THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 3 - MARCH 2021
Celebrity ski deaths inspire helmet debate
The recent high-profile deaths of Michael Kennedy and Sonny Bono have focused attention on head injuries in skiing. In biking, helmet use has become widely accepted and has been shown to substantially protect against head injuries (1). Is the time ripe for ski helmets? Some say yes, but others have doubts.
A Slow-Growing Trend
"It's time to mount the charge for ski helmets like we have for bicycle helmet use," says Jeffrey M. Brown, MD, MPH, director of the General Pediatrics Division at Denver Health in Colorado. Brown says that ski helmet use is widely promoted in Europe, particularly among children, and that ski racers have always worn helmets. But the trend has been slow to gain momentum on US slopes. "In Colorado I'm beginning to see adults with helmets. It's a very small number, but each year there seem to be more," he says.
Randy Swart, director of the Bicycle Helmet Safety Institute in Arlington, Virginia, says that helmets serve as a secondary defense when skiing near trees, rocks, or unpadded lift line pylons. The primary defense is reducing risky behavior. "Don't ski fast near trees," says Swart, "but then wear a helmet in case something does happen."
Even advocates speculate that helmets might not have saved Kennedy and Bono. However, helmets could prevent many concussions that contribute to missed work, insomnia, amnesia, or learning impairments, says Brown. He and his colleagues contend that physicians can reduce the number and severity of head injuries in skiing and snowboarding by advocating helmet use (2).
Others proceed more cautiously. After reviewing data on ski injuries, a committee of the American Medical Association (AMA) recently recommended that children and adolescents wear helmets when skiing or snowboarding. But they stopped short of supporting mandatory use of helmets, citing insufficient evidence (3). "The AMA recommendations are based on common sense, not strong data," says John C. Nelson, MD, a trustee of the AMA and an obstetrician in Salt Lake City.
Does Helmet Use Pay?
Also skeptical of compulsory helmet use is Jasper Shealy, PhD, who tracks ski injuries at Sugarbush Ski Resort in Warren, Vermont.
"It's hard to make a pressing case for everyone to wear ski helmets based on the statistical evidence," says Shealy. According to Shealy's Sugarbush survey over 15 ski seasons, 2.6% (309) of ski injuries were potentially serious head injuries—1% (3) were fatal, 3.4% (10) were skull fractures, 2.6% (8) were severe brain injuries, and 94% (288) were concussions. An average of 34 skiers (mostly adults) die yearly of head injuries, (3) compared with Swart's figure of 559 cyclists in the same category. Bicyclists outnumber skiers more than five to one, according to the National Sporting Goods Association.
Shealy also contends that while helmets can prevent mild concussions caused by glancing blows, they wouldn't help much in the kind of major collisions that cause skiing deaths. He says most such deaths occur when adult intermediate or expert male skiers slam into trees.
Shealy notes that the New York Legislature is considering a resolution to require children under 17 to wear ski helmets. He finds this ironic in that "they're not the ones dying from head injuries."
Another concern about ski helmets is that they introduce a minor risk of neck injuries; the lower rear edge of the helmet acts as a pivot point that can cause an anterior translation spinal injury, Shealy says. Helmets may also increase the risk of whiplash injuries in small children because their necks are weaker.
Shealy concedes that helmet use may prevent head injuries, particularly mild concussions, abrasions, contusions, lacerations, and facial injuries, but he fears that the benefit might be offset by increased reckless behavior on the slopes. Brown agrees: "That's always an issue in preventive medicine: If you do something to make people safer, do they feel more secure, then act in a hazardous way?"
What's a Good Ski Helmet?
What type of helmet to buy is as controversial as who should don one. Brown recommends wearing only specially designed ski helmets (2); he argues that helmets designed for other sports do not fully cover the head and may cause whiplash. Helmets are available from ski supply stores or from specialty mail-order houses. A helmet for recreational skiing (figure 1: not shown) costs from $75 to $160 or more. Ski helmets have an impact-resistant shell and two inner layers that provide shock absorption and warmth.
However, Swart says bike helmets are a safer bet because they provide better protection from the most severe collision impacts. Ski helmets, currently made only in Europe and Canada, are designed for penetration resistance such as protection against the tip of a ski pole. "But ski poles don't kill people the way trees do," he says. Swart, who helps establish helmet standards for the American Society for Testing and Materials (ASTM), says the ASTM is working on establishing a standard for ski helmets sold in the United States.
Swart believes the best current option is for skiers to wear ski helmets or bike helmets that carry the Snell Memorial Foundation rating of B-95 or N-94. "But skiers care a lot about fashion, so many want a ski helmet so they don't look funny. Ski helmets provide good protection too."
The US ski industry has been lukewarm about helmets, says Brown. "I think that may be because ski helmets are one more expense in an already expensive sport. If you have to pay $100 for each kid, it's a financial barrier to skiing."
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