Do helmets prevent injury, or do they enable us to act more recklessly?
Head injuries and head protection are dominating the sports landscape with the recent spate of concussions in the National Hockey League. But even when we're biking on our own or playing any sort of contact sport, what do helmets do to protect us? Science reporter Anne McIlroy, concussion expert Dr. Charles Tator and risk behaviour expert Dr. Gerald Wilde took your questions and comments on the much-debated topic.
Anne McIlroy is the science reporter at the Globe and Mail. Before joining the Globe in 1996, she covered science and the environment for Southam News and the Ottawa Citizen, where she began her career in 1985.
Dr. Charles Tator is a concussion and brain injury expert at Toronto Western Hospital advocating for stronger regulations around head shots in hockey.
Dr. Gerald J.S. Wilde is Professor Emeritus of Psychology at Queen's University in Kingston and the author of Target Risk 2. His teaching and research interests include ergonomic psychology, skill acquisition, mass media messages and behaviour change, human behaviour in transportation, and the psychology of risk taking.
Below is the edited text from the live discussion
Cliff Lee - The Globe and Mail: Hi everyone - thanks for joining us today. We'll be getting started in a few minutes with science reporter Anne McIlroy, concussion expert Dr. Charles Tator and risk behaviour expert Dr. Gerald Wilde. Please feel free to leave your questions and comments and we will try to get through all of them!
Sam: What are the differences between a good helmet and a bad helmet?
Anne McIlroy: I'd like to ask Dr. Tator if I should warn my daughter that a helmet doesn't mean she doesn't have to think about safety on the rink or on her bike. Also, as I understand it in hockey, helmets protect against catastrophic injuries, but not concussiosn. Dr. Tator, can you elaborate on that?
Gerry Wilde: Comment on Sam's comment. How do you define "good"? Better protection, less of a nuisance to wear, what?
Charles Tator: Safety is multifactorial which means that the helmet is only one aspect of being safe on a bicycle. A good helmet fits well without sliding from side to side or back and forth on the head, and has a strap that holds the helmet firmly on the head. Only one finger breadth between chin and strap.
Charles Tator: A bicycle helmet should not be worn for hockey or skating, and so each activity requires a specific helmet. Although some helmets such as hockey helmets are good for more than one activity. See our website for more information on which helmet for which sport. www.thinkfirst.ca
Charles Tator: A good helmet lasts only about three seasons, and then should be discarded. The padding can wear out and provide less protection.
Anne McIlroy: Are bike helmets o.k if they have been dropped on the ground a few times?
Charles Tator: After a drop on the ground a bike helmet should be inspected for cracks, and damage to the padding, and probably does not have to be discarded. However, after a drop of a helmet on cement, throw the helmet away.
Christopher Miller: I understand that there is increased risk in certain rough and high contact sports and this justifies using helmets (but why in Canadian football and not in rugby or soccer, one wonders?). However, I have yet to see a reasoned argument for why simple low velocity transportation like cycling should require a helmet. People slip and fall on sidewalks, staircases, ladders and hit their heads no less than people on bikes. Resulting head injuries in both cases span the gamut from trauma to simple scrapes and cuts, and these are normally not distinguished in the statistics I have seen. If you are hit by a car while walking across the road, the physics of the result are not appreciably different, and if you are hit by a car at high speed, it is well established that wearable bike helmets are not designed to attenuate serious trauma at that impact speed. It is also often pointed out that head trauma makes up a far from insignificant proportion of serious injuries and deaths in automobile crashes. Yet for bikes, we have the example of the safest cycling nation in the world, the Netherlands, where anyone wearing a cycling helmet is as likely as not a visitor from an English-speaking country. My question in relation to all this is whether there are *any* studies that actually account for possible safety effects of helmet use versus non-use across different everyday activities like cycle transportation, crossing streets (at intersections or elsewhere) etc, and not just cycling?
Charles Tator: The Netherlands is not Canada. There, motorists are bike-aware, and in Canada, they are not.
Anne McIlroy: Can you think of any examples, Dr. Tator, of where people should not wear a helmet because doing so makes them less safe?
Gerry Wilde: Are bike helmets OK if they have not been dropped on the ground a few times? What doe we mean by "OK?" Years ago I looked into the research evidence on bicyicle helmet wearing and effect on safety. Few good quality data seem to exist. This in conctrast with motorcycle helmets. Mandating the use of these does not seem to have reduced the motorcycle fatality rate per 100, 000 registered motorcycle licences in the US.
Charles Tator: A car striking a biker at 30kph is not low velocity. You only get one brain!
Marc: I am under the impression that bike helmets provide less protection than we think. In my estimation (please correct me if I am wrong) the helmet only serves to lessen the impact of the head itself but does nothing to protect the onslaught of havoc that will be unleashed on the brain itself if the head hits a hard surface at a great speed. Do helmets really do their jobs?
Sidney: What exactly do helmets protect our heads from?
Charles Tator: Helmets do a wonderful job of preventing MOST brain injuries, but not all. At 150 kph, the current bike helmets will not be completely protective. Motorcycle helmets will do a better job at this speed. Also, no helmet prevents all concussions.
Anne McIlroy: I'm wondering if perhaps people need to consider they may take more risks when they are wearing one?
Charles Tator: Helmets protect the head from skull fractures, brain lacerations, and contusions and blood clots in the brain or around the brain.
Chris: The data I saw a couple years stated that wearing a helmet during a bike crash will reduce the risk of serious injury by up to 80%.(Sorry I can't remember where I saw that data) So if that is even remotely true just wear the helmut. Think of your head as an egg with a yoke inside. If there is a fast decelration the yolk will smash against the inside of the shell. Your helmut absorbs some of the shock which as a result will slow down the acceleration of the "yolk." I always wear my helmet and the risks I take are the same.
Charles Tator: In my view there is little evidence to prove that helmets make people take more risks. This question has been in the minds of some people, and I do not feel that the evidence is there. We call this the risk compensation theory.
Christopher Miller: My question from a different angle: why would this not justify insisting on pedestrian helmets as well for those crossing the street? And how your answer w.r.t the Netherlands applies to segregated cycling infrastructure like the bike paths we have both there and here, where cars are not a factor? And again, the high risk of head trauma to car occupants in crashes?
Gerry Wilde: Anne, you hit the nail on the head! (pun intended). If the "behavioural factor" is not considered, ti is impossible to decide whether soms se-lf-proctive equipment is helpful to safety or not. Consider ABS, airbags, seatbelts, etc. Yes they could be helpful if people did not alter their driver behaviour when feeling better protected, but they do, as worldwide research (with proper controls) demonstrates.
Charles Tator: We always get questions from helmet haters and bicycle freedom folk about why motorists and pedestrians do not have to wear helmets. The answer lies in the attempt to advocate risk reduction for those most at risk.
Guest: I've been in the cycle industry for a number of years, and I've been a cyclist even longer. Helmets are worth their weight in gold the first time our skull bounces off the curb. I've had accidents in both cases and my recovery time personally from helmeted crashes has always been less. Thats not to say that the crash wasn't damaging because I was wearing a helmet, but the effects were far less serious.
Jeremy: I've only ever had a few run ins with cars whilst on my bike. The odds of a head injury (which I have sustained) while riding on paths, or car free zones is as high as when cars are involved. The car is usually merely a cause of the accident, and usually the results are the same if your head hits a bike path or a sidewalk.
Jeff: While there may be some debate about risk compensation, a 2006 study by Ian Walker, from the UK, found motorists passed closer to cyclists who were wearing bike helmets compared to cyclists who did not have a helmet. So... this is some evidence that helmets increase the risk of a collision, and therefore an injury. I still wear a bike helmet, but it may be causing me more risk than if I was bare-headed.
Charles Tator: Dear Jeremy, you have been lucky so far. Please don't continue to press your luck. Someday you will thank me. Cars and trucks deliver more punch than the ground ususally.
Cliff Lee - The Globe and Mail: Dr. Tator, I must ask - is there really no strong evidence, from what you've seen, to support risk compensation theory?
Anne McIlroy: I find it worrying when I see cyclists with their helmets half hanging off their head. They may think they are protected, and perhaps are more aggressive as a result, but they aren't.
Gerry Wilde: Yes, Jeff, this brings up the political dimension. I lived more that 30 years in the Netherlands (much of the time on my bike), and I know the political resistance of bicyclists against mandatory helmet use. They feel that it moves the responsibility for accident avoidance from motorists to biclyclists, and that they don' want.
Guest: My children and other youth that I have listened to on this subject inform me that they want to wear only one helmet for all activities and that the helmet must have a cool appearance. Is their request possible and would it ensure safety?
Charles Tator: I have read many unconvincing papers purporting to prove the risk compensation theory. I remain unconvinced. I have read more papers debunking the risk compensation theory, and I have found them much more convincing.
Jeremy: I agree Dr T. However I do believe that cars and trucks are merely one factor in what are never simple or happy situations. When there are collisions I think that its important to consider behaviour as much as safety gear. My helmet stays rooted to my head, but if I swerve in front of a sedan with a false sense of entitlement to a lane then I'm as much at fault as the car that runs me down.
Jeremy: @guest. Check out Bern helmets. Many of them are certified for several activities and they also have a nice aesthetic.
Guest: Military studies have clearly shown that helmets decrease an individual's ability to perceive their environment, most especially with regards to hearing- that's why special forces usually don't wear helmets in many situations.
Charles Tator: Unfortunately, there is no single helmet that will be appropriate for all sports. We are encouraging the engineers and helmet makers to try and make helmets more multi-purpose, and there is some headway (pardon the pun). Yes, cool is highly desirable, too.
Jeff: Unfortunately, most helmets are not designed to protect against concussions. I've done accelerometer drop testing of bike helmets, and have found that they are only effective at reducing the HIC levels to that 'typically' below the threshold for concussion at impact speeds under about 20 km/h. So, they are effective if you fall off your bike, but not if you are struck by a motorist.
Neil FitzGerald: Can you comment on any observed differences in the rate and/or severity of head injuries in rugby versus football. It seems the helmets in football do provide a new means of attacking/tackling that rugby players do not tend to engage in. Thoughts?
Guest: I think comparing riding a bike to the special forces is like comparing apples to oranges. The needs of soldiers compared to cyclists cannot reasonably be offered as grounds for eliminating helmet laws.
Charles Tator: It is true that helmets reduce the ability to hear sounds, especially in the range of the human voice. This is a definite shortcoming with helmets such as ski helmets when you might not hear someone overtaking you from behind. However, skiers should be aware of this shortcoming, and does not count very much in terms of the helmet's value in preventing death (Natasha Richardson should have worn a helmet).
Gerry Wilde: Comment on Neil FitzGerald: Could I extend that question to comparsions between soccer and other contact (i.e. colision, concusion) sports?
Charles Tator: Injury prevention in sports such as football and hockey require a large range of injury prevention measures including respect, education, and rules enforcement, and no one ever said that helmets can do the job alone.
Jeff: Sorry, to continue, also, hockey and football helmets are not designed to protect against concussions. Dr. Tator knows this, as does Hockey Canada. Fortunately, there is a helmet technology in development that dissipates impact energy when the impact is severe enough. This might be something that will give parents more 'peace of mind' since this actually attempts to prevent concussions, and not just stop skull fractures. You have to a a sacrificial component to the helmet, just like airbags in cars are sacrificial.
Charles Tator: Rugby has its own specific measures for injury prevention. Rules against the collapse of the scrum have been very important for preventing broken necks and other injuries.
Phil: I used to suffer from seizures which started after I bumped my head (understatement) snowboarding. I can't say for sure that the bump on the head caused the seizures but I can definitely (without a doubt) say that wearing a helmet protects you. I am a volunteer on a local ski patrol and I have seen countless head injuries over the last few years. The good news is that the kids seem to be getting it and I see more and more helmets every year. You can still take a huge whack wearing a helmet but you will always be better off. Get something that protects the back of your head!!!
Anne McIlroy: Are children and adolescents more vulnerable to brain injuries like concussions?
Charles Tator: We should continue supporting more research into the design of better helmets in terms of more protection against concussion and other brain injuries, use in more than one sport, and more "cool".
Guest: I think Dr Tator has it on the nose: RESPECT! I've watched my childrens sports become so much more violent in the last few years that I now shudder every time I see them step on the ice, the field and even our backyard. I think teaching respect is more important than anything in this debate.
Gerry Wilde: Comment on Dr. Tator. Right. What you are saying that the behvioural factor (including behavioural compensation, risk compensation, risk homeostasis) should be taken into account when designing and evaluating the actual impact (pun intended) of safety measures.
Charles Tator: Dear Anne, Yes, the young brain is more vulnerable to injury, and takes longer to recover. That is why we have to be good role models for our kids. Unhelmeted adults who ride bikes with their helmeted kids should ask themselves why they take these risks for themselves and their kids.
injuryfreekarma: Yup, always wear CSA approved helmet when cycling. It feels so good, I forget I'm even wearing it :D
Christopher Miller: Sorry, but I take exception to your stereotype of "helmet haters and bicycle freedom folks". This is a rhetorical trick to avoid the question. What evidence is there that cyclists are more at risk or that car occupants and pedestrians in traffic are less at risk? I understand the point for rough sports with high risk of concussion. I don't understand the specific emphasis on helmets for cyclists alone in non-sport contexts, and am not aware of any studies that compare the risks or statistics for collisions or falls while cycling versus walking versus sitting in a high speed moving vehicle. Do any such studies exist? And thank you for the Natasha Richardson example: I could not recall her name. She fell from a stationary position, not while skiing downhill. Would the same argument not apply to anyone walking on an icy sidewalk, or skating for recreation? I have often slipped and fallen on the sidewalk; I imagine it is pure luck that I have not fallen in such a way that I hit my head with results like poor Ms Richardson.
Gerry Wilde: Comment on Dr. Tator. Again a political issue (remember the election issues in Ontario some time ago?) Older people generally did not like the notion of compulsory helmet wearing. Kids have less electoral influence.
Charles Tator: Enhancing respect is the way to deal with violence and aggression in sports. We must get a culture change. Parents who yell "kill him, get him" at hockey games should be asked to wear helmets with the cage at the back of their heads.
Jeff: While increasing 'respect' for players will reduce the violence in childrens (and pro) hockey, the president of the Ontario Women's Hockey League stated that there was a problem with concussions in her league, even though there is no checking, nor fighting. Respect is important, but accidents will always happen, so improvements in helmet technology are at least as important as changing the culture of hockey.
Neil FitzGerald: 100% Agree on the comment regarding rules, education and respect. To that end, do you think the existing culture(s) of US football and hockey are leading contributors to the problem? Some research from Purdue quoted on PBS recently suggests that a single regular season of high school football is having measurable negative cognitive effects on the players - and this applies to players who have not been concussed at all during the year - just the regular hitting in practice and games. How can we best change the culture of these established sports to protect our children?
injuryfreekarma: Helmets help mitigate risks that are inherent in many high-risk activities. Always check inside the helmet for safety sticker.
Chucky: My wife and I are avid cyclist/triathlete. Last summer she was hit from behind going 10km. The helmet saved her life according to the Doctor. She is still suffering but alive. If helmets save only 1 life it's worth it.
Charles Tator: Dear Neil, your question is very important, and I do not have all the answers. However, I would certainly strongly advocate a no "hits to the head" rule for hockey. In football, hits to the head can be reduced drastically by rule changes with respect to players in many positions known to cause head contact. Many years ago, football introduced specific rules against spearing and clotheslining which reduced broken necks in football, and I have confidence that they can do the same with concussions.
Jeff: TO Neil F. I think that the research data you are quoting probably involves a lack of diagnosis of 'very' mild concussions. The players are probably getting concussions, but without losing consciousness. This happens, as it has happened to me. For these cases, there are two types of helmet technologies that will hopefully improve health. The energy-dissipating liners I've described above, as well as the new 'concussion-level' senors to indicate that a potentially injurious impact has occurred (although this is also a feature of the energy-dissipating helmet system). We will hopefully find that undiagnosed concussions will be severely limited in the future.
Adam: My kids (4 & 6yrs old) are learning how to ski, however, I learned from many of the ski shops that sell helmets that there is no current standard (i.e. CSA rated) that are applicable to ski helmets in Canada. is that true? If true, what advice can you give. I ensure that they use helmet for sports (skating/skiing/biking/etc...)
Charles Tator: CSA has a skiing-boarding standard for snow helmets. However, to date, it has not been enforced and so when you buy a helmet for these sports you will have to rely on standards developed elsewhere, including the USA and Europe. In my view, the Canadian standard is better because it is more protective. We should be active in promoting its use with industry and governments.
injuryfreekarma: Definitely agree with Dr. Tator...no hits to the head policy especially for minor hockey. Bringing the fun back to hockey.
Ben: I was hit by a call last summer while riding my bike. I think helemets should be required by law for everyone like they are in Nova Scotia.
Paul: When I ride without a helmet I have an overwhelming sense of vulnerability and ride slowly and stay out of traffic but when I wear my helmet I tend to ride faster and ride boldly in traffic, asserting my rights on the road, because I feel much safer with my head covered. I've heard similar anectodal evidence and wondering if there are studies supporting that behavior or if I'm a freak who can't control my subconscious response to the feeling of safety a helmet gives.
Charles Tator: I agree that all provinces should copy the excellent and comprehensive street activity helmet laws of Nova Scotia, where the laws cover all ages, and all wheeled and manually operated street activities such as bicycling, skateboarding, in-line skating , etc.
Gerry Wilde: Comment on "culture." In industrial settings the accident rate per capita (another pun) can be reduced significantly by the introduction of incentives for accident-free operation, as is shown in scores of studies). From incentives to culture, il n'a qu'un pas. What is ecconomically advantageous becomes the proper thing to do.
Charles Tator: Sorry, I have to go to look after people who were not wearing helmets.
Cliff Lee - The Globe and Mail: Yes, it does looks like our hours is just about up here. Thanks again for your time, today, Dr. Tator, Dr. Wilde and Ms. McIlroy.
Gerry Wilde: F0r people who like to make up theier own minds on risk compensation (homeostasis), here is website: psyc.queensu/target
Anne McIlroy: Thanks everyone
Neil FitzGerald: Gerry - are you suggesting professional and/or minor league teams offer a monetary incentive for the proper tackling behaviour on the field? Interesting - I wonder how that would be realized?
Cliff Lee - The Globe and Mail: Neil, sorry, we're out of time, but please feel free to check out Dr. Wilde's site, or seek him out for a one-on-one answer.
Jeff: Unfortunately, the CSA (and ASTM in the USA) standards for helmets are too lax. A suggested threshold for concussions is 90 g to 100 g. So what 'g level' do the CSA and ASTM limit hockey helmets when dropped from a height of 1 m (less than the height of a 5 year-old on skates? 275 g!!! The standards are only a first step, and not nearly stringent enough. This is partly why Hockey Canada acknowledges that current hockey helmets don't prevent concussions.
Cliff Lee - The Globe and Mail: And thanks again everyone for joining us today!