Bicycle and Motorcycle Helmets

The increase in bicycling and motorcycling has focused attention on injuries sustained during these activities. Most of these injuries are traumatic brain injuries (TBI), caused by the lack of rider head protection. This exposure of the rider accounts for the particular types of injuries seen during these activities.

• Although the crash scenario often dictates the area of the body injured, fatal crashes are most often a result of traumatic brain injury. Often these are isolated head injuries with no other serious injuries.
  
  
• Fatal traumatic brain injury occurs more often in adults than children, although children are more often injured in bicycle crashes. This simply reflects the greater proportion of children using bicycles, as well as the lack of experience of younger riders.
  
  
• Many studies have documented the particular risk of brain injury when riding a motorcycle. The increased speed of a motorcycle and use in vehicle traffic adds risk of injury far beyond that of a bicycle.
  
  
• Traumatic brain injury certainly can cause death, but it also can cause disabling injury requiring extensive and costly rehabilitation. For many people, a brain injury triggers a significant change in lifestyle and function. Brain injury can vary from essentially minor disability to prolonged dependence on a ventilator to breathe and permanent loss of normal function. These serious brain injuries take their toll on families caring for an injured loved one.

• The potential for injury and death—especially from head injuries—was recognized early in the use of bicycles and motorcycles.
  
  
  • Early bicycles with a large front wheel and small rear wheel were notorious for sending a rider over the handlebars from a dangerous height.
    
    
  • Early motorcycle racing, known as board racing around a wood board track, often resulted in spectacular crashes from loose boards and close racing.
  
  
• Helmets evolved slowly, and initially without scientific basis.
  
  
  • Early helmets used various materials such as pith (spongy material from plants) or leather and served to cushion the rider’s head from other objects during a crash. They weren’t very effective, but they represented all that was available at the time.
    
    
  • Advances in technology and crash mechanical studies brought improved function and design for bicycle and motorcycle helmets.
    
    
  • Helmet improvements include the shape of helmets, the introduction of plastics, improvement in methods of securing the helmet to the head, and the layering of materials.

Although the idea that helmets would help reduce injuries and deaths may seem obvious, proof needed to be demonstrated. In addition, the question of whether helmets themselves did not increase the risk of other unforeseen injury needed evaluation.

• Researchers into motorcycle safety took advantage of changes in state laws requiring helmets for all riders, regardless of age. There are no similar laws in the United States applying to all bicycle riders, although many states have laws applying to children.
  
  
  • Studies examining the rates of brain injury and deaths before and after the passage of a mandatory helmet law showed a significant reduction in the number of both head injuries and deaths. The reduction held true even when controlling for age, sex, and severity of crash.
    
    
  • The Harborview Injury Prevention Center in Seattle published a major study of bicycle helmet effectiveness that clearly identified the need for bicycle riders to use a helmet.
    
    
    • This case-controlled study examined injury probability and patterns in riders with and without a helmet.
      
      
    • It concluded that there was an 88% reduction in brain injury for riders who use a helmet.

• Opponents to mandatory helmet use have voiced some concerns. They point to restricted vision and a decreased awareness of the surrounding environment while wearing a helmet.
  
  
• Conceivably, a helmet could make it difficult for a rider to see objects to either side or to hear a horn—thus increasing the possibility of a crash. But no study has demonstrated these problems to be a factor in the experiences of real riders.
  
  
• Some riders, most often those who staunchly oppose mandatory helmet use, voice concerns that motorcycle helmets may actually increase the risk of cervical spine injury. Injury to the cervical spine, the portion of the spine in your neck, may cause paralysis, often from the neck down. However, controlled studies have failed to demonstrate an increased risk of cervical spine injury for a helmeted motorcycle rider.
  
  
• Congress stopped tying federal highway construction funds to the individual state mandatory helmet use laws in 1975. Many states have since repealed their universal helmet laws partially or completely. In 1991, the General Accounting Office of the US Congress concluded that motorcycle helmet use reduced rates of death and serous injuries. Universal helmet laws doubled the use of helmets while lowering the fatality rates by 20-40%. However, more states continue to repeal universal helmet laws.

Despite a large body of evidence that helmets save lives and reduce injury among both bicycle and motorcycle riders, a large percentage of riders still does not use them. There are many reasons for lack of use, often related to the circumstances and age of the rider.

• A number of riders are still unaware or do not appreciate the risk of riding without a helmet. Adults who were raised in an era before widespread helmet information are at particular risk for this lack of information.
  
  
• Children may live in an area where there is little education regarding safety from their parents or from school. Statistically, crashes tend to occur in close proximity to the rider's home.
  
  
• Other reasons for not wearing a helmet include the following:
  
  
  • The discomfort of a helmet
    
    
  • The lost feeling of freedom
    
    
  • The cost of the helmet
    
    
  • The influence by peers and parents who may not wear a helmet

As with many other aspects of injury prevention, education is the key to long-term helmet use.

• Education should start at home and include the educational system. Parents should be role models and wear helmets as well. Parents should encourage their children's friends to wear helmets. Reward your children for wearing helmets.
  
  
• Others, such as doctors and community groups, can help instill positive behaviors.
  
  
• In the case of motorcycles, most states have adopted laws requiring helmets for riders younger than 14 years, and many states have expanded the law to include riders of all ages.
  
  
  • No state requires helmets for bicycle riders of all ages, although many states require them for children.
    
    
  • Several cities also require bicycle helmets for all riders.
  
  
• As research into rider safety continues, efforts will continue to focus on educating people as to the benefits of helmet use.
  
  
• Young people are particularly influenced by early intervention and education and should reap the reward of fewer severe injuries. Parents should explain the importance of a helmet and then insist on their use.

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1. Bicycle Helmet Safety Institute. The History of Bicycle Helmets. 2000. The History of Bicycle Helmets. 2000.

2. CDC. Head injuries associated with motorcycle use--Wisconsin, 1991. MMWR Morb Mortal Wkly Rep. Jun 17 1994;43(23):423, 429-31. [Medline].

3. GAO. Highway Safety. Motorcycle Helmet Laws Save Lives and Reduce Costs to Society. Washington, DC: US General Accounting Office; 1991.

4. Thompson RS, Rivara FP, Thompson DC. A case-control study of the effectiveness of bicycle safety helmets. N Engl J Med. May 25 1989;320(21):1361-7. [Medline].

5. Van Camp LA, Vanderschot PM, Sabbe MB, et al. The effect of helmets on the incidence and severity of head and cervical spine injuries in motorcycle and moped accident victims: a prospective analysis based on emergency department and trauma centre data. Eur J Emerg Med. Jun 1998;5(2):207-11. [Medline].

Author: Thomas V Robb, DO, Director, Department of Surgery, Section of Trauma, Saint Barnabas Hospital.

Coauthor(s): Maurizio A Miglietta, DO, Consulting Staff, Department of Surgery, Division of Trauma and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland.

Editors: Patrick Taylor, MD, FAAEM, Medical Director, Department of Emergency Medicine, CHRISTUS St Frances Cabrini Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.