Why sticking a fork in your eye is a bad idea - or 'helmets work...and don't be silly'

A snowHead

Some of the helmet debates on SH are a bit bonkers. Probably because people have had a bang on the head.

Let’s try to get some evidence into the discussion. Some of the best data come from studies relating to cycle helmets. This transfers to snowsport helmets in key respects, but I refer to snowsport research where it exists.

First up … in the language of medical research, is there a mechanism in operation here? Yes. If you hit your head on something hard with sufficient force, then an injury will result. So we have a mechanism. Will a helmet attenuate the effects of an impact injury? Yes, up to a certain point. When the impact force becomes too great, the helmet will no longer attenuate the effect on the skull and on brain tissue. This can all be measured with the industry standard anvil test. So … do helmets work …yes, in preventing the transmission of energy to the skull and brain so that these do not ‘spike’ in a way which causes serious injury ( see - http://www.bmj.com/content/308/6922/173). So far so good. This points in the direction of wearing a helmet. Look at this re cycling helmets: a 63% reduction is very significant. It’s the kind of decrease in risk which I’d like to secure for my children when they ride a bike:

Subjects : 445 children presenting with bicycle related injuries during 15 April 1991 to 30 June 1992. The cases comprised 102 children who had sustained injury to the upper head including the skull, forehead and scalp or loss of consciousness. The controls were 278 cyclists presenting with injuries other than to the head or face. A further 65 children with injuries to the face were considered as an extra comparison group.
Main outcome measures : Cause and type of injury, wearing of helmet.
Results : Most children (230) were injured after losing control and falling from their bicycle. Only 31 had contact with another moving vehicle. Children with head injury were significantly more likely to have made contact with a moving vehicle than control children (19 (19%) v 12 (4%), P<0.001). Head injuries were more likely to occur on paved surfaces than on grass, gravel, or dirt. Wearing a helmet reduced the risk of head injury by 63% (95% confidence interval 34% to 80%) and of loss of consciousness by 86% (62% to 95%).
Conclusions : The risk of head injury in bicycle accidents is reduced among children wearing a helmet. Current helmet design maximises protection in the type of accident most commonly occurring in this study. Legislation enforcing helmet use among children should be considered.

But note the limits: from Dr Mike Langram’s site:

…whilst helmets may help reduce the incidence of minor and moderate head injuries and lacerations they may be less able to protect the foolhardy skier who pushes his or her limits and who (inadvertently) ends up wrapping themselves around a tree at typical skiing speeds. To give a stark example, biomechanics have demonstrated that in order to protect the head against a direct impact blow at 30 mph, with currently available materials, a helmet would need to be at least 18cm thick, 50cm wide and weigh 5kg+. Hhhmm….stylish. Radar data collected from ski areas suggests most intermediate skiers regularly travel at much higher speeds than this.....

Second up … are we only talking of a single type of impact injury. No. Research tells us that there are different types of injury – two main types being impact (like the anvil test, which simulates a direct blow to the head with a hard object) and rotational brain injury. This latter is different. In certain circumstances (eg a helmet ‘grabbing’ on something as the person hits the ground) the brain can rotate inside the skull. Brain tissue is strong in respect of compression forces and weak in respect of shear forces – imagine banging a pack of cards down hard on the table, on edge, but absolutely perpendicular to the surface. The pack stays intact, nothing moves relative to anything else. But do this at 45 degrees and the cards all move against each other. This reflects what happens in rotational brain injury (see http://cyclehelmets.org/1182.html and http://www.phillipshelmets.com/ROTATIONAL_HEAD_INJURY.htm ). The brain rotates in the skull and the brain tissue tears. Older style helmets with cheek pieces were fine at resisting impact forces, but could grab and rotate the head as the person hit the snow. Bad. POC has just produced a helmet explicitly designed to deal with rotational brain injury – the Back Country MIPS. Early cycling helmets had no shells. These increased the risk of rotational brain injury since the soft EPS could grab on the ground as riders hit the deck. It’s no accident that all cycling helmets now have a thin shiny shell on them, this is not cosmetic, but is designed to help the helmet slide over any surfaces which come into contact with it during an accident.

If the forces are sufficient there also the problem ofbrain stem separation – happened a lot in NASCAR until Sid Watkins (god bless his soul, great man) invented HANS. That’s the collar with straps which NASCAR and F1 drivers wear. This was common cause of death in NASCAR but I have not found anything on this injury in skiing, but it shows how good research on the dynamics of head injury can save lives. The POC MIPS system (a lining which can rotate in the helmet) may be just such a research-based live saver.

Third up …does the treatment have adverse side effects? Ie do helmets themselves carry direct risks? I’ve already said that some older helmets had a shape which increased the risks of rotational brain injury. Helmets weight something (usually around 500-700grams) – that’s quite a lot to add to your head mass, particularly in small children. Neck injuries in young children wearing helmets were originally thought to have gone up, and this may be a product of two things: the weight of the helmet on the head, changing the dynamics of a fall; and the fact that some children are escaping a significant head injury (getting a headache or concussion where previously they would have sustained something far worse), meaning that neck injuries are recorded as the principle injury. But better designed studies suggest that there is no real increase (see http://www.ncbi.nlm.nih.gov/pubmed/20406762 )

Remedy to kids wearing heavy helmets? Get a high quality lightweight helmet – the Giro range is great in this respect. There is, however, a genuine side effect – helmets can suppress your ability to hear. This can be important on-piste, when the noise of a skier or boarder can mean that split second reaction and avoidance of another person. This has not been well researched, but anecdotal evidence suggests that it is a genuine issue. Remedy: buy a helmet with good venting for the ears – most good helmets – Giro, POC, Red, Sweet P etc are well-thought out here. I will ignore the helmets which have built in speakers - sounds great, bad idea IMHO, though (killjoy). Reduced sidevision? Not an issue with good helmets.

A snowHead

Fourth –we already know that there IS a casual mechanism at play – we know that impact force is attenuated using a helmet. But are there any mediating variables which increase the expected rate of injury? Yes, and many of them are complex combinations of psychological and social variables.

1 there are more people on the hill. Simple as that. And so collisions may become more frequent. You can have increased helmet use but also increased injuries. But here, there’s no causal relation between helmet wearing and increased risk of injury.

2 improvements in equipment (new gen skis in particular) are increasing speed . Again, here, there’s no causal relation between helmet wearing and increased risk of injury. Modern skis encourage novices to go fast.

3 people are jumping higher and landing harder than ever before (see Candide Thovex). If people are pushing harder in the park and doing more high speed off-piste in the trees, then expect the head injury rate to go up. And we know that in the circumstances of an impact with a tree at high speed, or impact on hardpack from a 5m jump which goes wrong, the forces involved are way beyond the capacity of a helmet to deal with the energy involved. It’s not the helmet’s fault here – peoples’ skiing behaviour has changed, with serious impact from error now being more likely. Again, here, there’s no causal relation between helmet wearing and increased risk of injury.

4 do helmets engender a sense of invulnerability and thus encourage more risky behaviour? There was a previous argument that this is the case but a well-designed study showed that there was a balance of risky behaviour in wearers and non-wearers – but an association of wearing a helmet with higher skill levels (and thus higher speeds) (see Dr Mike Langram’s excellent analysis:

Issue: does wearing a helmet makes you take more risks?
This idea is called the "risk compensation theory". Basically, the argument goes along the lines that wearing protective equipment makes the user more likely to take risks. A study of self reported behaviour found that although skiers and snowboarders who were risk takers skied faster than cautious people (53 v 45 km/h), the use of helmets was nearly equal in both groups (59.2% v 59.7%).
One study of self reported behaviour found that although skiers and snowboarders who were risk takers skied faster than cautious people (53 v 45 km/h), the use of helmets was nearly equal in both groups (59.2% v 59.7%). In addition, significantly more skilled skiers wore helmets (76.9% v 59.0%), and a similar proportion of those who did and did not wear helmets exhibited risk taking behaviour (29.8% v 30.2%). An editorial in the BMJ in 2011 by the same authors concluded that "the use of a helmet is not necessarily associated with a higher level of risk taking but primarily with a higher level of skill".
I am aware of other unpublished (and therefore arguably less reliable) data including some of our own from Scotland that does indicate an association between helmet wearing and risk taking. Anecdotally, I and my fellow patrollers have seen this happening on the slopes. Perhaps its a factor that varies from country to country and may be associated with cultural differences as much as anything else. More work is warranted on this topic and hopefully will help to clarify the issue. But the take home message has to be that wearing a helmet does not make you invincible!

But this is not like trees all over the mountain suddenly growing 6 inch steel spikes. You can’t do anything about that. By contrast, you CAN do something about behaving badly. Remedy: Wear a helmet – and be conscious that it may increase your risky behaviour – increased speed, jumping all over the place etc – don’t do it such things, stop if you are pushing too hard.

Fifth, helmets may stop some injuries but we might therefore see a rise in others – if you would have died previously, then you might sustain a nasty injury instead – the injury would be recorded rather than a death (substitution) which gives the appearance in the stats of helmets ‘causing’ an increase in certain types of injury (concussion, brain injury, neck injury etc) But it’s not a negative thing. It’s a sign that helmets are working.

Finally, a few pragmatics. Helmets keep you warm. If you like to wear a beanie, then wear a helmet instead; it will protect you more. Helmets protect you and kids against silly injuries like people in lift stations swinging skies into your head. Do I wear a helmet? Yes. I started early in the history of mountain bikes in this country – and helmets have saved my life twice. Consultants have stood at the end of my hospital bed, with the smashed helmet in their hands, and said ‘this saved your life’ – in one case, after 7 hours of amnesia due to rotational brain injury. Do my kids wear helmets? Yes, and they worked in a couple of nasty incidents.

OK – so this post has tried to be evidence-based. There IS an underlying mechanism – hitting your head hard is a bad thing. Helmets reduce the effect of the forces in an impact. Is helmet design a factor in moderating the deleterious effects of wearing a helmet? Yes. But good helmets are well-designed now. Are there external factors which have accompanied the rise of helmet-wearing which are misinterpreted as having a relation with helmet wearing . Yes…and they are totally misleading. Are there mediating variables which increase the risks of injury to helmet wearers? Yes, but SLOW DOWN and don’t be so silly.

O yeah, I forgot. If Jon Coster wears a helmet then it’s simply a good idea. Period.

This is a clear statement of the balance of evidence – and note the emphasis on children:

The American Medical Association have produced arguably a more objective assessment of helmets for snow sports - see "Helmets for Recreational Skiing and Other Winter Sports in Children and Adolescents". Personally, I wear a helmet myself and would always recommend (but not force) others do so too - in my opinion there is no good reason not to wear a helmet other than personal choice. However, I also agree with the AMA's conclusion that there is insufficient evidence to support mandatory wearing of helmets on the slopes. Yes, head injuries do occur and yes, helmets will help in the vast majority of head injury situations. The argument is stronger for children who are at higher generic risk of injury on the slopes. In my opinion though, the fact remains that the risk of such an injury remains too small to insist that everyone on the slopes must wear a helmet. It should remain your personal choice at the end of the day. Nevertheless, parents should think long and hard before sending their kids out on the slopes without a lid on......

from http://www.ski-injury.com/prevention/helmet

Finally – watch these

http://youtube.com/v/VZnALI7Lz1A

http://youtube.com/v/G_BQf6XJHPw

So….is sticking a fork in your eye a good idea….no. Get real.

Well, the person's real but it's just a made up name, see?

Any chance that you could include the word 'helmet' in the thread title, so that the unwitting/unwilling don't need to get drawn in? Thanks. Obviously a labour of love, though. Chapeau. Or should I say casque? wink

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that was kind of the point - another helmet thread and people would have started screaming...I tried to sneak in under the wire...

Anyway, snowHeads is much more fun if you do.

Pedantica, ...not really a labour of love...since I'm a researcher I can crank this stuff out very quickly .... I just want to help people get to a balanced position, based on the evidence. there's been a lot of misleading stuff on here recently and there's a lot at stake when kids are concerned - it's not like choosing the colour of a jacket...I'll change the title if others get concerned too...meanwhile this thread might die cos it's a bit long...the vid on danny is worth watching, though

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valais2,

Then you can post your own questions or snow reports...

Valais2. Thank you for that. A fantastic post and fascinating reading. Evidence is the important thing.

I now wear a helmet. Why? Because I now wear goggles, rather than sunglasses. I have very pale blue eyes and need headwear with a brim to shield direct sunlight. With sunglasses, a peaked cap/hat did the job. With goggles, the only peaked headwear you can use is a helmet. Mine's a Giro.

The difference I have also found is that I now don't worry about getting smacked on the back of the head when someone pulls down the safety bar on the chairlift two milliseconds after everyone sits down.

After all it is free

Waddabout branches?

Best helmet post I've seen.
I was surprised, though, that high skill and helmet use were linked. I would have expected that in North America but not in Europe. For example it is rare for guides to wear one. Certainly younger people use them more than older skiers, because the former grew up with them.
I know I should wear a helmet but the only time I hired one (in Whistler because Extremely Canadian asked me to) I abandoned it after a couple of hours. Perhaps the fit was poor but I also normally wear nothing on my head much of the time. My group of skiers are now being converted to wearing them and last year I was in a minority.

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Good grief. How tedious. I am glad that the coming season will be my last. Thereafter there will be no more dire helmet threads to be dragged into.

snow reports

You know it makes sense.

narc, agreed re speed - but note this is a quote from mike langram - agree entirely with the hardpack line - note also JP Auclair (general maniac) wears a helmet when pelting in powder (see ALL I CAN on vimeo) and also Chad Sayers in the trees at La Grave (see A skier's journey la grave on vimeo).

Otherwise you'll just go on seeing the one name:

achilles, ...yes...research is tedious and reading it too ... but real evidence can cut through acres of nonsense....

A snowHead

narc, ...and your seat belt point very well made. Automotive designers have long since abandoned attempts to change driver behaviour (huge number of studies in the 60s and 70s) and have focussed on creating strong and safe cars. That's what has driven deaths down amongst car drivers. One ergonomist I know said 'best way of changing driver behaviour? remove seat belts, and put in ten inch stainless steel spikes sticking out the middle of the steering wheel...' (!)

A snowHead

Well, the person's real but it's just a made up name, see?

surprised that no-one has commented on danny's vid - no views?

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valais2, i've been following his story. Not seen the video through yet though. I've worn since 2000; my very first trip ended in one of our party being hospitalised with a concussion after an accident in the park that left the other guy involved being air-lifted to LA for surgery , and thats about as close to brain injury as I want to get any time soon thanks. Having been up there at the sharp end of an incident does focus you...

Anyway, snowHeads is much more fun if you do.

achilles,

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Pedantica, apologies - was trying to be humorous rather than annoying. Unfortunately the edit button has disappeared from the original post, so I can't change the title. If he moderators are watching - can you shift the title to 'Why sticking a fork in your eye is a bad idea - the hard evidence is that helmets help...up to a point'. The title relates to the first paragraphs - there is a genuine mechanism going on - ie hitting your head hard against solid objects will result in injury. If the titling has been counterproductive and annoying then I apologise.

The purpose of the post was to inject some solid evidence into the helmet comments on SH, I am genuinely concerned that some of the irrational posts on helmets might deter less experienced skiers from using helmets with their children and adolescents. Which the evidence suggests would be a very bad thing. Obviously people can make up their own minds, but it is surely best that they do so in the light of the best evidence available. Otherwise it all becomes like R4s 'Bigipedia' - the wisdom of crowds - with the brilliant quote: 'question: what is the colour of the rainbow - (then many voices citing thousands of colours) - concensus: brown'.

Then you can post your own questions or snow reports...

After all it is free

valais2, no problem. I'm not angry about helmet threads, if they're what people want to contribute to and to read, and your contribution to the debate is indeed splendid. It's just that - given the fact life's too short to read every thread on snowHeads! - I pick and choose by thread title, so misleading ones annoy me. It's just me. Take no notice. wink

PS I wear a helmet when skiing. wink

I watched the video on Danny's head injury, very interesting and I'm sure he'll be eternally grateful to the fantastic team who saved his life. I'm amazed he made a full recovery.

I've worn a helmet for about 5 years now, and find it warmer and more comfortable to wear than a woolly hat, apart from the obvious safety benefits.

It's noticeable that the majority of people now wear helmets. I ski with a group of 11-ish in early February every year, and more of us have started wearing helmets each year until finally the entire group now wears them!

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I have seen the effects of traumatic brain injury, via my brother. He wasn't skiing, but he was travelling under 30mph and struck his head, chin on, against a solid object. He wasn't skiing, but I can easily imagine plenty of people I know a) travelling at over 30 mph while skiing and b) being unlucky enough to sustain impact with a tree / lift pylon / element of park furniture etc.

There are no guarantees that wearing a helmet will prevent brain trauma, but the result of this type of injury can be dramatically life-changing or indeed life-ending so, for a relatively small outlay and no particular discomfort, you may as well wear a lid. I do.

Now, I'm off to get this fork out of my eye .....

snowball, ...many thanks - so it is possible to edit a title? This morning I've looked everywhere for the 'edit' function but just can't find it anywhere - the site FAQs mention a button but I'll be jiggered if I can find it. Can you point me to it?

You know it makes sense.

pam w, indeed relate to what you are saying - for inexperienced cyclists and skiers. looking over their shoulder is a challenging thing to do and throws them off line/on outside edge. It's actually something I teach to beginners to help balance and control.

I mentioned that this area of sound suppression is anecdotal rather than well-evidenced. Some friends (very competent skiers) have mentioned it as an effect which they have noticed, but there's no string evidence on this. I have seen it cited here as a single reason not to wear a helmet. I wanted to show that it is probably spurious since the most modern and well-designed helmets do not dramatically suppress sound.

Wearing helmets with built-in sound seems to create an artificial 'bubble' around the skier/boarder, and I have seen some people behaving like inattentive gits. But again, the helmet may not be the cause. It may be the other way around - ie inattentive gits are more likely to wear helmets with sound systems. Again, a properly designed study would be easy to do.

Otherwise you'll just go on seeing the one name:

zammo, ...sorry that you have experienced this directly. My own injury (from mountain biking) messed up my spelling for about a year but then I lost any obvious effects. But it was a salutary experience. My own kids (7 and 9) now wear helmets when scootering, climbing, kayaking, cycling and skiing. Some say 'cotton wool' - I say sensible precaution. When wearing a climbing helmet at climbing walls (and been laughed at for so doing), I have had carabiners dropped on my head from 6m up (which have just gone 'donk' rather than taken a chunk out of my skull), and when climbing in the Valais, have had quite large lumps of Alp come off the face and bounce off my helmet. I'm very sorry that your family have experienced the wrong end of accident.

A snowHead

achilles, Don't leave us!! Sad

A snowHead

valais2, Sterling work - perhaps it could be titled the season helmet thread so that grumps like achilles can avaoid it. The Danny Toumarkine video is well worth anyone's time - just a story of an everday screw up and it's effect as well as great publicity for High 5s athlete rehab centre/

Well, the person's real but it's just a made up name, see?

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Anyway, snowHeads is much more fun if you do.

pam w,

You'll need to Register first of course.

Pedantica, thanks all done...ran out of characters so just put a small rider on....

Then you can post your own questions or snow reports...

valais2, I didn't realise you didn't know how to edit at all - sorry. I often write a post and then have second thoughts a few seconds later (or simply realise i spelt something wrong) and go back and change it, or add something.

After all it is free

valais2, very interesting, thanks.

kat.ryb, ...well this got over 1500 views...but I figured that some of the '....helmets are the work of the devil and make your appendix explode....' might come out with a few contra- arguments. Any takers?

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oh lord, not another helmet thread, (I haven't read any of it). They'll be on at me about my drinking next.

Help!!

Why sticking a fork in your eye is a bad idea - or 'helmets work...and don't be silly'

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