Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
helmets not cycling
- douglas salmon (24 May 2002)
-
Re: helmets not cycling
- Jason L Carter (25 May 2002)
-
Re: helmets not cycling
- Lisa C Blakemore-Brown (25 May 2002)
-
Protecting our children's heads
- Lisa C Blakemore-Brown (26 May 2002)
-
Why should only Child Cyclists wear helmets?
- Peter W Ward (28 May 2002)
-
re : helmets not cycling
- Colin Guthrie (29 May 2002)
-
Re: helmets not cycling
- Nigel Perry, PB 4800, Christchurch, New Zealand (30 May 2002)
-
Poor presentation of a complex issue
- Malcolm J Wardlaw (1 June 2002)
-
Efficacy of cycle helmets
- John Wren (5 June 2002)
-
Reducing children's head injuries from cycling
- Dorothy L Robinson (7 June 2002)
-
Do helmets improve overall safety?
- Colin F Clarke (10 June 2002)
|
|
|||
|
douglas salmon, gp birmingham, b20 3he
Send response to journal:
|
is anything known about the value of helmets in other circumstances than cycling ? - recently ambulant toddlers and older children using playgrounds seem to appear regularly in A/E departments with head injuries, as do the elderly infirm from residential care. |
|||
|
|
|||
|
Jason L Carter, researcher Winnipeg, CAN
Send response to journal:
|
Douglas Salmon asked in the rapid response to this week's BMJ about helmet usage in non-cycling situations. I'm unable to provide you with citations, links or resources. However, I have read over the last 3 years about numerous 'hanging' type injuries in the US and Canada with kids wearing helmets while on playground structures or in seating stands (bleachers). The helmets get caught on the structure, and the buckle is simply too hard for the child to undo quickly. I believe there was a horrific case in Canada (Alberta, I think) where bullies hung a child up on a wire fence by his clothes; the clothes let go, but the helmet got caught on the top of the wire fence, killing him. A similar accident recently happened to my 4 year old boy. While wearing a helment when seated on a set of baseball bleachers, he fell off. The helmet got caught on the edge, but fortunately my wife got there in time to free him. He softly landed on his head on the ground and the helmet, ironically, protected him from serious injury. My point would be to suggest researching these types of injuries carefully before advocating helmet usage in playgrounds or any place where the child is elevated off the ground by a structure (although I fully support helmet usage while cycling). Cheers, Jason Carter |
|||
|
|
|||
|
Lisa C Blakemore-Brown, Independent Psychologist UK
Send response to journal:
|
As a psychologist specialising in developmental disorders such as ADHD and Autism, I see many children who have suffered head injuries as a function of their risky behaviour and those with a sudden onset of head banging behaviour, as just two examples. The sequelae of head injuries can be very serious and without a doubt our system does not understand the likely outcomes. This has numerous implications, including sufferers of head injuries not receiving appropriate assessment and treatment. Patients are patched up and if they can walk, they are encouraged to do so - straight out of the hospital. Educational systems have few clues about the reasons for sudden personality changes in children following head injuries. They are more likely to blame mothers or peer up the dark alleyways of psychoananalytic theory than into the head injury literature. Vast numbers of ADHD children take risks which result in accidents and blows to the head. Many toddlers, for instance, react to vaccines with confusion and motor instability - parents and teachers who are understandably not as vigilant with the ambulant toddler as they were weeks before with the dependent baby (as they intuitively encourage greater independence) may find they trip and fall - sometimes straight onto their heads - in situations where they appeared to be safe in the days before the vaccination. Prevention is something which is not considered if there is no recognition of the outcomes in the first place. In my book (1) I refer to problems linked with head injury from toddler head banging and in an attempt to help readers understand the 'tapestry' of disorders - I state 'some children have a terrible habit of smacking their heads against hard floors and walls. This will not help matters but it is likely that these children have neurological problems which cause them to engage in such behaviour. Bashing their heads will only tangle their tapestry. Perhaps there ought to be more hard hats for toddlers.' (Page 223) 1. Blakemore-Brown, L.C. Reweaving the Autistic Tapestry. Jessica Kingsley Publishers 2002. |
|||
|
|
|||
|
Lisa C Blakemore-Brown, Independent Psychologist UK
Send response to journal:
|
The examples of children's helmets, designed to protect them, actually causing them harm are very sad indeed. This perspective from a country where children clearly wear helmets more than in the UK, for instance, is very important. Gievn this informaiton, the argument for the use of helmets may be seen as a double edged sword. Perhaps therefore, this evidence indicates a two pronged approach to the type of research implicated. 1.Improve the designs of the helmets 2.Research types of head injuries. As Jason Carter mentioned, his child was actually saved from serious injury by the helmet when he fell on his head. |
|||
|
|
|||
|
Peter W Ward, GP Gateshead, NE8 1NR
Send response to journal:
|
Claims of a reduction in head injuries from a study such as this must be viewed with caution. It may be a real reduction or may just reflect reduced exposure, or the wearing of helmets by low risk takers. If there is indeed a genuine reduction then surely someone must do a study on helmets for child pedestrians, child passengers in cars or indeed children having showers (they might slip and bang their heads). If we find a reduction in head injuries here too, does it follow we should encourage helmet wearing in these situations? |
|||
|
|
|||
|
Colin Guthrie, General Practitioner 1448 Dumbarton Road Glasgow G14 9DW
Send response to journal:
|
Yes , there is a go-ahead company now producing helmets for children to wear at all times. Go to www.thudguard .com and see a great new idea which will dramatically reduce the rates of head injury to all our children. Children should wear head protection at all times. It is not just on bicycles that children should wear helmets or thudguards but also whenever they are a pedestrian or in a vehicle. For very young children it will also protect against falls in the home and from the major cause of head injury in children under the age of one, the assault by a parent. Continuous helmet wearing is best combined with a very disciplined and restricted use of the external environment. Children should not go out on their own. In order to get safely to and from school they should join a 'safe routes to school' club with their excellent 'walking bus' groups wearing day-glo vests, helmets or thudguards and have a responsible( non- menstruating ) mummies blowing whistles at each end. If there is over a kilometre to school then soon an American 'Yellow Bus' will be available in Britain to take all children direct from house to class and back again with no risk from any walking or cycling. The safest type of play is, of course, playing at home but if a child is determined to go 'out' then the parents should drive children to a government accredited indoor play centre where, for a small fee, they can fulfill themselves by bouncing happily in a totally cushioned environment. With this thoroughly sensible approach to the care of our children we can be sure that head injuries will be dramatically reduced. The real bonus for those of us in the medical world is the way we can then all profit from developing and prescribing even more expensive medication with dubious benefits but nasty side effects for all the resulting obesity, hypertension, diabetes, heart disease and mental illness that our insanity will produce. |
|||
|
|
|||
|
Nigel Perry, Senior Fellow University of Canterbury, PB 4800, Christchurch, New Zealand
Send response to journal:
|
Douglas Salmon asks "is anything known about the value of helmets in other circumstances than cycling?" Yes, rather a lot. It has long been known that the wearing of "bicycle" style helmets by seat-belted and air-bag protected motor vehicle occupants would result in a much great reduction in head injuries than if bicyclists wear them. Strangely the majority of advocates of bicycle helmets ignore this fact. How the Federal Office of Road Safety, now the ATSB, in Australia broke ranks a few years ago and openly acknowledged this is a researhc report - and they continue to publish research on the development of head protection for motorists. Jason Carter wrote "However, I have read over the last 3 years about numerous 'hanging' type injuries in the US and Canada with kids wearing helmets while on playground structures or in seating stands (bleachers). The helmets get caught on the structure, and the buckle is simply too hard for the child to undo quickly." Thsi problem was first openly acknowledged by the helmetists in Sweden in the early 90's. In 1995 they gave a talk in Melbourne where they stated, tearfully, that they came to a point where they knew they had killed but couldn't say they had saved anybody. However, their faith saved them, they recoverved from the shock and went on to develop the helmet buckle which comes undone on impact, thus mitigating this problem. They did then face the problem that the helmets came off (more than standard ones?) in accidents... BTW: Here in New Zealand we have had compulsory bicycle helmet wearing for years. The initial impetus came from a freak accident, but the vote-winning potential of pandering to parents fears was too much to turn down. The law has failed to reduce the head injury rate of bicyclists, which is at least better than a similar law in Victoria Australia where child injury/death rates went up post law. None of this is surprising, bicycle helmets are not designed to protect against vehicle impacts, yet are advertised, and in some cases enforced, on that basis - misrepresent the capabilites of any safety device and disaster in inevitable. Learn from the Dutch, Danish, etc. where it is safer to ride a bicycle unhelmeted than in New Zealand or Austrlaia which require helemts. Bicycle helmets have nothing to do with iimproving road safety. Yours, Dr N Perry |
|||
|
|
|||
|
Malcolm J Wardlaw, Transport Analyst 92 Drymen Road, Bearsden, Glasgow G61 2SY
Send response to journal:
|
“A poor presentation of a complex issue.” The subject of child cyclist injuries, in particular head injuries, is surely serious enough that such a prestigious publication as the BMJ can at least manage to get the facts right and present them in a fair way. Ellis makes two glaring errors, so I shall correct these first. 1) “1,000 children suffer major brain injuries each year from which they do not recover”. This is wrong. About 1,000 children each year are admitted to hospital for treatment of serious head injuries, yes, but very few of these will be truly grave injuries with lasting consequences, most will be cases of mild concussion. Incidentally, only 1.3% of all serious head injury admissions (2,500/190,000) are due to any kind of cycling accident, on-road or off-road. Ellis might have pointed out that cycling is a trivial cause of head injury. 2) “Motor cars are involved in only 2% of (cyclist) hospital admissions”. This is wrong. Currently the police report that about 3,200 cyclists suffer serious injuries in road traffic accidents. The definition of “serious injury” used by the police does not necessarily imply hospital admission, since a bone fracture is classed as a serious injury for STATS19 purposes, so the actual number of hospital cases may be less than 3,200. A total of about 7,000 cyclists are known to be hospitalised following any kind of bicycle accident, be it on-road or off-road [1]. It is fair to say, then, that almost half of hospital cases are due to road traffic accidents (involving vehicles of all types), while the rest are off-road accidents. Ellis also makes the error of exaggerating the scale of injuries due to cycling. It is no doubt true that 93,000 children annually are treated at hospital following a cycle accident, but only 3% of these have suffered injuries serious enough to require admission. Likewise, 21,460 children annually suffer a head injury on a bicycle, but less than 4% of these are serious head injuries. If it comes to that, the Leisure Accident Statistical Survey reveals that 850,000 people are treated at hospital following walking accidents not involving a motor vehicle. Does that mean walking is “dangerous”? Ellis should have been more specific in distinguishing (rare) serious injuries from (common) minor injuries, and (very rare) grave injuries from the serious. By the sloppy treatment of injury figures, she is likely to excite all those journalists out there who get into difficulties when they run out of fingers and toes. The claim that head injuries would be much reduced if all children wore helmets needs to be read cautiously in the light of the above confusion about minor and serious injuries. Yes, head injuries may well fall, but will SERIOUS injuries fall? And it is important to bear in mind that risk-compensation should have been mentioned, by Ellis if not by BHIT. In the United States, the incidence of head injury per cyclist increased by 40% with increasing helmet use during the 1990s, according to the research of the Consumer Product Safety Commission. This result was reported in the New York Times of July 29th 2001, but the CPSC has yet to issue any kind of formal report into the problem and still promotes the use of helmets, without any caution about helmet users becoming over- confident. It could happen here too. Another misleading statement is that “85% of injured or killed occur off-road”. I don’t doubt it, but again she is lumping deaths in with minor injuries. Most cyclist deaths are actually in road crashes because the vast majority of miles cycled are cycled vehicularly with motor vehicles – and they are quite low-risk miles too, if one takes the trouble to investigate risk in road cycling thoroughly. There are also deaths on cycle paths, the National Cycle Network and in MTB crashes. The number of such deaths is enormously out of proportion with the amount of off-road cycling activity, because off-road cycling is so much more dangerous than road riding by competent (or even incompetent) cyclists. The occasional jaunt with the family on the National Cycle Network provides no insight into the level of risk of many hours per week of use, and in fact that risk is high. Hence Ellis is right to imply off-road cycling is relatively dangerous, but she is right for the wrong reason. Finally, Ellis states there are 50 deaths of child cyclists per year, of which 75% die due to head injury. This is correct, but misleading, because it implies that children are not killed when walking or riding in cars, which is not correct, and that cyclists suffer severer head injuries than other road users, which is also not correct. In fact, five times as many children are killed as pedestrians. 80-85% of pedestrians, cyclists and car occupants killed in road crashes suffer lethal head injuries, but cyclists tend to suffer (slightly) fewer multiple lethal injuries, so the lethal head injuries appear to stand out more [2]. Concerning the severity of head injury in serious road accidents, the French National Transport Research Institute (INRETS) carried out a survey of road users hospitalised after road crashes [3]. It reported that 4.2% of the pedestrian cases suffered more than 24 hours’ unconsciousness, as against 2.3% of the cyclists (no helmets in 1987) and 1.3% of the car occupants. Only motorcyclists, at 3.9% of cases, came close to pedestrians for vulnerability. Bearing in mind that analysis of the National Travel Survey shows most child age groups face higher fatality rates as pedestrians than as cyclists, it is hard to assemble any logical case to narrow the helmet focus just to cyclists. In any case, I fail to see the relevance of road traffic deaths in any helmet discussion. The current BMA view is that a helmet will not prevent death in a hard crash with a motor vehicle, while any prevention of serious injury is not judged reliable enough to warrant estimation [4]. A helmet is designed to provide protection only for a simple fall at low speed. This is just the most likely kind of accident to happen to frustrated children, whose parents forbid them freedom, instead providing them mountain bikes with suspension, ultra-low gears and knobbly tyres, all encouragement to indulge in ever more daring and dangerous stunts – until someone bangs their head. It was so much safer when I was a boy. Our parents bought us sensible road bikes that were fine transport to take us safely all around the neighbourhood. No one ever hurt themselves badly just falling off their bike, although there was one boy in another year who was killed by a car…. But that’s another story. 1. Cook A, Sheikh A. Trends in serious head injuries among cyclists in England: analysis of routinely collected data. BMJ 2000;321:1055. 2. Kennedy A. The pattern of injury in fatal pedal cycle accidents and the possible benefits of cycle helmets. Paper presented at VeloCity 1995, Basle, Switzerland. 3. Ramet M, Valet G. Typologies des accidentes du trafic routier a partir de 5,459 dossiers. Rapport INRETS-LCB, August 1987, p106. 4. Cycle Helmets. BMA publications, London: 1999. |
|||
|
|
|||
|
John Wren, Senior Analyst, Safekids, Auckland, New Zealand
Send response to journal:
|
One of the best literature reviews I have read outlining the characteristics of bicycle injuries, the biomechanics of head injury and the effectiveness of bicycle helmets is a report prepared by Dr Michael Henderson for the Motor Accidents Authority of New South Wales, Australia. The report is available on the WWW. The full reference is: Henderson M. The Effectiveness of Bicycle Helmets: A Review: Prepared for Motor Accidents Authority of New South Wales, Australia; 1995. Report No.: MAARE-010995.ISBN 0 T310 6435 6 In http://www.helmets.org/henderso.htm The responses to the guidelines has been interesting, and seems to me to be very similar to the earlier debate over the banning of the word 'accident' from use in the BMJ. The reaction against bicycle helmets, puzzles me in that a move against bicycle helmet use is also strong within certain sectors of the cycle advocates network in NZ and seems to be based more upon the rejection of regulation and support for libertarian values rather than knowledge of the burden of injury and the effectiveness of protective helemets. It is not for nothing that protective helmets are required to be worn by motorcycle riders, construction workers, equestrian riders etc. |
|||
|
|
|||
|
Dorothy L Robinson, Statistician AGBU, UNE, Armidale, NSW, 2151
Send response to journal:
|
Editor's choice (BMJ, May 25 2001) advised us to be careful with what we believe. In the same issue, Anna Ellis' article claimed that only 2% of (cyclist?) hospital admissions involve cars. Yet a published study of all 1040 cycling injuries treated at the emergency department of Adenbrook's Hospital in 1992 reported that 102 had head injuries; 32 of these resulted in hospital admission and 52 (50% of cyclist head injuries) involved motor vehicles (1). As the severity of injury increases, so generally does motor vehicle involvement. Information was not provided for head injury admissions at Adenbrook's. However, for all cases of brain injury to cyclists in 1981 in San Diego County, California, all those without motor vehicle involvement made good recovery. In contrast, "15% of those whose injuries involved a motor vehicle had unsatisfactory outcomes in that they died or were discharged with severe or moderate disability or persistent vegetative state." (2) Given data with a similar trend, but only the more gradual increase in helmet wearing achievable without legislation, an uncritical thinker might attribute the entire decline to the effect of helmets. As was seen in an analysis of New Zealand data, unless trends are fitted in the statistical model, predictions of helmet effects may be grossly exaggerated (4). But critical thinkers might wonder if helmets can really be so much more effective in some countries than others. To verify the results, they might report comparisons of head injury percentages for other road users and areas without helmet promotion. They might also ask why guidelines promoting children's helmet wearing are predicted to reduce cycling injuries from 93,000 to 52,000 when only 21,400 of the 93,000 involve head injuries? The BMA's Board of Science and Education has a possible explanation: "A Transport Research Study reported that in 11 local authorities where child cycle helmet wearing campaigns were held, helmet wearing went up among children. However this increase was also found to be linked to a decrease in the number of cyclists observed in those areas where the campaigns had been held."(5) Is the projected 44% fall in total injuries due mainly to trends and the reductions in cycling activity noted above? Angela Lee stated: "Cycling is an activity we want to encourage because it is fun, healthy and environmentally friendly." Wouldn't it be ironic if most of the so-called benefits of helmets claimed in that article were due to reductions in cycling because of those helmet promotion campaigns? 1. Maimaris C, Summers CL, Browning C Palmer, CR. Injury patters in cyclists attending an accident and emergency department: a comparison of helmet wearers and non-wearers. BMJ 1994; 308: 1537-40. 2. Kraus JF, Fife D, Conroy C. Incidence, severity and outcomes of brain injuries involving bicycles. Amer. J. Public Health 1987;77:76-78. 3. Bicycle Helmet Safety Institute. Short Helmet Standards Comparison. http://www.helmets.org/stdchart.htm (accessed 7/6/02)4. Robinson, D.L. Changes in head injury with the New Zealand bicycle helmet law. Accident Analysis and Prevention 2001; 33:687-691. 5. BMA Board of Science and Education. Cycle Helmets. June 1999. |
|||
|
|
|||
|
Colin F Clarke, CTC National Councillor Retired
Send response to journal:
|
The first results of widespread use of helmets came from the VISS (1) and they gave details of the head injury rate for the 12 months before legislation to the periods after. They were 10.9% pre law, 9.3%, 9.7% and 10.3% for the 36-month period post legislation. Very little actual improvement to be seen from this simple comparison of the percentage head injury rate but looking at the accident involvement rate tells a different story. The accident involvement rate requires estimates of total cycling occurring and total accidents and the outcome was negative for children, Robinson's data (2) showed accident involvement to increase by around 16% for the VISS data. For New South Wales the increase was much higher at 68%. The reasons I do not think helmets actually work is because the research to date has not considered various aspects in full, namely. 1. near misses for a bare head could be classified as prevented head injuries for helmet wearers giving an illusion of benefits. 2. helmets increase accidents by higher risk taking by some cyclists, affects on balance and riding stability, incur more impacts to the head due to the larger size of the helmet compared to the bare head and increase neck injuries due to extra impacts. 3. rotational effects on the brain increase due to extra impacts and increased turning moments. Because accidents increase by wearing helmets and head injuries (part covered by a typical cycle helmet, not including face that incurs more injuries than the head) are only about 10% of typical cyclist's injuries. Other injuries, 9 for each head injury, increase at higher numbers than head injuries could possibly reduce due to helmets. In total, injuries increase by helmet wearing effects so as a safety product they fail a basic test of reducing injuries. The VISS data showed head injuries due to cycling to be 8% of total children's head injuries. Each activity needs very careful research before donning helmets on children and alternatives should be investigated fully. Children up to age four for example may be much safer on a three-wheeled bicycle manufactured to a high standard specification. Monitoring a child's ability to balance may indicate if he or she is ready for two wheels. The degree of balance required for activities and a child's ability to balance could be assessed before the child is given the go ahead, controlling the degree of risk a child faces. C Clarke
1. Data from Victorian Injury Surveillance System, Monash University Accident Research Centre, Melbourne, Australia. 2. Robinson D, “Head injuries and bicycle helmet laws” Accid Anal and Prev 28, 4,1996, p 463-75 |
|||
It is questionable whether helmets (designed to limit impacts of a 5 kg headform to 300 g when dropped from 2
meters (3)) would have helped much in many of the serious cases resulting from bike/motor vehicle crashes in San Diego. In New South Wales, the proportion of cyclist hospital admissions with head injury remained virtually unchanged from the overall trend, despite increases in helmet wearing in less than a year from 26% to 77% of adult and 31% to 76% of child cyclists (see graph). This was the real life experiment.