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J Athl Train. 2001 Oct-Dec; 36(4): 361.
PMCID: PMC155429

Letters to the Editor

In our recently published article (Potteiger JA, Randall JC, Schroeder C, Magee LM, Hulver MW. Elevated anterior compartment pressure in the leg after creatine supplementation: a controlled case report. J Athl Train. 2001;36:85–88), my coauthors and I incorrectly credited the National Athletic Trainers' Association with funding the research. The correct funding entity was the National Athletic Trainers' Association Research and Education Foundation, grant 399 A004. We apologize for this error.

J Athl Train. 2001 Oct-Dec; 36(4): 361.

I wish to comment on the article by Ransone et al entitled “The Efficacy of the Rapid Form Cervical Vacuum Immobilizer in Cervical Spine Immobilization of the Equipped Football Player” (J Athl Train. 2000;35:65–69). I commend the authors on their investigation of this new product. I wish to address one major point in their work. There are major clinical implications of their conclusions, and I ask the authors to explain the rationale of their stated position.

The authors state in the conclusions that “immobilization of the cervical spine is enhanced when the face mask is left in place.” Two references1,2 were given to support that statement. The study design in Prinsen et al1 would not allow one to make this assumption from the data, and neither paper presents any discussion to support this assumption. In a recent review of cervical spine injuries in helmeted football players, no articles that would support leaving the face mask in place during transport were found.3,4 Sports medicine texts state clearly that the face mask should be removed before patient transport, regardless of current respiratory status.5

The design in the study by these authors used helmeted subjects with face mask removed to allow each subject full movement of the cervical spine. With this study design, it would be difficult to extrapolate any data to support increased stability of cervical spine immobilization with the face mask left in place. I know of no published study that supports a biomechanical advantage to cervical spine stabilization by leaving a face mask in place during transport. One would not want to use the face mask to stabilize the helmet in place, because this might inhibit easy access to the face mask in the event that removal and airway management become issues. It would be better to remove the face mask in a controlled environment before transport in preparation for the necessity of airway management.

The face masks can be safely removed during transport.3 This allows easy access to the airway if management becomes an issue during transport. Professionals working with football teams should be well trained in the methods of face-mask removal, and the proper equipment to remove the face mask must be readily available. Prehospital and sports medicine teams need to formulate a plan in advance to prepare for unexpected clinical scenarios such as cervical spine injuries, and skills such as face-mask and helmet removal, if necessary, should be practiced. Clinical policies need to be based on well-designed studies or clinical consensus. One must be careful extrapolating face-mask and helmet management to other helmet designs without further studies in this area.6

Thank you for your consideration of these points.


1. Prinsen RK, Syrotuik DG, Reid DC. Position of the cervical vertebrae during helmet removal and cervical collar application in football and hockey. Clin J Sport Med. 1995;5:155–161. [PubMed]
2. Segan RD, Cassidy C, Bentkowski J. A discussion of the issue of football helmet removal in suspected cervical spine injuries. J Athl Train. 1993;28:294–305. [PMC free article] [PubMed]
3. Waninger KN. On-field management of potential cervical spine injury in helmeted football players: leave the helmet on! Clin J Sport Med. 1998;8:124–129. [PubMed]
4. Waninger KN. On-field management for the injured football player. Clin J Sport Med. 2000;10:82–83. [PubMed]
5. Holmes CF, Hershman EB, McCance SE. Cervical spine injuries. In: Schenck RC, editor. Athletic Training and Sports Medicine. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999. p. 215.
6. Waninger KN, Richards JG, Pan WT, Shay AR, Shindle MK. An evaluation of head movement in backboard-immobilized helmeted football, lacrosse, and ice hockey players. Clin J Sport Med. 2001;11:82–86. [PubMed]
J Athl Train. 2001 Oct-Dec; 36(4): 361–362.

Authors' Response

Katie Walsh, EdD, ATC-L, Jack Ransone, PhD, ATC, and Robert Kersey, PhD, ATC

Thank you to Dr Waninger for his letter concerning our article entitled “The Efficacy of the Rapid Form Cervical Immobilizer in Cervical Spine Immobilization of the Equipped Football Player.”

The purpose of our study was to measure the effectiveness of the Rapid Form Cervical Vacuum Immobilizer in controlling cervical forward flexion, extension, and lateral movements of an equipped football player. In 10 healthy subjects, we demonstrated that when a player is wearing a football helmet and shoulder pads, a properly placed cervical vacuum immobilizer does indeed restrict cervical movement radiographically compared with a similarly equipped person without the vacuum immobilizer in place. We were pleased to note that our study was referenced in the Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete document.1

The position of the National Athletic Trainers' Association (NATA) is that face masks should be removed, regardless of the respiratory status of a spine-injured football player. Our 1999 study demonstrated the effectiveness of the cervical vacuum splint applied without the face mask in place, as the new protocol dictates. Furthermore, the guidelines of the American Orthopaedic Society for Sports Medicine,2 NATA,1 and other well-documented research papers clearly call for keeping the helmet and shoulder pads on in a spine-injured athlete unless there is cardiac cessation, because these equipment pieces work together to maintain cervical alignment. Our study provided data to support these findings and allowed for ease of application, flexibility in use, and the ability to take an x-ray film through the splint. We did not test subjects with a face mask on; therefore, we could draw no conclusions regarding the face mask. We do agree that further exploration is warranted in this area, but we stand by the cervical vacuum immobilizer as an excellent tool to preclude cervical movement in an equipped football player.


1. Kleiner DM, Almquist JL, Bailes J, et al. Prehospital Care of the Spine-Injured Athlete: A Document From the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete. Dallas, TX: National Athletic Trainers' Association; 2001.
2. Wojtys EM, Hovda D, Landry G, et al. Current concepts: concussion in sports. Am J Sports Med. 1999;27:676–687. [PubMed]

Articles from Journal of Athletic Training are provided here courtesy of National Athletic Trainers Association