Bicycle Helmets: Don't Say Something by Not Saying Something : Clinical Journal of Sport Medicine

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Bicycle Helmets

Don't Say Something by Not Saying Something

Maitland, Murray E. PhD

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Clinical Journal of Sport Medicine 23(6):p 415-416, November 2013. | DOI: 10.1097/JSM.0000000000000037
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Bicycle helmets work. I've tested them. Sometimes, the most innocent ride can result in a crash, and the consequences can range from something relatively harmless to emergency room quality.

As an example, our small group of 4 cyclists rode through a residential area when a dog ran out of a yard and into our group. The dog hit my front wheel causing me to be flung over my handlebars. The front of my helmet took the entire brunt of 70 kg traveling 30 kph. My first response was hoping that nobody would ask me to count backwards by sevens, since I normally don't do very well. The crash was no big deal this time.

The incident with the dog was very similar to a previous experience with a young child. He ran from the sidewalk into my line of travel on the road. In that incident, 70 kg was moving at over 50 kph. I launched myself over the handle bars and over the child. Both of us were a little shaken, but we were both fine otherwise.

Trees, rocks, and cars have provided other test modes over the years. In other crashes, my bike has slid out from under me because of oil, leaves, gravel, road edges, and flat tires. So far, the helmets have won the skirmishes even though other parts of my anatomy haven't fared so well.

Goudie and Page1 provide an update of the Canadian Academy of Sport and Exercise Medicine (CASEM) position statement on mandatory helmet laws. They provide support for the premise that wearing a bicycle helmet is a risk-moderating behavior. The authors draw from Canadian studies, Cochrane Library reviews, and representative peer-reviewed literature, as well as professional opinions. The authors reiterate the summary of an earlier paper by Thompson et al2 that states “helmets reduce bicycle-related head and facial injuries for bicyclists of all ages involved in all types of crashes, including those involving motor vehicles.”

The position statement is an important public reinforcement of safe cycling standards. For the clinician, the reference list provided by the Goudie and Page1 review is not as extensive or as current as it could be. Also, the controversies are not as well described as they might be. At the risk of reducing this editorial to another review, current references in support of helmet use and legislation are included here, along with some information on finding arguments against these premises.

Generally, recent literature provides additional support from around the world. Boufous et al3 studied 6432 cyclist crashes in Victoria, Australia. According to the authors, their data “indicates the need for further promotion and enforcement of helmet use, particularly among children.” Olivier et al4 concluded that their study shows that the beneficial effect of mandatory helmet laws in New South Wales has been maintained over 2 decades. Gomei et al5 concluded that “to effectively reduce bicyclist fatalities from traffic accidents (in Japan), helmet use should be required for all bicyclists.”

Observational studies remain the foundation of the helmet/no helmet discussions. In addition to observational studies, a recent modeling study found that bicycle helmets reduced the probability of head and neck injuries, and helmets did not have negative implications for severity.6

Bicycle education and helmet promotion programs, with all of their effectiveness issues, can be beneficial.7,8 However, helmet usage programs by themselves do not generate the adherence that can prevent a significant number of tragedies. A recent Canadian study9 of school-aged children found that among bicycle riders, 43% reported never wearing and 32% inconsistently wearing a helmet. While it is simplistic to say the legislation will solve this problem, laws seem to help. Karkhaneh et al10 reviewed 41 270 emergency room visits and 2782 hospitalizations for bicyclists in Alberta, Canada. Comparing bicyclist and pedestrian trends in head injuries suggested a bicycle helmet legislation effect. All the positive press isn't the entire story though. For all the recent literature, one merely needs to “people-watch” and read more deeply in the literature to understand that reality is a little more complex.

Yesterday, a young person in scrubs rode their bicycle through the “No Cycling - Pedestrian Zone” in front of the University of Washington Medical Center. Music was audible from their headphones. They weren't wearing a helmet. How ironic if, after counseling patients on behavioral health risks, they acquired a traumatic brain injury falling off a bicycle without a helmet. I felt compelled to ask what other rule-breaking behaviors she would demonstrate that day, but I just walked past her.

Are you, the healthcare professional, saying something by not saying something? Patients, the public, and other healthcare professionals are looking to you as a resource and role model. Not bringing attention to helmet use during sports suggests acceptance of the behavior.

Like any other risky health behavior, in sports with head impact steps for risk modification such as helmet adherence should be stated and restated. The CASEM position statement does this very clearly. Healthcare professionals should have ready access to this position statement, knowledge of other supporting literature (as well as the controversies), patient education materials, and contact information for local programs that support the CASEM position statement objectives. For example, in Seattle, we have the Kohl's bike, ski, snowboard and multisport helmet program at Seattle Children's Hospital.11

Interestingly, the CASEM position statement does not mention mountain bikes or differences in various cycling sports. The most recent study of mountain biking and helmets was identified through a PubMed search.12 In that observational study, only 1 of the injured cyclists was not wearing a helmet. The authors remark that the high level of helmet use by mountain bike enthusiasts demonstrates the utility of protective equipment. They also remark that “of those whose helmet shattered on impact, 68% suffered no head injury, suggesting that modern helmets afford the wearer good protection.” Unfortunately, cohort studies lend themselves to multiple interpretations.

The current CASEM position statement is not an unbiased academic paper, and it is difficult to find meaningful discussion of alternative interpretations and contrary perspectives or issues. Importantly, one must consider the opposing arguments regarding the efficacy and effectiveness of helmets, and even alternate mechanisms of injury, that have been raised repeatedly. For example, Dennis et al13 concluded that “the incremental contribution of provincial helmet legislation to reduce hospital admissions for head injuries seems to have been minimal.” For a broad overview of the issues opposing helmet promotion and helmet laws see This group keeps a running list of literature that “cast doubt on the effectiveness of cycle helmets in reducing head injuries…, or on the wisdom of helmet promotion or laws.” Realistically, I understand the effects of fashion, comfort, cost, convenience, herd behaviors, and controversial issues. Like seat belts, all that controversy with helmets will hopefully provide better equipment and safety in the long run.

At the end of the day though, my current experience and review of the literature support mandatory use of helmets. The United States National Highway Traffic Safety Administration simply says: “Everyone, regardless of age or cycling experience, should wear a bike helmet.”15 Promotion of healthy behaviors, such as cycling, should be accompanied by patient education on risk-minimization like helmets, lights at night, and safer routes. If you don't say something, you're saying something.


1. Goudie R, Page JL. Canadian Academy of Sport and Exercise Medicine position statement: mandatory use of bicycle helmets. Clin J Sport Med. 2013;23:417–418.
2. Thompson DC, Rivara F, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 1999;CD001855. doi: 10.1002/14651858.CD001855.
3. Boufous S, Rome LD, Senserrick T, et al.. Risk factors for severe injury in cyclists involved in traffic crashes in Victoria, Australia. Accid Anal Prev. 2012;49:404–409.
4. Olivier J, Walter SR, Grzebieta RH. Long term bicycle related head injury trends for New South Wales, Australia following mandatory helmet legislation. Accid Anal Prev. 2013;50:1128–1134.
5. Gomei S, Hitosugi M, Ikegami K, et al.. Assessing injury severity in bicyclists involved in traffic accidents to more effectively prevent fatal bicycle injuries in Japan [published online ahead of print August 14, 2013]. Med Sci Law. doi: 10.1177/0025802413481011.
6. McNally DS, Rosenberg NM. MADYMO simulation of children in cycle accidents: a novel approach in risk assessment. Accid Anal Prev. 2013;59:469–478.
7. Cusimano MD, Faress A, Luong WP, et al.. Evaluation of a bicycle helmet safety program for children. Can J Neurol Sci. 2013;40:710–716.
8. Nolén S, Ekman R, Lindqvist K. Bicycle helmet use in Sweden during the 1990s and in the future. Health Promot Int. 2005;20:33–40.
9. Davison CM, Torunian M, Walsh P, et al.. Bicycle helmet use and bicycling-related injury among young Canadians: an equity analysis. Int J Equity Health. 2013;12:48.
10. Karkhaneh M, Rowe BH, Saunders LD, et al.. Trends in head injuries associated with mandatory bicycle helmet legislation targeting children and adolescents. Accid Anal Prev. 2013;59:206–212.
11. Seattle Children's Hospital, Research and Foundation. Kohl's helmet safety program at Seattle Children's. Accessed August 25, 2013.
12. Aitken SA, Biant LC, Court-Brown CM. Recreational mountain biking injuries. Emerg Med J. 2011;28:274–279.
13. Dennis J, Ramsay T, Turgeon AF, et al.. Helmet legislation and admissions to hospital for cycling related head injuries in Canadian provinces and territories: interrupted time series analysis. BMJ. 2013;346:f2674.
14. Bicycle Helmet Research Foundation. Published evidence sceptical of helmet effectiveness or promotion. Accessed August 25, 2013.
15. National Highway Traffic Safety Administration. Bicycles. Accessed August 25, 2013.
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