March is Brain Injury Awareness month.  Let’s kickoff with a discussion of prevention. This blog post is derived from an editorial I wrote after suffering a concussion.  The editorial was published in Optometry (the journal of the American Optometric Association) in 2010. 

helmets galore

I am an avid cyclist.  A few years ago, I went for a bike ride with a couple of friends.  It was a beautiful morning.  We were riding on familiar roads, with very little vehicular traffic.  I remember the sensation of riding over some rough road and then the split-second realization that I was going to fall, but I don’t remember hitting the road.  My friends immediately called 911. I spent the next several hours in the emergency room of the nearest hospital.  I had road rash all along the left side of my body, black and blue eyelids, a headache and a soreness along the left side of my head. I had multiple lacerations on my face, one of which required 8 stitches. I had a CT scan and was diagnosed with nothing worse than a concussion and I was able to walk out of the emergency room.

I WAS WEARING A PROPERLY FITTING HELMET AND PROTECTIVE EYEWEAR WHEN I CRASHED.  When I got home, I took a look at my helmet and my glasses.  The helmet had multiple cracks along the left side.  My helmet cracked but my head did not.  My “sports goggle”/prescription eyewear wasn’t even bent.  But most of the paint was scraped off the front of the frame and the lenses were deeply gouged.  The glasses will be replaced; my eyes, which cannot be replaced, required no treatment. I don’t like to think about what would have happened if I wasn’t wearing a helmet and protective eyewear.  They may have saved my life.  At the very least, they saved me from far more serious injury and resultant disabilities.

There are evidence-based reviews of the relationship between bicycle helmets and the prevention of head injuries. The first review examined whether helmets reduce the incidence of injuries resulting from a crash.[1] This review noted that head injury is the greatest risk faced by cyclists; they account for 1/3 of emergency room visits, 2/3 of hospital admissions and ¾ of deaths associated with cyclists’ injuries. This review concluded that helmets reduced the risk of head and brain injury by 63-88% across all age groups of cyclists. This protective effect was not dependent upon the cause of the crash and included crashes involving motor vehicles. A second review evaluated the effectiveness of non-legislative interventions on rates of helmet use among school-aged children.[2] These interventions included media campaigns, helmet distribution programs and school-based educational programs. The review concluded that the programs were successful at increasing the use of helmets, especially those that included the distribution of free helmets. However, no data was collected to evaluate whether there was any impact on the incidence of injuries. A third review examined studies evaluating the effectiveness of bicycle helmet legislation on helmet use and rates of head injury.[3] Helmet use increased significantly by 45-85% with helmet legislation, and head injuries decreased. Currently, legislation mandating the use of bicycle helmets varies significantly across jurisdictions. In Australia, for example, bicycle riders of all ages are required to wear a helmet. In the United States, 21 states, the District of Columbia and 200 cities and municipalities have bicycle helmet laws.[4] However, the majority of these laws apply only to children under the age of 16.

Of course helmets are not reserved for cyclists. It has been estimated that 44% of all head injuries sustained during snowboarding and skiing could be prevented by the use of helmets. Among children, helmet use could reduce the incidence of head injuries by as much as 53%. However, observational studies report helmet use among skiers and snowboarders as low as 12%.[5]   Ski resorts are implementing programs aimed at increasing the use of helmets and changing ski resort culture. Many resorts now require their employees (ski patrollers and instructors) to wear helmets.[6]

Helmet use significantly reduces the incidence of head injuries among skateboarders as well, but once again, despite compelling evidence of the protection provided by helmets, the use of helmets is very low. In one study, only 7.2% of skateboarders requiring hospitalization were wearing helmets when injured. Unfortunately, skateboarders older than 16 years are less likely to wear helmets than younger children, which may contribute to the higher incidence of severe head injury in that age group.[7] Similar patterns of helmet use have been noted in skaters. In a population of children between 1 and 18 years of age treated for skating-related injuries in the emergency room of an urban hospital, 76.5% were not wearing ANY protective equipment of any kind.[8] The incidence of head injuries for ice skaters was notably higher when compared with other types of skaters.[9] Children should wear helmets during ALL recreational skating activities, but especially ice skating.

The number of eye injuries associated with sports and recreational activities may be as high as 100,000 per year,[10] but the use of protective eyewear is woefully inadequate. In reports evaluating data from the National Health Interview Survey, only 32% of adults[11] and 15% of children[12] reported wearing protective eyewear when engaged in activities that could cause eye injuries. Among adults, only 15.3% of 18-24 year olds reported wearing protective eyewear.9 Prescription glasses with polycarbonate lenses are not adequate. In fact “streetwear” may impose an additional risk. Although the number of eye-injuries related to eyeglasses is only a small percentage of all eye injuries treated in emergency rooms, most of them can be prevented with appropriate protective eyewear.[13]

Many disabilities, including visual disabilities, cannot be prevented.  They result from genetic disorders, disease processes, or aging. But some disabilities can be prevented. Public health organizations do their best to provide education concerning prevention, and in a few instances, prevention is legislated (seatbelts, no smoking laws, etc.).  Most of the time, it is the individual who must choose.  I have chosen to invest in myself. I will continue to wear protective eyewear and a helmet, and  demand the same from my family members. Now I must reach out to my community and help others choose prevention. After telling my story to anyone who will listen, I have convinced at least 3 people to purchase helmets and protective eyewear.

The American Optometric Association Eye Safety Project Team 10 outlined 4 levels that must be addressed with patients in order to change their behavior: perceived susceptibility, perceived severity, perceived benefit and perceived barriers. Patients must understand that this can happen to them; that the consequences can be devastating; that they can choose prevention; and that the downside is very limited. These conversations must occur at every patient visit to prevent life-threatening injuries or lifelong disabilities.  I hope that this editorial stimulates those discussions and encourages many more individuals to choose prevention to be safer when engaged in activities associated with head and eye injuries.

[1] Thompson DC, Rivara FP, Thompson R. Helemts for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev 1999;4:CD001855.

[2] Royal ST, Kendrick D, Coleman T. Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database Syst Rev 2005;2:CD003985.

[3] Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database Syst Rev 2007;2:CD005401.

[4] Bicycle Helmet Safety Institute. Helmet laws for bicycle riders. Revised July 1, 2010. Available at: Accessed July 14, 2010.

[5] Ackery A, Hagel BE, Provvidenza C, Tator CH. An international review of head and spinal cord injuries in alpine skiing and snowboarding. Inj Prev 2007;13:368-75.

[6] Cusimano MD, Kwok J. Skiers, snowboarders and safety helmets. JAMA 2010;303:661-2.

[7] Lustenberger T, Talving P, Barmparas G, Schnuriger B, Lam L, Demetriades D. Skateboard –related injuries: not to be taken lightly. A national trauma databank analysis. J Trauma 2010.

[8] McGeehan J, Shields BJ, Smith GA. Children should wear helmets while ice-skating: a comparison of skating-related injuries. Peidatrics 2004;114:124-8.

[9] Knox CL, Comstock RD, McGeehan J, et al. Differences in the risk assiociated with head injury for pediatric ice skaters, roller skaters and in-line skaters. Peadiatrics 2006;118:549-54.

[10] American Optometric Association Eye Safety Project Team. Eye safety—you can make a difference. Optometry 2006; 201-4.

[11] Forrest KYZ, Call JM, Cavill WJ. The use of protective eyewear in U.S. adults: results from the 2002 National Health Interview Survey. Ophthalmic Epidemiology 2008;15:37-41.

[12] Matter KC, Sinclair SA, Xiang H. The use of protective eyewear in U.S. children: results from the 2002 National Health Interview Survey. Ophthalmic Epidemiology 2007;14:37-43.

[13] Sinclair SA, Smith GA, Xiang H. Eyeglass-related injuries treated in U.S. emergency departments in 2002-2003. Ophthalmic Epidemiology 2006;13:23-30.