Surgeons in Scotland debate the helmet issue - do they increase cyclists' safety or not?

Neurosurgeon argues for wearing them... trauma specialist (who chairs CTC Scotland) opposes compulsion

by Simon_MacMichael   February 27, 2013  

White cycle helmet

Two surgeons in Edinburgh, both of whom ride bikes regularly and both experienced in treating injured cyclists have crossed scalpels over the issue of whether cycle helmets improve riders’ safety.

Lynn Myles, a consultant neurosurgeon at the Western General Hospital in the Scottish capital, described as a “keen cyclist” believes they do.

Taking the opposing view is Chris Oliver, consultant trauma orthopaedic surgeon at Edinburgh Royal Infirmary, who also happens to be chair of cyclists’ organisation CTC Scotland.

The issue is debated by them on Surgeons’ News, the website of the Royal College of Surgeons of Edinburgh, which has some 20,000 fellows and members throughout the world.

Ms Myles begins by acknowledging that she is “under no illusion that it [a helmet] will save me in the event of a high speed collision with a car or lorry (nothing will)” – a common criticism aimed at those who insist all cyclists should wear one – but adds that “most cycling accidents aren’t of the high-speed variety.”

Instead, after outlining other things that can be done to improve cycle safety such as addressing traffic speed and improving road layout, she says: “Most of the head injuries I have seen in cyclists are the result of low velocity crashes or simple falls due to ice or wet roads.

“There is no doubt in my mind that a well-fitting cycle helmet will reduce the incidence of scalp laceration and open fracture and will help to reduce the energy transfer to the brain.”

Apart from in sports, where she believes the type of potential injuries justifies governing bodies making helmets mandatory, Ms Myles isn’t calling for helmets to be made compulsory; she does point out though, that “in my department all neurosurgeons, neurologists neurointensivists and neuroanaesthetists wear cycling helmets when cycling – we can’t all be mad!”

Mr Oliver, however, maintains that “there is no justification for helmet laws or promotional campaigns that portray cycling as a particularly ‘dangerous’ activity, or that make unfounded claims about the effectiveness of helmets.

“By reducing cycle use even slightly, helmet laws or promotion campaigns are likely to cause a significant net disbenefit to public health, regardless of the effectiveness or otherwise of helmets,” he adds.

Like Ms Myles, he points out that helmets “are (and can only be) designed to withstand minor knocks and falls, not serious traffic collisions,” and says there is evidence that wearing one can increase certain types of injury.

Mr Oliver acknowledges that “whilst there is a correlation between helmet guidelines and reduced cyclists’ injury numbers, the evidence suggests this is wholly or mainly due to reductions in cycle use, not improvements in safety for the cyclists who remain.”

He goes on to highlight that a fall in the number of cyclists can put remaining ones at greater risk due to the absence of a safety in numbers effect, and outlines other arguments against compulsion.

He also warns against what can be termed compulsion creep, saying that “schools, employers and the organisers of non-sporting cycling events (e.g. sponsored rides) should not seek to impose helmet rules for their pupils, staff and participants.

“These rules are not justified in terms of health and safety, they are likely to reduce the numbers and diversity of people who take part in cycling, and they may in some circumstances be illegal.”

Mr Oliver believes that “individuals should be free to make their own decisions about whether or not to wear helmets, with parents making these decisions in the case of younger children. Their decisions should be informed by clear information about the uncertainties over helmets.”

As we regularly see here on road.cc, the helmet debate is an emotive one and it’s an issue that strongly polarises opinion; the fact that two senior medical professionals working in the same city and dealing with the aftermath of incidents in which cyclists have been seriously injured have such differing opinions on the subject is a reflection of that.

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Phytoramediant wrote:
Of course, in most of Northern Europe, where cycling is a normal means of commuting, they regard helmet wearing as just silly.
They also regard not having decent cyclepaths and proper laws to protect cyclists as insane.
But... what would they know? They're just cyclists who aren't dictated to by a car-culture and regard cycles as transport rather than an Extreme Sport.

Spot on !!!!! Cool

posted by Krd51 [19 posts]
27th February 2013 - 22:13

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I wish I'd put my lid on before I'd started reading this thread, because my head REALLY hurts now.

Oh and for the record, two sheets per wipe and front to back.

posted by jarderich [78 posts]
27th February 2013 - 22:30

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The only thing i have to add to this is that Mr Oliver operated on my broken pinkie, which i broke in a crash in a bike race. - How's that for a claim to fame?!

p.s. I was wearing a helmet but it didn't save my pinkie :'(

posted by mustard [71 posts]
27th February 2013 - 22:55

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MercuryOne wrote:
Fully in favour of non compulsion. In 95/100 cases better some padding than none at all but still - it's a personal choice.

It's as simple as that and doesn't need this lengthy, tedious hairsplitting every time.


[[[ "Hairsplitting? Ouch! But isn't this thread fun? In fact, if you'all have enjoyed it half as much as me, then I must have enjoyed it twice as much as you'all. Now, where's me Cinelli banana-hat?
P.R.

PhilRuss

posted by PhilRuss [203 posts]
27th February 2013 - 23:14

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Most of the "evidence" for helmets' benefit is based on the "I fell off and broke my helmet but my head was OK" type of comment; or on the basis of a doctor or health professional saying that a helmet saved someone's life.

A broken helmet gives no indication of the level of damage that would happen to a head without one. A doctor is not qualified know whether a helmet saved a life in any particular situation.

There is simply no evidence that helmets significantly reduce rates of injury but there is plenty of evidence that helmet compulsion reduces cycling rates and as such is significantly harmful to public health.

For all the "show us the evidence" requests above I suggest a visit to http://cyclehelmets.org/ where plenty of evidence is detailed with references.

My advice is look at actual evidence, think about it, make up your own mind and let everyone else do the same!

Shay

posted by shay cycles [142 posts]
27th February 2013 - 23:23

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nadimk wrote:
to say that helmets are a red herring is false, to say they are not a relatively cheap, unharmful way to protect the head is false and has no basis in evidence.

i'm not arguing that helmets can't protect your head: they can. i'm arguing that the evidence points to the fact that helmets don't actually decrease the overall incidence of head injuries: hence, they're a red herring. they can protect your head but it's not as simple as whether they'll take a blow if you fall off your bike. there's lots of other factors, eg the altered perceptions and attitudes of other road users, or whether your safety is adversely affected by your own risk compensation, or what road conditions make people feel that they're necessary. who knows whether these negate the benefit the helmet can give? I don't for sure, but I haven't seen any large scale data that shows a correlation between helmet use going up and head injury levels going down. where mandatory laws have required the use of helmets the incidence of head injuries among cyclists has remained on the same trajectory (slightly down) in spite of a dramatic increase in helmet use. there's all sorts of factors in the equation and some of them correlate; helmet usage and safety levels don't.

nadimk wrote:
You like others cite "evidence" from countries where they do x, y, and z to say helmets aren't needed. This is highly biased "data" and does not constitute evidence. It lacks generalizability to England and the US where we don't have anything like Copenhagen and Amsterdam.

nope, what i'm doing is saying: if you want to make cycling safer, forget about helmets and concentrate on the real issues. look at what the safe countries are doing, and do that. don't focus on stuff that will make a minimal difference, if it makes a difference at all.

nadimk wrote:
Just wear a helmet and save us the cost of taking care your head injury when you crash, particulary in England's publically funded healthcare system.

why is it my responsibility all of a sudden when i'm on a bike? what changes? why not the same argument for car occupants? or diy enthusiasts? or rugby players? or pedestrians?

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posted by purplecup [229 posts]
27th February 2013 - 23:28

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Comparisons to the Netherlands seem a bit silly considering the much better cycling infrastructure they have.

Like others, I'd like to see some information on the injuries that helmets can cause.

posted by paulfg42 [335 posts]
27th February 2013 - 23:58

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I used to wear a helmet all the time, then I read the research literature! The evidence for helmets usage reducing head injuries in cyclists as a population is quite strong. However, the argument is much more nuanced than just saying helmet wearing is a good thing, because other factors need to be taken into consideration.

Firstly, there is some evidence that helmet usage adversely affects risk taking behaviour, i.e. riders feel safer, so take more risk and drivers perceive riders as being safer so drive more dangerously around them.(see for example, Adams and Hillman, 2001, The Risk Compensation Theory and Bicycle Helemts, Injury Prevention,7, 89-91)

Secondly, if we are interested in reducing in negative health consequences, then we need to consider all the effects of increased helmets as a whole. For example, there is evidence that, if helmet’s are made mandatory, cycle use decreases and that the negative effects of reduced physical activity outweigh any gains from reduced head injuries (de Jong, 2012, The health impact of mandatory bicycle helmet laws, Risk analysis, 75, 782-790).

The final point is a little more complicated. Whilst increased helmet usage may reduce head injuries within a population, what about for you as an individual? If the occurrence of severe head injuries occurring in common cycling crashes is reduced by helmet usage but certain uncommon ones are increased, then at a population level, there may well be a net positive effect, but if you’re one of those individuals with an increased risk, then that is little compensation. There is evidence that the probability of serious head injuries resulting from angular accelerations may be increased when a helmet is worn (see for example, Curnow, 2003, The efficacy of bicycle helmets against injury, Accident Analysis and Prevention, 35, 287-292). The theory being that firstly, making the head effectively bigger makes you more likely to hit it in a crash and secondly it increases the torque (turning force) by increasing the length of the lever for any applied force. These types of loadings are not examined in some of the research that has carried out direct measurements of head impacts with/ without helmets(and current helmet testing procedures) . The case for helmets reducing neck injuries is also much less strong. Further, there are strong suggestions that modern soft-shell helmets are more likely to suffer from these effects than older hard-shell ones (because the hard-shells are more likely to slide). So, if you are a rider in a situation where the common low-energy, ‘falling off’ type crashes are unlikely, then wearing a helmet could be more dangerous than not in the less common high-energy impacts. Potentially, leading to an increased overall risk.

My take on all this is :
Where there is a relatively high probability of low-energy impacts but less of high-energy impacts (i.e. off-road or in group riding situations or in general for less-experienced riders), wearing a helmet may make you, as an individual, safer and in these situations, I still where mine. However, as an experienced rider when the probabilities are reversed (e.g. commuting through traffic) I no longer wear my helmet.
I would therefore, also encourage others whose riding does not fit in the ‘exceptions’ case to wear a helmet, but based on the research, strongly oppose any form of compulsion.

posted by tendecimalplaces [3 posts]
28th February 2013 - 0:01

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I remember in my youth no one wore helmets. If you just dicking about in the streets or you were a pro. I also remember the streets were littered with dead children and dead pro cyclists, hundreds of them. The Tour De France would loose several riders every year - sometimes dozens - all killed by head injuries. Im amazed i myself made it to adult hood and that there were any pro cyclists left to race in the pre helmet era - such was the casualty rate.
Since helmets have become more common no one has ever died whilst riding a bike.
Thank heavens for helmets.

posted by Some Fella [574 posts]
28th February 2013 - 0:38

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Please stop writing about helmets.

Please http://www.writetothem.com and ask them to stop building crap cycle lanes, if you haven't recently.

posted by a.jumper [632 posts]
28th February 2013 - 1:14

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Any choice wearing a seat belt No

Any choice wearing a crash helmet on a motor cycle No

At least you have a choice on a cycle all I am reading here are the same old arguments about choice not about safety.

Until they are made compulsory some will, some wont.

So if you crash at 60mph on a motor bike and hit a sign post smash your chest and abdomen then bleed out before help arrives motor cycle helmets shouldn’t be compulsory should they as they don’t always work.

The above statement is the same as what people are saying about cycle helmets and makes as much sense as some comments on here, not a lot. By the way don’t say that kind of accident couldn’t happen as that is exactly what happened to a friend of mine about 20 years ago.
Do I wear a helmet yes. Why? Beacause I have a choice and every little helps.

posted by sodit [51 posts]
28th February 2013 - 4:51

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Very interesting reading and comments as well. But while arguments against mandating helmet use - because the resulting drop in cycling (poorly studied, IMHO) results in lower average fitness and hence more public "danger" - ignores the reality that when YOU fall, it is YOUR head. Not an average public head. YOUR head.

So, I agree with the UK status quo. No mandated helmet use for adults. Public education. And I always wear a helmet. I care more about my head than yours. I mean you might smoke, too. Or jump lights. Ride with headphones or at night with no lights. You take yer chances, I'll take mine.

BTW - quite a few US states do not have helmet laws for motorcyclists. There seems to be a divide in who wears helmets and who doesn't. Young men don't. Harley riders don't. A nurse friend tells me the A&E workers refer to them as "organ donors".

Ride your own ride

posted by CanAmSteve [59 posts]
28th February 2013 - 7:24

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Geoffroid wrote:
I think all cyclists should wear a full face motorcycle helmet. You can never be too careful.

I realise that was facetious but this was a debate we had in motor rallying years ago - full face vs. open face helmets. I would always ask - would you prefer to break your neck or your jaw?

Like the seat-belt debate this will run for years until there is enough data to make a convincing case one way or the other. But, also like the seat belt argument, I am convinced that the data will show that wearing a helmet significantly reduces the risk of serious injury. In the meantime I'll just belt-up

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posted by Tovarishch [26 posts]
28th February 2013 - 7:32

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Ah, more fallacies:

"You don't get a choice about seat belts or motorcycle helmets, do you?" - no, but cars and motorcycles are different things, with different issues, to bicycles. E.g., for one thing there are *NO HEALTH BENEFITS* to using a car or motorcycle (the contrary).

"Statistics, smishtics, it's *your* head - if you happens to *you* you'll want a helmet". Except, if lots of helmet use depresses cycling rates (e.g. by making cycling appear more dangerous than it actually is and so less attractive), then the lower cycling rates result in more cars that can hit you, and less political will to actually fix any of the problems cyclists have (with road safety, infrastructure). So you may be making things worse for cyclists, such as yourelf, and cycling, for a benefit that will matter to you only in a statistically unlikely event (if you cycle sensibly, and control your speed, e.g. on hills, etc.). Further, do you apply the same logic to when you go for a walk?

I've tried to collate some links on this blog post:

http://pjakma.wordpress.com/2011/10/28/the-case-against-bicycle-helmets-...

You can find links to meta-studies there which suggest the net effect of helmets on injury is *minimal*, because the decrease in head injuries is accompanied by increases in other injuries (facial, neck). The bibliographies in the meta-studies will lead you to the primary studies describing these things.

I try add further studies in the comments when I find them.

posted by Paul J [399 posts]
28th February 2013 - 7:52

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Here in Victoria, Australia we started the whole helmet compulsion thing, tragically for common sense, without evidence. Now the evidence suggests the only benefit was to reduce the number of cyclists on the road as the figures for reductions in accidents are similar.
If you really want bike safety, look to the Netherlands. I rode there and in Denmark and Sweden over a few weeks and concluded that the whole area but Netherlands in particular is safer because of one thing, protective laws.
Our government had a chance to apply such laws in the 70's as they actually knew about the changes going on in the Netherlands but the whole debate was hyjacked by our motoring advocacy group, the Royal Automobile Club of Victoria (RACV.
The RACV and the government worked together to create the first bike helmet laws thus ensuring that no motorist in Victoria would have to ever suffer laws that required him to be deferential around a bike rider.

posted by Pjrob [21 posts]
28th February 2013 - 8:08

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Not that it makes any difference to peoples views but over the years i've done my job (close to 26) i believe i can count on one hand the number of head injuries sustained by pedestrians tripping over (its usually wrists, shoulders, knees) and likewise for muggings / robberies (usually threatened with violence / knife) whereas bike accidents run nearly into the 100's and the vast majority suffer some sort of head style injury even with a helmet.

These are MY experiences, not fact or scientific proof. I wear a helmet because i want to, its everyones choice and no Govt should ever try to change what is fundamentally an individuals choice unless undeniable proof is brought forward to justify a decision.

If you must break the law, do it to seize power: in all other cases observe it. Gaius Julius Caesar.

posted by stumps [2289 posts]
28th February 2013 - 9:02

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The case of Fabio Casartelli seems a case in point. He would be alive today (most likely) if he had been wearing something on his noggin. I sort of feel that you don't need to wear a helmet, but given they are light weight and do not impinge performance that they might protect me better than a cloth cap, or styling gel.

But what I would like to know is the stats of head injuries per population of cyclists, compared to other activities. As other people have mentioned it would be a red herring if, for example, there were more hospitalisations due to head injuries from dog walking over cycling. The problem is that we sit in a well on unknowing.

Also, it would also be interesting to know what injuries are sustained by various cycling populations, the regularity of an injury and the experience of a rider. I suspect that people popping to the shops (with few bike handling skills and heavy bikes) suffer injuries more readily than road cyclists. So perhaps the issue is to get people learning bike handling and making them aware of road safety issues, rather than slamming a lid on their head. Perhaps even banning heavy bikes which quite possibly add to the risk factors.

I have no gripe with wearing a helmet or not. I've not needed to wear one, and recognise that there are dangers involved. But putting facts and statistics out there will at least focus this debate (of which I have none).

posted by Colin Peyresourde [917 posts]
28th February 2013 - 9:09

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As other statistics and statisticians have shown, it's all about our attitude to risk. Those brought up to look out for the bogeyman (remember him?) will think 'Be careful' and wear a helmet, those who think 'life is an adventure, and I'd rather die tomorrow than miss out on the thrills', won't. This is the attitude of the ones who smoke, in spite of all the known risks, too. My gripe is that the health service, and the emergency services, pick up the pieces for free whatever the attitude of the suckers who got themselves sick or injured, and as a non-risk-taker (except when I'm in a nice safe car with a ton of steel all around me!) I feel I'm paying more than my fair share of the cost.

ChrisS

posted by Chris S [41 posts]
28th February 2013 - 9:26

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jayme wrote:
In this debate several people have claimed that in certain situations a helmet may make the injury worse. Is there any actual evidence for this to back up the claim? What type of situation is it?

A helmet effectively makes your head bigger. That means that there's a bigger lever to twist stuff like necks and it also means you've got more chance of hitting it to start with (as does the slightly increased weight). This is elementary physics.

It's also not very relevant, because you can't choose your accident type. What you can do is look at the overall effect of helmet wearing on serious injuries and see that there's none to speak of.

How about minor injuries (according to someone up there ^^^ any head injury is serious, hell, I was lucky to get away with cutting myself shaving the other day!)? A helmet is very likely to be good against these, but how many do you get cycling? I get more round the house, but ICBA to wear a helmet there. I suspect you can't either.

Helmets are specced for low speed falls with no motor vehicles involved. if any extra protection in these instances is good then the Dutch would wear them, because their much vaunted infrastructure doesn't protect them from low speed falls with no motor vehicles involved. But their wearing rates are the lowest in the developed world, and coincidentally so are their rates of serious head injury.

Pete Clinch
often seen riding a bike around Dundee...

posted by pjclinch [46 posts]
28th February 2013 - 9:39

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Colin Peyresourde wrote:
The case of Fabio Casartelli seems a case in point. He would be alive today (most likely) if he had been wearing something on his noggin.

Casartelli's head hit a concrete post at 80kph+.

At most, helmets are designed and tested to withstand impact speed of 24kph and that's without the momentum of the body behind the head.

No autopsy was conducted.

The doctor who examined him on behalf of the coroner said that had he been wearing a hard helmet "some injuries could have been avoided."

Max Testa, Motorola team doctor at the time (and now doctor to BMC Racing) said that even had he been wearing his usual helmet (Specialized Air Piranha) "he would not have survived."

Simon_MacMichael's picture

posted by Simon_MacMichael [7208 posts]
28th February 2013 - 9:43

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Colin Peyresourde wrote:
The case of Fabio Casartelli seems a case in point. He would be alive today (most likely) if he had been wearing something on his noggin.

Then the same would be true of the American author Kurt Vonnegut, killed by the head injuries he sustained falling down the stairs in his home.

People are killed in trips and falls. Trips and falls are the biggest cause of head injury. So don't separate cycling out as especially dangerous or productive of head injuries, because it isn't!

There was not mass head-injury related carnage amongst cyclists before the introduction of styrofoam hats for cyclists, and the degree to which cyclists /are/ killed hasn't changed obviously since they were But you wouldn't know that from the general assumption of Doom for those not wearing them now.

Pete Clinch
often seen riding a bike around Dundee...

posted by pjclinch [46 posts]
28th February 2013 - 9:46

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Taking advice from an orthopaedic surgeon over that of a neurosurgeon for a problem which affects the brain is like asking an opthalmologist versus a urologist as to the benefits or otherwise of wearing a box during cricket! The opthalmologist will probably tell you that wearing a box is beneficial only if you really want to prevent yourself from crying after a direct hit to the goolies... but crying won't kill you, will it.
I can't believe you guys are seriously "debating" this! For a developed country, there are still a lot of things that I don't get about the UK... this and the Royals are about as laughable as they come!
Try this on for size... anyone who buys their eggs in egg cartons should wear a helmet. Don't be taken by the advice of an orthopaedic surgeon... they don't have anything to protect... I should know... I'm an anaesthetist.

posted by Hypoxic [2 posts]
28th February 2013 - 9:53

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Hypoxic wrote:
I can't believe you guys are seriously "debating" this! For a developed country, there are still a lot of things that I don't get about the UK... this and the Royals are about as laughable as they come!

Ah, you're in Melbourne Wink

Funny that, because while I think this is the first time we've ever reported two British professionals debating the issue, we've done plenty of articles where it's Aussie academics arguing hammer and tongs over it.

Royal family... yeah... but just remind me which large Antipodean country voted against becoming a republic in 1999...?

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posted by Simon_MacMichael [7208 posts]
28th February 2013 - 10:37

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Oooh some actual facts - they might help me down from the fence Smile thanks Paul

[oops: I meant to quote, I was referring to Paul J's comment at 28th February 2013 - 7:52]

posted by smoothhound [39 posts]
28th February 2013 - 12:04

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I'm sorry if this has already been said before, maybe we need to look at the word "safety".

Does a helemt make a fall safer? Yes to a point.
Does it make me feel safer? Yes
Does is make me ride in a safer manner? Not always. I take more risks than I would without.
Does it make the other idiots on the road safer? Nope.
Does it make the idiots on the road drive/walk/cycle safer? Nope!

How does an inanimate object improve the suicidal/murderous tendancies of those organic sqishy things around it?

The safer things are made, the more of a risk people will take.

posted by Yorkshie Whippet [172 posts]
28th February 2013 - 12:50

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Yorkshie Whippet wrote:
Does is make me ride in a safer manner? Not always. I take more risks than I would without.

That's right, I have never been white water kayaking without a helmet, it must be the helmet that makes me do it.

David Bowie agrees with me

bikeboy76's picture

posted by bikeboy76 [989 posts]
28th February 2013 - 13:07

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bikeboy76 wrote:
Yorkshie Whippet wrote:
Does is make me ride in a safer manner? Not always. I take more risks than I would without.

That's right, I have never been white water kayaking without a helmet, it must be the helmet that makes me do it.

I hope you never raft without a helmet. It will save your life. Seriously. Just put it on and go rafting. You will be safe.

posted by Ush [302 posts]
28th February 2013 - 14:50

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nadimk wrote:
Don't people in England call physicians by their proper prefix,Dr., not Ms or Mr. Typical. Y.

No - because by tradition in the UK Consultants and Surgeons use the title Mr and Physicians use the title Dr. It's a mark of status. You would be insulting a Surgeon if you addressed him as Dr.

Why is that "Typical" btw?

posted by Pauldmorgan [109 posts]
28th February 2013 - 21:36

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You got me there. I wish I could say New Zealand... but sadly I can't. At least it was a close vote.
As for helmets... just wear them for God sakes. It's clearly of benefit in many types of accidents and as for it making you feel more secure ao as to take more risks... don't forget you've still got the other 95% of your body which is clad in only 1-3 layers of fabric... Ooch! Has anyone forgotten that it is possible to die from other injuries other than a head injury... very possible!

posted by Hypoxic [2 posts]
1st March 2013 - 3:51

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Compulsory crash helmets for car occupants would reduce head injuries save lives.

posted by DM [40 posts]
1st March 2013 - 20:56

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