertically upwards, and must not cover the face.

AFFIXED AT BOTH SIDES

CLOSE PROXIMITY TO JAW

7KG

Figure 13 - Any chin strap must withstand a static load of 7kg without opening or breaking.

4KG

Figure 14 - The retention system must hold the product on the head with a force of 4kg dropped pulling on the rear of the headgear.


5.7 IRB REGULATIONS 5.7.1 What are the IRB Regulations? The IRB outlines a number of restrictions which need to be taken into consideration when designing headgear to be worn whilst playing rugby. As this project is conceptual, with no immediate plans to commercialise, it was decided that some of these regulations may be ignored if they threaten the functionality of the product. However, these regulations give an ideal starting point, and should be considered when designing rugby headgear of any sort. 5.7.2 relevant Regulations: Material Selection - Headgear should minimise discomfort and not impede the movement of the player - All materials should not be significantly affected by UV radiation, dirt, perspiration, toiletries, or common household soaps and detergents - All materials should not cause abrasion on either the player wearing the garment, or other players on the field - Padding facing the player and opponent must be homogeneous in texture, hardness and density - Sandwich padding is not allowed (for the purpose of this product this regulation will be ignored to house components) - Padding materials must have a density of no greater than 45kg/m3 (± 15kg/m3)

headbands and other simple ear taping applications used to protect the ears in the scrum) - There must be a total padding thickness of no more than 10mm (± 2mm) plus 2mm fabric allowance - Ear holes must be between 25mm-30mm in diameter. It may have a cross-mesh but must not significantly affect hearing - Must provide adequate ventilation - The headgear should provide peripheral vision clearance of at least 105° on either side (See Figure 11) - The headgear should also provide visual clearance of 25° vertically upwards, and must not cover the face (See Figure 12) - Any chin strap must be affixed to both sides of the headgear and pass under the jaw and be in close proximity to the neck (See Figure 13) Testing - Any chin strap must withstand a static load of 7kg without opening or breaking (See Figure 13) - The retention system must hold the product on the head with a force of 4kg dropped pulling on the rear of the headgear - It may move but not fall off (See Figure 14)

Design - There shall not be any hard or sharp edges, seams, buckles or other items on the surface which may harm the user or any other players - The garment must cover the crown, temple, forehead and ears (it was however noted that in many cases this regulation is ignored - such as

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5.8 PDS LIMITATIONS The product design specification (See Appendix - Product Design Specification) contains a number of key points which would affect the design of the headwear. Prior to the design phase, these were analysed and reviewed as a starting point for the development. The PDS points were labelled as “desirable” or “essential”, dependant on their importance. Those which were essential at this stage were much more important to take forward into the initial designs. 5.8.1 RELEVANT PDS restrictions - The product/garment could be customisable to each user in terms of fit (desirable). Analysis: An element of adjustability would be desirable, however this could also be achieved by producing the headwear in a number of different sizes (XS-XXL - dependant on head diameter). - The product/garment itself could reduce impact forces, protecting the user from the possibility of a concussion (desirable). Analysis: Since the production of the initial PDS it was discovered that it is not possible to fully protect from concussion. Any extra padding actually instils false confidence and encourages risk-taking in play. Therefore, this point should be ignored in the design ideation phase. - The product/garment must be safe to wear, with no threat of injury to the user (Essential). - The product/garment must have no threat of injury to any other player than the user (Essential). - The product should not create a hazard if used incorrectly (Essential). - The product should not create a hazard if exposed to poor weather conditions (Essential). Analysis: The ‘safety’ section of the PDS outlines a number of important safety requirements to protect the user and other players. All of these points are deemed ‘essential’ and therefore must be obeyed in the design phase. At all key decisions in

the design phase, the safety of the user and other players must be of primary importance. - The product/garment must be comfortable to wear during a full 80-minute rugby match and all of it’s features; including running, tackling, scrummaging and communicating with team-mates (Essential). - The product/garment must not limit the playing ability of the user (Essential). Analysis: Each of these points are essential to the success of the product. If the product renders it more difficult or impractical to play the sport - it will not be used. The focus group made up from target demographic users should be consulted during the design/testing process to ensure the product meets their needs. - The product/garment itself must be able to withstand the impacts imparted during a rugby match (Essential). - The product/garment should be waterproof, wipe clean or have the ability to be removed for washing (Essential). Analysis: These PDS limitations will be of most importance when selecting suitable materials for the application. Although PPP2 must not necessarily be wash-proof (as it is just an aesthetic model), the materials selected and the design of the headwear itself should allow for washing in theory.

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5.9 ANTHROPOMETRIC CONSIDERATIONS The anthropometric features of the headwear were considered to ensure the designed product was comfortable and did not restrict the playing ability of the user in any way (e.g. by blocking peripheral vision of the player). Henry Dreyfuss Associates’ famed work on anthropometrics - “Measure of Man and Woman” was consulted to assess the human field of vision. From this, the designer could make use of ‘blind spots’ to ensure the field of vision was not obstructed. If the user cannot see the headwear garment during use - it will also not feel too overbearing to wear; which psychologically will make the user feel more comfortable in addition to reducing the false confidence in its protective qualities (Tilley, 2002). Another important consideration is the user’s hearing. Player communication is vital in a rugby match and so the headwear garment must not limit hearing in any way. This can be ensured by careful consideration of where the protective foam is placed on the head and the materials used. In terms of sizing, this product requires a tight fit to the head to ensure the impacts read by the sensors are true to the head’s movement. Therefore, in real production the garment would be manufactured in a number of sizes (XS-XXL) based on head size; but for the purpose of prototyping, a mannequin head with a circumference of 600mm was used as the test model for sizing. Adjustability is also an important feature here, to ensure the garment can be worn comfortably.

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1

3

3

4

4 BATTERY /OTHER

4 3

Figure 15 - The location and axis of each of the accelerometers. They are arranged to ensure a reading can be taken from an impact at any angle.

1

2

1

2


5.10 LOCATING THE components To ensure the best possible functionality of the product, the location of each of the sensors must be considered. The AXDL193 accelerometers used are capable of reading impact in both directions across a single axis. Therefore, each of the 4 sensors are placed in such a position to ensure an impact could be read from any direction - covering all axis (See Figure 15). The battery, processing components and any other components will be located behind the ear; at the top of the neck. The location of the sensors and battery lent themselves to a headwear design based around a ‘headband’ - which became the starting point for the initial design ideation sessions.

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Figure 16 - Single layer sandwiching of an accelerometer allowed the component much less impact absorption resulting in the player being able to feel the component under impact.

= Padding = No Padding Figure 18 - ‘Positive padding patterning’, as used in the majority of existing headwear for the rugby market. This gives the illusion that the head is better protected than it actually is - largely due to the majority of the surface area of the head being covered in padding

Figure 17 - Sandwiching the accelerometers between two densities of foam was considered the best way to protect both player and component during an impact.

= Padding = No Padding Figure 19 - ‘Negative padding patterning’ does not give the user the false illusion of protection which ‘positive padding patterning’ does.


5.11 PADDING/PROTECTING THE COMPONENTS 5.11.1 Limitations In order to protect the components, and to a lesser extent the player - the wearable headgear will utilise foam padding. The padding which can be used is dictated by IRB regulations in terms of density (see ‘5.7 IRB Regulations’); which offered the starting point for foam selection. The maximum density allowed to meet IRB regulation is 45kg/m3 (+/- 15kg/m3). 5.11.2 Foam Selection A number of samples which met the IRB standards were collated for review and their properties assessed. The majority of these samples were a variant of EVA foam, which is an easily heat formed material and available in a wide range of densities and sizes. Following the sample review, Evazote 50 (density: 50kg/m3) was selected for this application. This is a foam similar in composition to standard EVA but with slightly enhanced properties. It is a closed cell cross-linked ethylene copolymer foam which renders it slightly tougher and more durable than traditional EVA (Zotefoams.com, 2014). This material is more normally used for industrial kneepads due to its resilience; however its properties render it perfect for this application; particularly its ability to instantly return to shape after impact. 5.11.3 Foam Use In order to best protect the components, it was clear that the maximum density and thickness enabled by the IRB should be used. This meant Evazote with a thickness of 10mm and a density of 50kg/m3 would be used on areas of the head where components are at risk of damage. However, it was decided at this juncture that the components would be sandwiched between two layers of foam. Although this goes against IRB regulations (see ‘5.7 IRB Regulations’), It is the best way to protect both the component and player. Therefore it is expected that this regulation will be reviewed and removed when wearable technology

becomes commonplace in rugby over the coming years. Following testing, sandwiching the accelerometers between two densities of foam (See Figure 17) was considered the best way to protect both player and component. Single density foam sandwiching (See Figure 16) allowed the component much less impact absorption resulting in the player being able to feel the component under impact. Initially, there was no intention to pad the rest of the headwear - where there were no components to protect. However, following discussions with the target demographic, it was revealed that head protection, even if it is just perceived, is an important factor when selecting headwear (See ‘7.6.3 Concept Progression’). All of those in the focus group argued that a small amount of padding to protect from slight knocks and scratches would be desirable, even if the actual concussion protection gained is null. Therefore, the decision to include some thinner padding (5mm), distributed over the head where components are not located was made. 5.11.4 NEGATIVE Padding Patterns For this application, it was decided during the research phase that care must be taken to ensure any padding on the head does not give the illusion of over protection. To achieve this, it was decided that a ‘hexagonal honeycomb’ pattern would be used; but with padding in the negative spaces between the holes in the honeycomb pattern (See Figure 19). This is unlike existing headwear which tends to use a number of small padding ‘pods’ to protect the head (See Figure 18). This gives the illusion that the head is better protected than it actually is - largely due to the majority of the surface area of the head being covered in padding. By using this ‘negative padding pattern’, the design does not offer a false illusion of protection; something which testing proved to be true (see ‘5.16 Game Testing: PPP2’).

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5.12 MATERIAL INVESTIGATION FABRIC 5.12.1 Fabric Short-list Five fabric samples were short-listed following research into fabrics currently used for sportswear and other outdoor applications. These were then tested/exposed to extreme conditions to select the best material for this application based on its properties. The five initial short-listed fabrics were: 1) Slinky Lycra 2) Lycra 3) Stretch Nylon 4) Waterproof Polyester 5) Rip-stop Nylon (PU Coated) 5.12.2 Fabric Testing Aesthetics/Touch test This stage of the testing was used simply to assess the material visually and through touch - would the material suit the application? Would a macho rugby player wear it? Following this stage, ‘Slinky Lycra’ was removed as a possibility due to its weakness - the material ripped from just moderate hand strength. Stain/Wash test To align with the IRB regulation which dictates that materials must not be affected by water, dirt or household soaps and detergents (See ‘5.7 IRB Regulations’), staining and washing tests were carried out. For this, each sample was covered in mud and allowed to dry (as most players would not wash rugby kit straight after use). The samples were then washed amongst other dirty rugby kit at 60° with a non-biological washing powder, before being dried at a low heat in a tumble drier. The majority of the materials were unaffected by this process and came clean with no issues, however ‘waterproof polyester’ was stained and discoloured in areas following this process - so was removed from the selection process.

Stretch test This test was used to test the stretch characteristics of the material - ensuring it can flex with the head, and return to shape after stretching. Following this test, ‘Lycra’ revealed an stretch of around 50% and returned to the original shape unharmed. ‘Stretch Nylon’ could stretch by almost 150% which is far too much for this application. It also returned to its original length but was mis-shapen in areas after the stretch. Following this test, ‘Stretch Nylon’ was removed from the selection process. 5.12.3 Fabric Selection Result Following material testing, two materials were short-listed to be included in the final product development phases: 1) Stretch Nylon Selected as the primary ‘soft’ material for product development/prototyping. 2) Rip-Stop Nylon* Selected as the a secondary ‘stiff’ material for product development/prototyping. *This material was not included in the final product design. 5.12.4 Testing Process Analysis This testing process allowed for a fast and economical analysis of the materials; therefore it was an effective method of short-listing materials for further development. However, for more extensive results (if time and cost allowed) much more extensive testing into the properties of the materials would be carried out to gain a more thorough knowledge of the material, allowing for a more educated material decision to be made.

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5.13 CONCEPT Development 5.13.1 Concept Ideation Concept ideation began through iterative phases of sketching and prototyping; consulting a focus group of rugby players for feedback throughout the design process. Previous research and insights into existing products revealed that the designed garment must be comfortable to wear and definitely must not instil a false sense of confidence in its protective qualities. In order to achieve this, the designs were kept very minimal in order not to be overbearing initially the design was just based around a simple headband. This, combined with the ‘negative padding’ (See ‘5.11 Paddding/Protecting the Components’) allowed for a garment which could be worn to protect the ears in the scrum, but players would not use to ‘protect’ their head when taking risks in a game.

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Fig. 20 - Prototype 1

Fig. 21 - Prototype 2

Fig. 22 - Prototype 3

Fig. 23 - Prototype 4

Fig. 24 - Prototype 5

Fig. 25 - Prototype 6

Fig. 26 - Prototype 7

Fig. 27 - Prototype 8

Fig. 28 - Prototype 9

Fig. 29 - Prototype 10

Fig. 30 - Prototype 11

Fig. 31 - PPP2


5.13 CONCEPT Development 5.13.2 Initial Prototyping In order to better understand the comfort of wearing soft headband-based headgear, prototypes were manufactured for comfort testing with the focus group. To make wearable prototypes, a scalable template was needed to model around the head. To save time and money, in addition to allowing quick iterations, paper was used to make the initial quick miniature mock-ups of the headband templates. Following this, fabric prototyping was completed as an iterative process, consulting the focus group for feedback at regular intervals.

opposing team - entirely not what this design hoped to achieve!

Prototype 1 is a micro-sized fabric headband shape with a rear support, which was later scaled up to establish the shape of further iterations with rear supports (such as prototype 3-5).

5.13.4 Prototype development Following the focus group meeting, Prototype 7 through to 9 were developed. The final design uses a ‘negative padding’ pattern to reduce false confidence in it’s protective qualities (See ‘5.11 Paddding/Protecting the Components’). These prototypes were used to establish how this padding pattern can be applied to the shape of the headwear - and leave space for the components to fit within the pattern.

Prototype 2 is the bare minimum required ‘vessel’ for the impact sensing technology - a simple headband. This prototype proved very ‘loose’ on the head, often slipping over the eyes and difficult to hold in place. It quickly became clear that more would be required of the headwear to offer improved comfort and ensure it does not slip - this came in the form of a rear support. Prototype 3 to 5 are taken from the process of developing the shape of the rear support of the headband, to closely fit to the contours of the head. Prototype 5 was taken forward to the focus group for feedback. 5.13.3 Concept Progression Discussions with the focus group following the initial prototyping phase revealed that in fact, players preferred having the top of their head covered, at least with a thin layer of padding, to protect from scratches and cuts from stray boots in a tackle. One member of the focus group even suggested that a headband design can lead to the top of the head looking like a ‘target’ for the

The next phase of prototyping (prototype 6) offered full head coverage; and was quickly mocked up during the meeting with the focus group. All present agreed this shape would be preferable to wear. However careful attention was paid to ensure peripheral vision was not affected and a chin strap was not in use. This decision was made to align with the decision not to make the headwear garment too overbearing - which can lead to false confidence in its protective qualities.

Prototype 10 was the next stage; introducing adjustability through a lace-up section at the rear of the garment. Cardboard was used here to allow for quick prototyping, which proved the principle to be taken forward into the final design of PPP2. Prototype 11 proved to be the final stage of prototyping before the manufacture of PPP2. This prototype bought together all of the features from previous prototypes as well as the addition of the top head section taken from prototype 6. When complete, this rough prototype was offered to the focus group for feedback - with the unanimous decision to take this forward to the final design.

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Figure 32 - Laser Cutter; used to cut the components.

Figure 33 - CorelDraw X6 CAD software was used to create cutting paths for the laser cutter.

Figure 34 - Spray adhesive was used to affix the foam to fabric temporarily during manufacture.

Figure 35 - Thicker 10mm Evazote used to store batteries and other electronic components.

Figure 36 - The thicker 10mm Evazote foam would also be used to protect the accelerometers.

Figure 37 - White inner fabric improved comfort, covering the rough Evazote foam edges.

Figure 38 - Black edge trim was applied to conceal edges and provide aesthetic contrast.

Figure 39 - Stitching was concealed by working with the product inside-out.


5.14 Manufacturing PPP2 PPP2 is a ‘looks-like’ prototype; which is intended to look like the designed product; but without the functionality. Whitgift School were kind enough to allow the use of their laser cutting facilities for the manufacture of PPP2. This allowed for extreme accuracy and exceptional finish quality when cutting components - without the laser cutter, it would have been very difficult to cut the negative hexagon padding pattern to any degree of accuracy. Each component outline was produced on ‘CorelDraw X6’ CAD software to create the cutting paths for the laser cutter to cut the components. Another benefit of this CAD approach is that it ensured each of the components fit together exactly as intended - and it could be replicated on screen before cutting. After each component had been cut, spray adhesive was used to affix the foam to the outer layer of fabric (red stretch nylon). In real production - this process would be completed by heat-forming the 5mm Evazote foam and the fabric together - in the same way existing scrum caps are made. However, for the purpose of the visual PPP, spray adhesive achieved the desired outcome.

head. Following this, the decision was made to conceal the edges with a black stretch lycra edging material. This covers unsightly stitches in addition to providing an aesthetic contrast to the bold red coloured outer fabric. Whilst previous prototypes were created quickly using an electronic sewing machine, PPP2 had to be stitch-perfect; therefore all stitching was carried out by hand. In real production, this accuracy could be achieved through the use of CNC sewing machines but this was not possible for the production of PPP2. The majority of the stitching was also concealed by stitching the product together inside-out, and then reversing it to fold over stitches and conceal them. This produced a neat, visually true-to-production PPP which looks exactly as it would if it were to be produced enmass.

Within the headwear, each sensor location and a section where the battery/other components would be held were cut out and the area filled with a thicker 10mm Evazote foam (See Figure 35 and Figure 36). This foam is the maximum thickness allowed by IRB regulations (See 5.7 IRB Regulations) and therefore offers maximum protection to the components. The inner fabric (white stretch nylon) could then be affixed using the same spray adhesive. By sandwiching the Evazote foam (both 5mm head cover & 10mm component protextion), the finished product is very comfortable to wear - with no uncomfortable foam sections rubbing on the

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5.15 GAME TESTING: ppp2 5.15.1 Game testing Scope & Purpose Whilst function testing PPP1, the aesthetic prototype PPP2 was also comfort tested in some of the gameplay scenarios. The purpose of this was two-fold: 1) To discover how comfortable the product is to wear in common gameplay situations (e.g. tackling, rucking, running etc). 2) To question the test subjects on their opinions of the aesthetic side of the design - is it something they would wear to play rugby? 5.15.2 Pros and Cons of the Design: Following the gameplay scenarios and product photo-shoot; the two selected test players were given the time to voice their opinions on the design and comfort of PPP2. Both players were asked to be completely honest and air any concerns they have with the design; as it could aid development after the major project finishes. pros: - Both players commented on the comfort of the design. One of them wears an existing scrum cap (similar to that used for PPP1) and passed a comment about how much less restrictive this design is. He commented that this design offers a much greater field of vision - actually suggesting it may allow him to play better! - Comments were also made on the negative padding pattern used; both players suggesting that they do not necessarily feel protected by the hat. Whilst this may initially sound like a negative comment - this product is not intended to protect; it is only intended to read the impact. By not offering a feeling of ‘protection’, players are much less inclined to take risks whilst playing rugby. CONS: - PPP2 lacked in ventilation; after just a few

minutes of gameplay scenarios the test player was sweating! By simply cutting ventilation holes through the fabric in some of the areas between the negative padding pattern, it would allow for heat to escape and go some way to solving this problem. Excessive sweating is a problem associated with all sports headwear and so would be difficult to defeat, but improved ventilation would definitely help. - Another negative was the risk of it slipping off. As this design does not include a chin strap, upward force to the headwear can allow it to slip off. Both players agreed this would be a problem in a match, but could be counteracted by making it a much tighter fit. They both suggested that PPP2 had quite a loose fit, and could be much tighter before comfort was compromised; something which can be taken forward into the next phase of development, after the end of the ‘major project’. 5.15.3 Summary Feedback from the players was overwhelmingly positive. Both PPP1 and PPP2 received a great amount of praise - the test players wanted the product to be available to wear in a real game! In addition to this, some excellent critical feedback was received which can now be taken forward into the product development after the project finishes as a ‘major project’ and continues as personal work.

“Visually, this is so much less restrictive than my scrum cap... I can actually see to pass to my teammates!”

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5.16 PPP2 - THE DELIVERABLE

PPP2 uses a ‘negative hexagonal padding pattern’ (See ‘5.11 Paddding/Protecting the Components’) with 5mm Evazote foam covering the whole head. The sensors and electronic components are located within the padding pattern and are protected using the maximum allowed 10mm Evazote foam.

PPP2 can be size adjusted using the stretch lycra lacing at the rear of the head. This allows for fine sizing adjustments with the added comfort of stretch lacing.

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6. THE END OF THE MAJOR PROJECT

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6.1 FINAL DESIGN PROPOSAL The final design proposal for the major project is comprised of three deliverables: 1) Experience Diagram This explains the refined concussion diagnosis experience step-by-step in a storyboard format. The improved diagnosis experience will include the designed product. The purpose of this deliverable is to present exactly how wearable technology can be introduced into amateur rugby; without affecting the fundamentals of the game. 2) Functional Prototype (PPP1) This is a ‘works-like’ prototype, proving the function of the product. Whilst this is not a fully refined prototype (wireless & app functionality are not yet completed), it presents the ‘bare minimum’ functionality of the product - it proves the principle. The purpose of this prototype is to prove that the technology to read impact within rugby is a possibility. 3) Visual Prototype (PPP2) This is a ‘looks-like’ prototype; which lacks functionality but presents the envisioned form of the product. The purpose of this prototype is to present how the technology and components can be incorporated into a headwear garment which rugby players would be happy to wear during a match.

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DIAGNOSING CONCUSSION IN AMATEUR RUGBY

1

86G

2 MATCH REVIEW

114G

AVERAGE FORCE

TIME

STAGE 1 - GAMEPLAY

Throughout game, players wear headwear containing impact recording sensor technology. This headwear will measure and record each impact in the game above a threshold pre-defined by the player (set by age/weight/concussive injury history).

3

STAGE 3 - DIAGNOSIS

If a medical professional can see evidence of a concussion, the player will undergo a graduated return to play (GRTP) scheme.

STAGE 2 - REVIEW

After the game, each player can review his/her ‘impact profile’ via a mobile app. The impacts they endured during the match are presented visually; if there are severe impacts, the player is advised to seek a medical professional.

4

STAGE 4 - RETURN TO PLAY

After completing a full GRTP, with no further signs of concussive injury - the player can return to playing full rugby.


6.2 DELIVERABLES

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6.3 personal EVALUATION As the project ends as an academic ‘major project’ and transforms into a personal project for further development, it is the ideal time to reflect upon the project as a whole, so far. This project has been extremely challenging. Since I first discovered the ‘concussion crisis’, it was clear it would be too good a major project design opportunity to miss, but such a huge problem is incredibly difficult to approach. Working through the three-stage design process (opportunity + experience = product) however, has allowed me to approach the problem systematically - which has proved an invaluable decision. As I had no previous experience of neither sportswear design nor coding for electronic functionality; it was a real baptism of fire! I decided from the outset however, to dive into any challenge to ensure the best possible design outcome - rather than design to apply my existing strengths. Because of this, on an academic level, I have learnt a huge amount. I am now confident in my skills with Arduino coding an area I would have previously avoided working with. In addition to this, working on a sportswear design project has really opened my eyes to a career in this area. In terms of the project itself, on the whole, it has been a huge success. The amount I have achieved in a relatively short space of time has been surprising - something I can put down to working on a project in an area I have remained passionate about. The functionality of the product is the main area I will be working on following the end of this project as a ‘major’. As I learn more and more coding skills, the improvements to the functionality are becoming clearer and more achievable. Wireless functionality and linking to a smart phone is the next stage for this area of the design. Visually, the design of the headwear has been a great success and the feedback received from the players after testing has proved testament to this. The production quality of PPP2 far

exceeded my expectations; which is largely thanks to Whitgift School for the use of their laser cutting facilities and workshops. In terms of the product as a solution to the concussion crisis, it has been received very positively. At a number of points throughout the project members of my focus group have expressed a desire to use such a product in real games. However, the real need for this product became clear through talking to the wife of a man who had suffered an early onset of dementia because of a head injury. Listening to this woman explain how her husband had changed noticeably over the past few years and the damage it had caused to the marriage was difficult to hear and really spurred me on to design a product which was feasible to introduce into the game. A product to help to prevent this situation in the future can only be a positive. If the project were to be conducted again, more attention would be paid to the scope of the potential applications of this impact-sensing technology. Throughout the project various suggestions for the technology have been suggested to be - ranging from cycle helmets to headwear for epilepsy patients. This project largely focused on its application in rugby, but there are many other (perhaps better suited) possible applications. Also, an attempt to collaborate with an existing sportswear manufacturer for the project would be made, to enable a greater understanding of how to bring the product to market - and design to do so; as opposed to the feasibility study of introducing wearable technology to rugby which this project has been. On a final note, the positivity towards the project I received throughout the project by rugby players (and their families) has been really encouraging; and serves only to highlight the real need for such a product in the amateur game.

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6.4 EXTERNAL EVALUATION The prototypes were taken to O.W.R.F.C for discussion following the final design. The following comments were made in evaluation of the product and the concept as a whole:

“The amount of times I have finished a game and felt drunk before I’ve even had a drink.. I think I need this!” “My wife would definitely want me to wear this! I’ve never really thought about the dangers, but she refuses to watch me play after seeing me get knocked out a few years ago.” “Anything as comfortable as this which can help diagnose concussion can only be a good thing!” “The smartphone [functionality] is important; it needs to be really easy to check your impacts otherwise I probably wouldn’t bother.” “I’m always guilty of ignoring my injuries - I once tried to play with a dislocated shoulder, so concussion wouldn’t stop me! This would help though, seeing you’re injured in plain black and white is hard to ignore.”

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7. FUTURE POSSIBILITIES

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7.1 COMMERCIAL POTENTIAL This project has always been intended as an investigation into the feasibility of introducing wearable technology into amateur rugby - which is the reason behind the focus on the diagnosis experience. At a number of times throughout the project, interest arose from external parties into the commercial potential of the product. The amateur sport is in extreme need of a product like this offering a solution to ‘the concussion crisis’ and therefore the commercial potential of such a product is huge. However, there are a huge number of difficulties to face in order to bring this product to market. The litigation issues of introducing any product which claims to assist in the diagnosis of an injury are huge and difficult to face alone as a start-up company. For this reason, collaborating with an existing, trusted sportswear manufacturer would be the best way to bring this product to market - covering costs and reducing the risks of introducing the first wearable technology into amateur rugby.

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MATCH REVIEW

114G

AVERAGE FORCE

IMPACT PROFILE

SYNCING

IMPACTS

SYNC DEVICE

TIME

!

IMPACT PROFILE

EDIT PROFILE

JOE BLOGGS STATUS: SAFE TO PLAY

CONCUSSION WARNING

GAMES THIS SEASON

YOU HAVE SUSTAINED A POTENTIALLY CONCUSSIVE IMPACT.

IMPACTS THIS SEASON

CHANGE PHOTO EDIT NAME

AVERAGE IMPACT FORCE

UNDERGO A PROFESSIONAL CONCUSSION DIAGNOSIS IMMEDIATELY

TOTAL CONCUSSIONS

JOE BLOGGS EDIT TEAM NAME

RUGBY CLUB RFC EDIT WEIGHT/AGE

76KG / 28

OKAY

EDIT PROFILE

Figure 40 - The wireframes used to gauge the functions needed for the smartphone application.

SAVE CHANGES


7.2 FUTURE Development As the major project comes to an end, it is the ideal checkpoint to plan the next stages of the project. 7.2.1 Improved Fitting In terms of aesthetic prototyping; the main development will come through improving the fit. Discussions with the test players revealed the product could be much tighter without sacrificing comfort. This would also reduce the risk of the headwear coming loose or falling off during a game. 7.2.2 Improved Functionality The primary issue to face in further developments is the product’s technical functionality. The current solution has a tendency to give incorrect readings. This is caused by a bug in the code where the voltage reading is converted to a g-force. The code uses a formula to convert voltage to g-force by subtracting the ‘rest voltage’ and using the remainder to calculate the shift. However, the ‘rest voltage’ is based on the assumption that the rest is at exactly half of the supply voltage - which in reality is not exact enough - the rest actually fluctuates by around 0.03v which causes incorrect readings. The next step in product development which is currently being explored is to develop the code to read the ‘rest voltage’ at that moment in time and using this reading when calculating the g-force.

the impact data to a smartphone after a match. Some initial research into achieving this has been carried out and a component called an ‘xBee’ has been found, which will be purchased for prototyping following the major project deadline. This component allows for data to be transferred wirelessly through the cloud from the arduino (Xbee, 2014). Further electronic prototype development will reveal whether this is a practical solution for the product. 7.2.4 APP Design Once the product can function wirelessly - the smartphone app can be developed. Initial wireframes have been planned (See Figure 40) to gauge which functions/buttons need to be on each screen of the application. These were tested with a quick application prototyping tool on an iPhone to measure the ‘flow’ of the application. The app does not need to be complicated - it is just a simple tool to review impacts after each match alongside an on-going personal ‘impact profile’ for the season as a whole.

The functionality is also currently limited by the accelerometers available on the market. The accelerometers used for this project perform well in reading direct impacts across an axis, but do not read the rotational forces. Currently, there are no accelerometers on the market which can assess rotational forces as large as required for this application. 7.2.3 wireless Functionality The product should work wirelessly - transmitting

Fig 41 - The wireframes tested for ‘flow’ of the application using the iphone prototyping tool - ‘pop’.

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GLOSSARY

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CTE = Chronic Traumatic Encephalopathy; a form of neurodegenerative disease which can currently only be definitively diagnosed after death. It is most common in those who have suffered from multiple head traumas and concussions. [Previously known as ‘Dementia Pugilistica’] Deviant Over-conformity = A term used to describe the mentality of an athlete who will do anything to participate as long as possible due to a love for the sport. Grass-Roots = The amateur level of sport, including school and club teams. GRTP = Graduated Return To Play; a minimum 21 day process comprising of 6 stages; each gradually exposing an athlete to higher levels of exercise and impact with the ultimate goal of returning to playing contact rugby. IRB = The International Rugby Board; the governing body of rugby globally. NFL = National Football League; the professional American football league. PSCA = Pitch Side Concussion Assessment; a 5-minute method of assessing a player suspected of a concussion, currently being trialled in professional rugby. RFU = The Rugby Football Union; the governing body of UK rugby. Scrum Cap = Headgear worn by rugby players primarily to protect ears in the scrum. SIS = Second Impact Syndrome; a rare condition when the brain swells rapidly, thought to be after a person suffers a second concussion before symptoms from an earlier one have subsided. The condition is often fatal, and almost everyone who is not killed is severely disabled.

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REFERENCES

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REFERENCES Books Banzi, M. (2009). Getting started with Arduino. 1st ed. Beijing: Make:Books / O’Reilly. Tilley, A. (2002). The measure of man and woman. 1st ed. New York: Wiley. Reports Gavett, B., Stern, R. and McKee, A. (2011) ‘Chronic Traumatic Encephalopathy: A Potential Late Effect of Sport-Related Concussive and Subconcussive Head Trauma’ | National Institutes of Health Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995699/pdf/nihms240764.pdf [Accessed 18th November 2013] IRB (2013) PSCA Procedures & Definitions p.3, | IRB [Online] Available at: http://www.irpa-rugby.com/ wp-content/uploads/2013/08/130812-PSCA-Procedures-and-Definitions.pdf [Accessed 23rd October 2013] McCrory, P., Meeuwisse, W., Aubry, M. et al (2013) ‘Consensus Statement on Concussion In Sport: The 4th International Conference on Concussion in Sport Held in Zurich, November 2012’, p.1, [Online] Available at: http://bjsm.bmj.com/content/47/5/250.full.pdf+html [Accessed 10th November 2013] Websites Adidas (2013) Adidas MiCoach: The Interactive Personal Coaching and Training System [Online] Available at: http:// micoach.adidas.com/com/x_cell [Accessed 2nd November 2013] Bailey, L. (2011). Real-time data recorded on football player who broke neck | University of Michigan. [Online] Available at: http://ur.umich.edu/1011/Jul25_11/2512-real-time-data-recorded [Accessed 5th February 2014] Beineman, A. (2010). Punch Acceleration Sensor | Bieneman’s Blog [online] Available at: http://abieneman. wordpress.com/2010/04/04/punch-acceleration-sensor/ [Accessed 24th November 2013] Cleary, M. (2013) ‘Concussion a massive problem for rugby’ |The Telegraph, 2nd September [Online]. Available at: http://www.telegraph.co.uk/sport/rugbyunion/10282064/Concussion-a-massive-problemfor-rugby-says-players-union-manager-David-Barnes.html [Accessed 5th October 2013] Fainaru, S. and Fainaru-Wade, M. (2013) Youth Football Participation Drops | ESPN.com [online] Available at: http://espn.go.com/espn/otl/story/_/page/popwarner/pop-warner-youth-footballparticipation-drops-nfl-concussion-crisis-seen-causal-factor> [Accessed 19th November 2013] IRB GRTP (2013). IRB GRTP | IRB Player Welfare [Online] Available at: http://www.irbplayerwelfare. com/pdfs/IRB_Concussion_Guidelines_EN.pdf [Accessed 2nd October 2013] Medline Plus. (2013) Concussion | Medline Plus [online]. Available at: <http://www.nlm.nih.gov/ medlineplus/concussion.html> [Accessed 18th November 2013] NZ Rugby Union, (2013). Pitch Side Concussion Assessment | NZ Rugby Union [Online] Available at: http://files.allblacks.com/nzru_media_releases/2012/08_August/ITMC_PSCA_Process.pdf [Accessed 7th October 2013] Peters, S. (2013a) ‘Concussion: The Invisible Killer. Former Wasps player Nic Berry talks about the worries that forced him to quit’ | The Daily Mail, 7th September [Online]. Available at: http://www.dailymail.

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REFERENCES co.uk/sport/rugbyunion/article-2415128/Concussion-The-invisible-killer-Nic-Berry-talks-worries-forcedquit.html [Accessed 5th October 2013] Peters, S. (2013b) ‘My son Ben died from concussion… he should not have even been on the pitch’ | The Daily Mail, 7th September [Online]. Available at: http://www.dailymail.co.uk/sport/othersports/ article-2415108/Peter-Robinson-My-son-Ben-died-concussion.html [Accessed 10th October 2013] Peyton, M. (2009) Kobe Demonstrating Deviant Overconformity |Societysportculture.blogspot.co.uk. [Online] Available at: <http://societysportculture.blogspot.co.uk/2009/12/kobe-demonstrating-deviant. html> [Accessed 19th October 2013] RFU (2013) Concussion in Rugby | RFU Headcase [online] Available at: <http://www.rfu.com/takingpart/ playerhealth/concussion/concussion-in-rugby> [Accessed 23rd October 2013]. Rugby365 (2013) Lamont: Concussion tests flawed | Rugby365 [Online] Available at: <http://www. rugby365.com/article/55396-lamont-concussion-tests-flawed> [Accessed 22nd November 2013] Ungerleider, N. (2013) ‘Can This Football Helmet Detect Concussions?’ | FastCompany Tech Forecast Blog, November 20th [online] Available at: http://www.fastcompany.com/3021850/tech-forecast/canthese-football-helmets- detect-concussions#3 [Accessed 20th November 2013] Welch, C (2013) ‘Reebok’s Checklight indicator warns athletes of dangerous head trauma, now on sale for $149.99’ | The Verge Blog, July 10th [Online] Available at: http://www.theverge.com/2013/7/10/4512044/ reebok-checklight-warns- athletes-of-dangerous-head-trauma [Accessed 2nd November 2013] Wilson, M. (2013) Why NFL Helmets Will Never Be Concussion-Proof | Co.Design [Online] Available at: <http://www.fastcodesign.com/1671752/why-nfl-helmets-will-never-be-concussion-proof> [Accessed 5th October 2013] Xbee, (2014) XBee: Connect Devices To The Cloud - Digi International | digi.com [Online] Available at: http://www.digi.com/gp/xbee/?utm_expid=4651060-4.yBY0f5M4R_20K194xMSIMA.1&utm_ referrer=https%3A%2F%2Fwww.google.co.uk%2F [Accessed 1st April 2014] Zotefoams, (2014) Evazote | Zotefoams.com [online] Available at: http://www.zotefoams.com/pages/en/ evazote.asp [Accessed 3rd March 2014] Video Concussion: The Invisible Injury (2013) Directed By Walsh, E. [Vimeo] Available at: http://vimeo. com/55942223 [Accessed 5th October 2013] GuineaPigs, (2007). Human Guinea Pigs - Rugby Tackle. [Youtube] Available at: https://www.youtube. com/watch?v=NvVntLPq_PI&feature=player_embedded [Accessed 22nd April 2014] Images Used In Report “Concussion Diagram” Page 4 - Image Taken From: http://www.kemptvillephysio.com/media/ img/350238/cross_section_motion.jpeg [Accessed 15th April 2014]

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REFERENCES “Brain Scan” Page 4 - Image Taken From: http://www.brainfacts.org/~/media/Brainfacts/Article%20 Multimedia/Diseases%20and%20Disorders/Injury/Concussion%20tissue.ashx [Accessed 15th April 2014] “Brian O’Driscoll Concussed” Page 6 - Image Taken From: https://static-secure.guim.co.uk/sys-images/ Sport/Pix/columnists/2013/12/13/1386961725506/Brian-ODriscoll-014.jpg [Accessed 15th April 2014] “Headcase Poster” Page 10 - Image Taken From: http://www.rfu.com/~/media/files/2013/taking%20part/ concussion/rfu_headcase_changingroomposters_artwork.pdf [Accessed 15th April 2014] “Lewis Moody Knock Out” Page 12 - Image Taken From: http://i.dailymail.co.uk/i/pix/2013/09/21/article2428431-181EA79500000578-261_634x424.jpg [Accessed 15th April 2014] “Ben Robinson” Page 12 - Image Taken From: http://www.theguardian.com/sport/2013/dec/13/death-ofa-schoolboy-ben-robinson-concussion-rugby-union [Accessed 15th April 2014] “Nic Berry” Page 12 - Image Taken From: http://www.london24.com/polopoly_fs/spt_wk40_12_nic_ berry_1_1539283!image/4293163636.jpg_gen/derivatives/landscape_630/4293163636.jpg [Accessed 15th April 2014] “NRL Bad Tackle” Page 14 - Image Taken From: http://cdn.3news.co.nz/3news/AM/2014/4/1/338324/ newcastle-knights-alex-mckinnon-1200.jpg [Accessed 15th April 2014] “NFL Concussion” Page 24 - Image Taken From: http://assets.nydailynews.com/polopoly_fs/1.1583698!/ img/httpImage/image.jpg_gen/derivatives/article_1200/saints-seahawks-football.jpg [Accessed 15th April 2014] “Concussed Austrialian” Page 28 - Image Taken From: http://www.rugbyworld.com/wp-content/uploads/ sites/7/2013/11/173075386-822x1024.jpg [Accessed 15th April 2014] “French Tackle” Page 34 - Image Taken From: http://i.dailymail.co.uk/i/pix/2011/10/15/article-00E615BA100000578-861_468x307.jpg [Accessed 15th April 2014] “Concussion Care” Page 36 - Image Taken From: https://www.flickr.com/photos/70179951@N03/ sets/72157632681085004/ “Ice Pack” Page 52 - Image Taken From: http://www.unfinishedman.com/avoiding-injury-in-sports-fromrugby-to-parkour-stop-getting-hurt/ [Accessed 15th April 2014] “Aussie Training” Page 56 - Image Taken From: http://www.lionsrugby.com/2013tour/12311.php [Accessed 15th April 2014] *All images not references are personal images taken by Tom Adcock.

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Acknowledgements

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Acknowledgments I always find writing acknowledgements a strange addition to academic writing, or writing of any kind - after all, who watches the credits after a movie finishes? That said, there are a number of people who have helped to make this project possible; and they deserve to be mentioned. - Dr Richard Bonser An excellent, supportive and encouraging major project supervisor, Thank you. - The Dave Granshaw Foundation Without the funding I have received, this project would never have been such a success, Thank you. - Janie Grover For giving me the (surprise!) opportunity to speak about my project to a room full of people much more important than me, Thank you. - Mike England For agreeing to meet with me at the beginning of the project to discuss Concussion. Iâ&#x20AC;&#x2122;m not sure Iâ&#x20AC;&#x2122;ll ever attend a meeting in a better location than Twickenham Stadium! Thank you. - Whitgift School Particular thanks to Angela Nicholls and Bob Johnstone for allowing me to utilise the facilities to produce prototypes. - Old Whitgiftians Rugby Football Club To everyone at OWRFC for their input, Thank you (and my apologies for the number of matches missed this season to work on this project!) And finally thanks to all of the staff and students I have encountered during my time at Brunel working amongst such a talented group of people has been an honour.

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APPENDIX

109


CONCUSSION IN CONTACT SPORT

investigating the diagnosis of concussion in club rugby Tom Adcock

THE BRIEF

It is estimated that a player will suffer a concussion during every 120 minutes of rugby. Medical experts suggest that repeated concussions without recovery could lead to memory loss, depression and dementia. This project will develop a product to help quantify the severity of collisions in club rugby - allowing players to safely diagnose the possibility of a concussion on the pitch without the presence of a medical professional. Image © Wingham Chronicle

CONCEPT DIRECTION 1

PLAYER GETS TACKLED. A ‘DEVICE’ MEASURES THE IMPACT; IF THERE IS A POSSIBILITY OF A CONCUSSION, THE PLAYER IS ALERTED

2

THE PLAYER SHOULD LEAVE THE PITCH FOR 5 MINUTES WITH A TEMPORARY REPLACEMENT (UNDER NEW 2013 SEASON ‘BRAIN BIN’ RULING)

4

A. IF THE ASSESSMENT IS PASSED, THE PLAYER CAN PLAY ON WITH CAUTION B. IF THE ASSESSMENT IS FAILED, THE PLAYER MUST BE SUBSTITUTED AND UNDERGO A GRADUATED RETURN TO PLAY (GRTP) SCHEME

STAGE 1. OPPORTUNITY Establishing the position a product will take in the market. This stage encapsulates the collection of both qualitative and quantitive data, including; media research, market trend analysis, recording of primary and secondary numerical data, patent review, styling trend review and competitive product analysis.

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STAGE 2. EXPERIENCE Gaining an understanding for the environment in which a product is used, including; personas, user research, user observation, system design and user testing.

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STAGE 3. PRODUCT Product development; using the knowledge gained from stages one and two the product design stage can be approached with a hollistic and user-centered frame of mind. This allows for a considered, ‘function over form’ outcome.

Who’s seen this:

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PLAYER WILL UNDERGO A DEVELOPED VERSION OF A ‘PITCHSIDE CONCUSSION ASSESSMENT’. THIS INCLUDES; A STANDARDISED ASSESSMENT OF COGNITION, A BALANCE ASSESSMENT AND A SYMPTOMS AND SIGNS ASSESSMENT


a1 INDUSTRIAL REVIEW EVENING Feedback/advice Received: Mark Howard - Research ‘Contre-coup’; the rebound effect the brain will have in the skull. Katie (Sports Scientist) - Research overconformity/positive defiance; the reason rugby players will play on whilst injured. Andrew Gatford - Worry about the size and cost of components; try ‘Sparkfun Electronics’ to source components. - Worry about the comfort of fit. Can you play in it? Be sure to do comfort testing. - Who should get the impact data? Can you trust player honesty - why not give data to the referee? David Tilbury - There is a similar problem in football. - Why not review data after the game? Ian Burrows - System Possibilites; you could run a service to inform teams of their results independently; subscription based concussion management. Rich Coomber - Concerns over integration; is headwear better? - Make a test rig and test concepts. Toby Massey - Keep it simple; how complex can it be? Remember the time restrictions. - Does it need to collect data? Why not just an impact alarm?

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a2 PRODUCT DESIGN SPECIFICATION 1 Target Market 1.1 Primary Target Market The primary target market is the amateur rugby player playing at the grass-roots level of the game. This mainly includes (but is not limited to) upper school rugby (aged 17-18) and young adults (aged 19-30). 1.2 Secondary Target Market 1.2.1 Professional Rugby Players There should be an awareness that the product/garment may be used by those at the other end of the spectrum - at the professional level of the game 1.2.2 Youth Rugby The product/garment could also be developed to be used by younger rugby players (aged 6-16) 2 Performance 2.1 The product/garment must accurately and successfully quantify impacts to the head during a rugby match (Essential). 2.2 The product/garment must have a battery life of more that 2 hours (Essential) 2.3 The product/garment could allow the users coaching staff to monitor impacts in order to track the possibility of a concussion (Desirable) 2.4 The product/garment could relay impact data in real time to coaching/medical staff via a smartphone app or mobile computer (Desirable) 2.5 The product/garment could record impact data over a period of time (i.e. a full rugby season) and allow the player to build up an ‘impact profile’ which can be reviewed at set checkpoints (i.e. after each match) (Desirable) 2.6 The product/garment could alert the user in real time of severe impacts and advise the user to remove themselves from the field of play (Desirable) 2.7 The product/garment could be customisable to each user in terms of fit (e.g. custom-moulded) (Desirable) 2.8 The product/garment itself could reduce impact forces, protecting the user from the possibility of a concussion (Desirable) *Removed following the research phase. 3 Safety 3.1 The product/garment must be safe to wear, with no threat of injury to the user (Essential). 3.2 The product/garment must have no threat of injury to any other player than the user (Essential). 3.3 The product should not create a hazard if used incorrectly (Essential) 3.4 The product should not create a hazard if exposed to poor weather conditions (Essential) 4 Ergonomics and Comfort 4.1 The product/garment must be comfortable to wear during a full 80-minute rugby match and all of it’s features; including running, tackling, scrummaging and communicating with team-mates (Essential). 4.2 The product/garment must not limit the playing ability of the user (Essential). 5 Testing 5.1 Prototypes for testing should have full safety considerations so as not to injure the test subject

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a2 PRODUCT DESIGN SPECIFICATION (Essential). 5.2 No forced concussions will be carried out on a test subject (Essential). 5.2 Where possible, human testing will be prevented (Essential) 6 Environment 6.1 The product/garment itself must be able to withstand the impacts imparted during a rugby match (Essential). 6.2 The product/garment should be waterproof, wipe clear or have the ability to be removed for washing (Essential). 7 Legal Requirements 7.1 The product/garment will not diagnose concussion and this must be clear at all stages and during all marketing/exhibition of the concept (Essential). 7.2 The ‘diagnosis’ experience will not be orchestrated in partnership with a medical professional and therefore should not have a medical focus; instead focusing on the use of the product/garment. However, the experience will be based on current medical procedures and aligned with the product/garment to enhance these (Essential). 8 Time Frame 8.1 The project as a whole, including all relevant models, prototypes and documents should be completed by 10th April 2014 (allowing a 14 day ‘slack period’ before the submission date) (Essential).

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a3 GRADUATED RETURN TO PLAY (GRTP)

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A4 PITCH-SIDE CONCUSSION ASSESSMENT (PSCA) Who can call for a Pitch Side Concussion Assessment to be completed? The Team doctor or the Referee can independently request a PSCA. What are the indications for a request for a PSCA to be completed? A PSCA should be requested if any of the following are witnessed: - Suspected Loss of Consciousness - Ataxia (unsteady on feet) - Disorientated or confused - Player appears to have been “dazed, dinged or had their bell rung” - Inappropriate behaviour - Other symptoms or signs suggesting a suspected concussion When does a player have a confirmed concussion and therefore does not need to be referred for a PSCA? A player has a confirmed concussion (and should be removed from further play) if a loss of consciousness (LOC) is confirmed. A LOC is confirmed if: a) the player exhibits tonic posturing b) the player has a traumatic convulsion c) a medically trained person confirms LOC through direct observation that the player is not responding verbally or via movement to commands. Where will the PSCA be completed? The PSCA will be completed in the medical room or an agreed private area. If the PSCA cannot be completed in the medical room because the medical room is too distant from the field of play the team Doctors will identify an agreed and appropriate area prior to the commencement of the game. Can a player undergoing a PSCA be replaced or substituted? A player undergoing a PSCA can be temporarily substituted for up to 5 minutes whilst the PSCA is completed. If the player undergoing this PSCA does NOT return to the field of play the temporary substitution becomes a permanent substitution. How long is available to complete the PSCA? The PSCA, must be completed within 5 minutes (absolute time not playing time). This period commences when the player leaves the field of play (crosses sideline) and finishes when the player presents to the 4th official cleared to return to play. The 4th official will have control of the player’s entrance to the field of play. When does a player fail a PSCA? One incorrect answer in the memory test or one current symptom or one abnormal sign observed by the Team Doctor or more than 4 errors on balance test is a failed PSCA and removal from further playing. (NZ Rugby Union, 2013)

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A6 Code /* PrintGForceLCD- Accelerometer Reads analog inputs from accelerometers, converts them to g force, and prints the highest result to the LCD. Also holds the peak g-force of that ‘session’ on the LCD Attach the output pin of the accelerometer to pin A0/A2/A4, and the other pins to +5V and ground.

*/

#include <SoftwareSerial.h> // Use the softwareserial library to create a new “soft” serial port for display. This prevents display corruption when uploading code.

SoftwareSerial mySerial(3,2); // pin 3 = TX, pin 2 = RX (unused) // Attach the serial display’s RX (Black) line to digital pin 2

// the setup routine runs once when you press reset:

void setup() {

// initialize serial commun4ication at 9600 bits per second:

mySerial.begin(9600); // set up serial port for 9600 baud

delay(500); // wait for display to boot up

mySerial.write(254);

// move cursor to beginning of first line

mySerial.write(128);

mySerial.write(“

“);

mySerial.write(“

“);

mySerial.write(254);

// clear display

// move cursor to beginning of first line

mySerial.write(128);

mySerial.write(“READY”);

// write “READY” on screen

} //define the boundaries and names for events float g_force; float max_force = 30;

//define g_force as an impact //define max force as max impact in an event. Reset boundary at 30g following end of impact event.

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A6 Code float max_overall_force = 0;

//max overall force is the largest impact in the session. set max overall force as 0 to begin

boolean impact_progress = false;

//false = no impact event, true = impact event. Begin with no impact event, change to an event if it reaches the threshold of 30

void loop() {

int sensorValue1 = analogRead(A0); int sensorValue2 = analogRead(A2); int sensorValue3 = analogRead(A4);

// read the input on analog pin 0: Accelerometer 1 // read the input on analog pin 2: Accelerometer 2 // read the input on analog pin 4: Accelerometer 3

float voltage1 = (float) sensorValue1 * (5.0 / 1023.0); // treat the int as a float (casting technique), then convert the analog reading (which goes from 0 - 1023) to a voltage (0 - 5V): float voltage2 = (float) sensorValue2 * (5.0 / 1023.0); float voltage3 = (float) sensorValue3 * (5.0 / 1023.0);

float accel1 = abs((voltage1 - 2.48) / 0.008) ; float accel2 = abs((voltage2 - 2.48) / 0.008) ; float accel3 = abs((voltage3 - 2.48) / 0.008) ;

if (accel1 > accel2){ g_force = accel1; }else{ g_force = accel2; }

//work out the g-force reading from the voltage // the function abs() returns the given parameter without the sign (+/-)

//if Accel1’s result is greater than accel2’s result; then call the result from accel1 ‘g_force”

//otherwise, call result from accel2 ‘g_force’

if(accel3 > g_force){ g_force = accel3; }

//if accel3’s result is greater than ‘g_force’, call the result from accel3 ‘g_force’

if (g_force>30){

//if ‘g_force is greater than 30, do the following..

impact_progress = true;

//begin an ‘impact progress event’ because 30g threshold has been reached

if(g_force > max_force){

//if ‘g_force’ is greater than current ‘max force’ from session

max_force = g_force;

//make ‘g_force’ the new ‘max_force’

if(max_force > max_overall_force){

//if ‘max_force’ is bigger than the ‘max_overall_force’ then

max_overall_force = max_force;

//re-define the ‘max_force’ as ‘max overall force’

// move cursor to beginning of second line

mySerial.write(254);

mySerial.write(192);

mySerial.write(“

“);

// clear display

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A6 Code mySerial.write(“

“); mySerial.write(254);

// move cursor to beginning of second line

mySerial.write(192);

mySerial.print(“PeakHit = “) ;

// print “PeakHit =”

mySerial.print(max_overall_force);

// print the new max overal force (peak force from the session”

} }

}else{

//Otherwise:

if(impact_progress == true){

impact_progress = false;

mySerial.write(254);

//reset the impact event - switch off // move cursor to beginning of first line

mySerial.write(128);

mySerial.write(“

“);

mySerial.write(254);

// clear display // move cursor to beginning of first line

mySerial.write(128);

mySerial.print(“LastHit = “) ;

mySerial.print(max_force);

max_force = 30;

//Print “LastHit = “

//Print the last impact force over 30g //reset max force as 30 - redefine the boundary

} } }

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Tom ADCOCK | 1006472 | DM3306 MAJOR PROJECT

Brunel University 2014

Major Project Report - The Concussion Diagnosis Process In Amateur Rugby  

This report gives an overview of the design and development of a product which aims to improve the current experience of diagnosing concussi...

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