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News

Bicycle-related head injuries plummet

Natalie Dunleavy
CMAJ May 13, 2003 168 (10) 1313;
Natalie Dunleavy
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  • Helmet believers believe what they want to believe
    Avery Burdett
    Published on: 09 July 2003
  • Scant data on denominator flaws report
    Douglas J Carnall
    Published on: 27 June 2003
  • The Need for Controls in Reported Observation
    Malcolm J. Wardlaw
    Published on: 27 June 2003
  • Published on: (9 July 2003)
    Helmet believers believe what they want to believe
    • Avery Burdett, Former Researcher

    In claiming that bicycle-related injuries among Ontario children is declining, "likely because of increased helmet use and parental diligence", Donleavy refers to information sourced from two Canadian studies.[1,2]

    Nowhere in Macpherson et al's injury study[1] do the authors relate rates of head injuries to rates of helmet usage. Compared instead are rates of injuries among helmet legislating provinces and non-...

    Show More

    In claiming that bicycle-related injuries among Ontario children is declining, "likely because of increased helmet use and parental diligence", Donleavy refers to information sourced from two Canadian studies.[1,2]

    Nowhere in Macpherson et al's injury study[1] do the authors relate rates of head injuries to rates of helmet usage. Compared instead are rates of injuries among helmet legislating provinces and non-legislating provinces. There is no indication however what effect, if any, the laws had on helmet usage. In Ontario, helmet usage was already very high at 65% among children prior to the law's implementation,[3] and since the law has not been enforced no assumptions can be made regarding changes in helmet usage rates. Any increase following the law would have been modest although that would be difficult to verify as no Ontario-wide surveys were conducted after the law came into effect on October 1, 1995.

    Robinson identifies contradictions between the authors’ data and conclusion.[4] Using Macpherson et al’s data she shows that for the two largest legislating provinces, Ontario and BC, the greatest decreases in head injuries did not occur in the years immediately after respective helmet laws came into effect. That throws further doubt on the study method.

    The absence of enforcement in Ontario also explains Macpherson's quoted claim that the number of children riding bicycles does not decrease because of mandatory helmet legislation. Kids seem to know intuitively when a dubious adult discipline is foisted on them. It didn't take long for Ontario’s kids to figure out that if the cops don't care about helmet laws then why should they. In British Columbia, helmet use increases were observed after legislation[5] but that was coincident with aggressive enforcement campaigns by local police.[6]

    The BC government didn't feel it important enough to organize pre-law and post-law surveys to gauge the law's impact on cycling levels. A 35% reduction in all reportable cycling accidents between the two complete years immediately before and after the law's enforcement (1995 and 1997)[7] however suggests significant declines in cycling. Interestingly head injuries in BC declined at a slower rate than the number of cycling accidents.

    The problem with poorly designed helmet studies is that helmet campaigners uncritically latch on to any claim to push helmet agendas. One prominent UK helmet organization has already cited Macpherson et al's Ontario cyclist exposure study to support its campaign in favour of a helmet law[8] and has embellished it by claiming that mandatory helmet legislation in Canada saves lives. (Two requests for a citation from the author for this have gone unanswered.) I hazard a guess that the claim originated from non-significant fatality data in Macpherson et al's head injury study. An analysis[9] of 27 years of Transport Canada's traffic fatality data however shows that the fatality trend for cyclists is virtually identical to the one for pedestrians. That suggests other factors, not helmets, account for declining fatality and injury trends.

    In view of the life extending benefits of cycling and the value of exercise in reducing heart disease, cancer, and obesity, the repetition of doubtful claims by misguided lobby groups must not be allowed to go unanswered.

    1. Macpherson AK, To TM, Macarthur C, Chipman ML, Wright JG, and Parkin PC, Impact of Mandatory Helmet Legislation on Bicycle-Related Head Injuries in Children: A Population-Based Study, Pediatrics Vol. 110 No. 5 November 2002, e60 http://pediatrics.aappublications.org/cgi/content/full/110/5/e60

    2. Macpherson AK, To TM, Parkin PC, Mandatory helmet legislation and children’s exposure to cycling, Inj Prev. 2001;7 :228–230, http://ip.bmjjournals.com/cgi/content/full/7/3/228

    3. Statistics Canada, Factors Associated with Bicycle Helmet Use, Health Reports, vol. 9 no. 2, Autumn 1997

    4. Robinson DL, Confusing trends with the effect of helmet laws, Pediatrics, 7 July 2003, http://pediatrics.aappublications.org/cgi/eletters/110/5/e60

    5. Highway Safety Research Center, Effects of the helmet use law in British Columbia, http://www.hsrc.unc.edu/pubinfo/bike_bchelmets.htm

    6. Private correspondence from BC cyclists.

    7. Insurance Corporation of British Columbia, Traffic Collision Statistics, http://www.icbc.com/Library/research_papers/Traffic/index.html

    8. Lee AJ, Mann NP, Cycle Helmets, Arch Dis Child 2003;88: 465-466 http://press.psprings.co.uk/adc/june/ac220214.pdf

    9. Ontario Coalition for Better Cycling, Helmet Effect Undetectable in Fatality Trends, http://www.magma.ca/~ocbc/fatals.html

    Show Less
    Competing Interests: None declared.
  • Published on: (27 June 2003)
    Scant data on denominator flaws report
    • Douglas J Carnall, GP

    Dunleavy reports a 26% reduction in hospitalisations for bicycle related head injury in children in Ontario over the last 5 years, and uncritically attributes this to the province's compulsory helmet laws. <http://www.cmaj.ca/cgi/content/full/168/10/1313> She provides detailed data on injury rates but accepts uncritically the statement of the researcher that a recent paper demonstrates that compulsory helmet laws...

    Show More

    Dunleavy reports a 26% reduction in hospitalisations for bicycle related head injury in children in Ontario over the last 5 years, and uncritically attributes this to the province's compulsory helmet laws. <http://www.cmaj.ca/cgi/content/full/168/10/1313> She provides detailed data on injury rates but accepts uncritically the statement of the researcher that a recent paper demonstrates that compulsory helmet laws do not reduce bicycle use.

    The Injury Prevention website has several recent papers showing the law is an effective way to increase helmet use, there are none whose primary aim is to review the effects of helmet use on cycle use.

    Studies from Australia where cycle helmet use was made compulsory in 1990 suggested that the subsequent fall in cycle-related head injuries was related to the subsequent fall in cycling. <http://bmj.com/cgi/eletters/318/7197/1505/a> Given the beneficial effects of exercise, the change is entirely compatible with an overall reduction in the public health.

    And as pedestrian and motor vehicle occupant injuries and deaths outnumber those of pedal cyclists several fold, why has Ontario no laws making helmet wearing compulsory for those groups too? In fact, given the prevalence of accidental falls, why wait until you get out of the house to don your helmet? Risk averse legislators should logically make helmet wearing anywhere other than bed compulsory, though that ignores the risk that young children may fall from their cot or bed.

    Show Less
    Competing Interests: None declared.
  • Published on: (27 June 2003)
    The Need for Controls in Reported Observation
    • Malcolm J. Wardlaw, Research Engineer/cyclist safety campaigner

    “The Need for Controls in Reported Observation”

    Effective researchers have long respected the need for controls to avoid drawing flawed conclusions from seemingly persuasive evidence. In the recent commentary on time trends in bicycle-related head injuries in Ontario (CMAJ 2003;168:1313), it was reported that head injuries had fallen by 26% but the number of cyclist hospitalisations by only 12.5%. It was not m...

    Show More

    “The Need for Controls in Reported Observation”

    Effective researchers have long respected the need for controls to avoid drawing flawed conclusions from seemingly persuasive evidence. In the recent commentary on time trends in bicycle-related head injuries in Ontario (CMAJ 2003;168:1313), it was reported that head injuries had fallen by 26% but the number of cyclist hospitalisations by only 12.5%. It was not made clear whether the definition of head injury was restricted to “primary cause of hospitalisation”, or just any sort of head injury. The effect was assumed to be due to cycle helmet use, yet nowhere is this claim verified against a control trend of non-helmet users.

    Reference to a wider database of experience renders it unlikely that all of the above improvement was due to helmets. The state of Western Australia provides a uniquely fine record of serious road injuries dating back to 1973(1). Between the early 1980s and the late 1990s, serious head injuries as a proportion of all serious cycling injuries declined from c. 43% to c. 26%. During this time, helmet use increased from about nothing to c. 85% following law enforced during 1992-94. Yet the equivalent fall for pedestrians was not meaningfully less. Almost all the improvement must have been due to changes in diagnosis and less violent road crashes. Another study for New Zealand(2) covered the period 1989 to 1996. The proportion of serious injuries that were to the head declined by 30% as helmet use increased from a very low level to >90% following the well- obeyed law of 1994. Yet the control trend of unhelmeted non-cyclists followed exactly the same trend. No benefit could be attributed to such an uptake in helmet use. In the United States, the Consumer Product Safety Commission (CPSC) provides ongoing data on cycle use and injuries(3). It reports that during the 1990s, helmet use increased from under 20% to over 50%, yet the percentage of injuries that were to the head remained constant at 12%. One study in Britain claimed reduced head injuries from helmet use, but the observation was uncontrolled. In fact, the effect reported was due to the deep recession of the early 1990s4.

    Cycle helmets are not effective to prevent serious injury in the real world, or at least, not effective enough to matter. It is time to accept this reality, not bluff it off with bad science.

    Those who believe that an excessive focus on cycle helmets will not suppress cycling levels are deluding themselves. Cycle use has fallen sharply in every country where helmet promotion/compulsion has figured strongly. In New Zealand, the fall was 37% between 1989 and 1997(5). In Britain, the fall was around 30% during the 1990s(6). Countries such as the Netherlands that did not pursue promotion at least sustained cycling levels(7).

    The importance attached to cycle helmets is a mystery to those familiar with the actual risk of utility cycling. A recent study of on- road cycling demonstrated that the risks lie comfortably within the range of risks faced by drivers and pedestrians(8). In Britain, cycling is still one of the biggest childhood activities, yet just 4.5% of child leisure head injuries are cycle-related (of which only a quarter require hospital admission)(9). Only 0.9% (1,700/186,00) of all serious head injuries in Britain are due to cyclists in road traffic accidents. The belief that cycle helmets are required to meet some dreadful scale of injury is flatly contradicted by the evidence.

    If driving speeds fell nationally by just 5 mph, how many lives would be saved? How much more walking and cycling would be encouraged by the benigner environment resulting? How much would that improve public health?

    References

    1. Hendrie D et al. An economic evaluation of the mandatory helmet legislation. University of Western Australia Public Health Department. www.transport.wa.gov.au/roadsafety/papers/bicycle_helmet_legislation.html 2. Scuffham et al study Scuffham P, Alsop J, Cryer C, Langley J. Head injuries to bicyclists and the New Zealand helmet laws. Accident Analysis and Prevention 2000;32:565-73. 3. Consumer Product Safety Commission data presented at www.bhsi.org/injuries.htm 4. Adams, Hillman et al. Cycle Helmets. British Medical Journal 2001;322:1063-5 5. Land Transport Authority of New Zealand data presented at: www.cosc.canterbury.ac.nz/~nigel/cycling2001 6. Department for Transport. Road Accidents in Great Britain; the Casualty Report. The Stationery Office. London. Various years. 7. Dutch bicycle policy in the 1990s, Chapter 3 in: The Dutch Bicycle Master Plan. Ministry for Transport, Public Works and Water Management, The Hague, March 1999. 8. Wardlaw M. Assessing the actual risks faced by cyclists. Traffic Engineering & Control. pp 420-424; Dec 2002. 9. The Department for Trade and Industry. 23rd Annual Report of the Leisure Accident Surveillance System. DTI. The Stationery Office. London 1999.

    Show Less
    Competing Interests: None declared.
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13 May 2003
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Natalie Dunleavy
CMAJ May 2003, 168 (10) 1313;
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