The protective effects of helmets in skiers and snowboarders
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d857 (Published 10 February 2011) Cite this as: BMJ 2011;342:d857
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Following the success of SUVA's campaign in Switzerland to encourage
the wearing of helmets for skiing and boarding, this winter the SUVA
campaign is to encourage skiers and boarders to reduce their speed (see
http://www.suva.ch/fr/startseite-suva.htm). Bearing in mind that
adolescents have a different response to risks than adults, one wonders if
encouraging the use of helmets might also encourage young people to ski
and ride faster and with less control; perhaps resulting in more rather
than fewer accidents. Of the 70,000 accidents each year on Swiss ski
slopes, it might be that human behaviour is a bigger consideration in the
cause and avoidance of accidents, rather than the use or absence of
personal protective equipment.
Competing interests: No competing interests
Having recently returned from a ski trip to my favourite resort in
Austria I was struck by the huge increase in helmet wearing on the slopes.
Prior to the trip I had some concerns about how wearing a helmet might
interfere with my enjoyment but was delighted to find that my fears were
unfounded.
I thought back to over ten years ago when I first started wearing a
cycle helmet and, again, once I wore it the first time it felt like I had
never been without. So, those of you who are afraid to commit, take the
step, you won't regret it!
If still unconvinced, try the following:
1. Get your partner to try on a helmet.
2. Take a hammer and, with moderate intensity, strike your partner on
the head.
3. Now ask your partner to take off the helmet.
4. (Offer to) strike your partner's head with the same moderate
intensity.
5. Observe response.
Competing interests: I enjoy skiing & cycling & would like to continue to do so!
I don't know why this issue is even being debated: it is obvious that
wearing a helmet when skiing/snowboarding will protect your head if you
have an accident! Motorcyclists have been legally obliged for years to
wear a helmet because they save brains and lives. The comments about off-
piste are silly: this is usually powder (in other words soft snow, absorbs
impacts) and less busy = nobody to crash into, nothing in the way except
the odd tree if you're not looking or can't steer. If you fall over and
smash your head on well-used icy pistes, or collide with someone you can
easily acquire a brain injury (ABI) - even if only a mild one, which is
known in medical circles as 'concussion'. People are also known to fall
off ski-lifts. I believe all children should wear a helmet, this is
already happening, especially amongst those who know and understand the
mountains. Adults can choose whether to gamble with their brains; those
who ski or snowboard drunk are at greater risk (also from alcohol-related
brain damage!). Unless people are educated about helmets they cannot weigh
up their view of the risks and benefits to make any choice. It has ceased
to be 'uncool' to wear a helmet and they are not hot to wear, they keep
you snug. Because I live with a brain injury and know how awful it is I
want others to be encouraged to try to protect themselves from the risk of
acquiring this injury and disability: you can cut your risk by wearing a
helmet and you can't fix a broken brain.
Competing interests: I have an acquired brain injury (not from skiing/snowboarding).
Ruedl et al. make a case for wearing helmets whenever skiing or
snowboarding. Commentators will debate the quality of evidence, which
seems far from clear to me. But their editorial also seems to want to
oversimplify a complex debate.
It is notable that guides who ski off-piste in Europe (the only area
I can comment on with some authority) almost never wear helmets, yet many
of them do wear them while skiing on the piste. Many of them have told me
the same thing: when off-piste the main dangers are ones that they can
avoid if their senses are alert. Recognising subtle changes in snow noises
under their skis, the early rumble of potential avalanches and a change in
wind are crucial to staying safe. All of these can be dulled by helmets.
Yet when on the piste there is often much less any of us can do to
avoid being crashed into by out of control skiiers on crowded slopes. The
risks are far less recognisable and as such the extra protections from a
helmet seems less of a sacrifice for the associated slight dulling of the
senses.
More study should be made of the area and it should allow for the
different types of skiing that exist (there are, of course, many more than
the above two categories). In the meantime the public should be able to
make their own decisions based on common sense.
I am lucky enough to be going skiing tomorrow and am packing both my
helmet and my woolly hat.
Competing interests: No competing interests
A major disadvantage of ski helmet use for some people is the
excessive heat build up inside the helmet. Also the extra weight is
unwelcome in ski activities which involve going uphill without mechanical
assistance, e.g. ski mountaineering.
Incidentally, regarding the discussion on the impairment of hearing:
From working in an A+E department near to a ski resort I can report that
the sound of a skier breaking is a loud snap rather than a hiss. On the
other hand a skier or snowboarder braking makes a scraping sound,
especially if the surface is hard or icy, which may be in a similar
frequency range to a hiss.
More seriously I would not want to see the BMA taking a stance on
ski helmets similar to their position on cycle helmets. Rather, the pros
and cons should be openly discussed and people should make their own
choice.
Competing interests: I am a Member of the Cycle Touring Club which is against compulsory helmet use.I am also a member of the BMA which takes the opposite view.
Ruedl and colleagues note the benefits of wearing a helmet when
participating in winter sports, specifically in reducing the risk of
sustaining a serious head injury.1
During a recent junior doctor ski trip, 6 of the 9 skiers wore
helmets. This number has increased substantially from previous trips of
the same group, and this increase mirrors trends seen in helmet uptake
elsewhere. In our group at least, this was largely due to a combination of
high-profile accidents reported in the press with old-fashioned peer
pressure. New helmet design now offers protection with minimal reduction
in visual awareness, and crucially (especially for younger
skiers/snowboarders) ever-improving fashion appeal mean it is no longer
seen as an inconvenience to wear one.
Non-medical friends and family often look to us for advice on matters
of health protection. By conveying the benefits of wearing a helmet,
hopefully the number of serious and fatal accidents will be minimised.
1 - Ruedl G, Koop M, Burtscher M. Helmets for skiers and
snowboarders. BMJ 2011;342:d1035
Competing interests: No competing interests
In 2002 four decades of accumulated evidence about the protective
effect of hormone replacement therapy against cardiovascular disease was
shattered by a single well designed RCT (1). The evidence amounted to
clinical experience, laboratory research, but mostly case controlled
observational studies. These studies convinced so many doctors that a
protective effect of about 50% was widely assumed (2). I remember going
to a debate at my medical school about whether all women over 50 should be
on HRT. It turned out systematic bias pervaded all the case controlled
studies. One authors 'post mortem' on the debacle noted that when
looking at observational studies one should not disregard contradictory
evidence or be seduced by a plausible mechanism but maintain skepticism
and suspend belief (2). Dr Ruedl and colleagues should heed this advice.
The accumulated evidence about ski helmets is insufficient to allow
one to state the benefits are clear, that skiers should be advised to wear
them or to imply public health doctors should be leading the charge.
Anecdote, a meta analysis relying almost entirely on case controlled
studies and enthusiastic advocacy fall way short of evidence to guide
public health advice. On the Centre for Evidence Based Medicines scale
this would score a 3 (3). The research to date is useful for raising
questions, but not answering them. It is poor science to accept the case
is made. With HRT, the main bias was probably that early adopters were
health conscious and affluent so skewed the results. With ski helmets a
similar type of bias may exist, we just don't know yet. It's far better
to wait and see if helmet adoption changes long term head injury trends
before we declare them effective.
If better evidence does emerge there is another matter that must be
settled before helmets can be advised. One must understand the risk of
head injury when skiing compared with other common sports and activities.
What is the risk compared with say, tennis, golf, cricket, basketball or
for the more leisurely minded gardening or walking home from the apres ski
venue with a skinful? If these activities turn out similarly productive
of head injuries why stop at skiers?
1. Krieger et al, Hormone replacement therapy, cancer, controversies
and women's health: historical , epidemiological, biological, clinical and
advocacy perspectives. J Epidimiol Community Health 2005;59.740-748
2. Petitti D. Hormone replacement therapy and coronary heart disease:
four lessonsHormone replacement therapy and coronary heart disease: four
lessons . Int Journal of Epidemiology, 2004;33:461-463.
Competing interests: I enjoy nordic skiing and hope plastic battering rams do not replace woolly hats in that sort of skiing.
Eye protection for skiers and snowboarders
Dear Editor,
We read with interest the article by Reudl, Kopp and Burtsher
extolling the benefits of helmets for skiers and snowboarders[1]. While we
agree entirely with the articles stance on helmets we were concerned by
the negative stance taken towards ski goggles. While some research
demonstrates that ski goggles can increase reaction time and that from the
point of view of ocular trauma skiing is a relatively low risk sport[2],
the use of suitable eye wear is still of great importance. Due to the
combination of increased UV light at high altitude and reflection from
snow a skier or snowboarder may be exposed to double the amount of
damaging ultraviolet (UV) light as at sea level[3]. Acute UV light
exposure can damage the conjunctiva and cornea leading to snow-blindness 4
-10 hours after exposure while chronic exposure can lead to pterygium
formation and may increase the risk of cataract[3]. Basal cell carcinoma
accounts for 90% of all eyelid tumours[4]. The importance of sun
protection in skiing and snowboarding has been highlighted by public
education programs at resorts and ski schools stressing the importance of
wearing goggles or sunglasses[5].
1. Ruedl, G., M. Kopp, and M. Burtscher, The protective effects of
helmets in skiers and snowboarders. Bmj. 342: p. d857.
2. Protective eyewear for young athletes. Ophthalmology, 2004.
111(3): p. 600-3.
3. Ellerton, J.A., et al., Eye problems in mountain and remote areas:
prevention and onsite treatment--official recommendations of the
International Commission for Mountain Emergency Medicine ICAR MEDCOM.
Wilderness Environ Med, 2009. 20(2): p. 169-75.
4. Young, S. and J. Sands, Sun and the eye: prevention and detection
of light-induced disease. Clin Dermatol, 1998. 16(4): p. 477-85.
5. Walkosz, B., et al., Randomized trial on sun safety education at
ski and snowboard schools in western North America. Pediatr Dermatol,
2007. 24(3): p. 222-9.
Competing interests: No competing interests