Helmet use and risk of head injuries in alpine skiers and snowboarders: changes after an interval of one decade Steinar Sulheim, 1,2 Arne Ekeland, 3 Ingar Holme, 2 Roald Bahr 2 1 Orthopaedic Department, Gjoevik hospital, SIHF, Gjøvik, Norway 2 Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway 3 Martina Hansens Hospital, Baerum, Norway Correspondence to Dr Steinar Sulheim, Orthopaedic Department, Gjoevik hospital, SIHF, Kyrre Grepps gate 11, Gjøvik 2819, Norway; steinar.sulheim@ sykehuset-innlandet.no Accepted 3 July 2016 Published Online First 16 August 2016 To cite: Sulheim S, Ekeland A, Holme I, et al. Br J Sports Med 2017;51:44– 50. ABSTRACT Background In a previous study, we concluded that a safety helmet can reduce the risk for head injury by 60%. Other studies reported similar effects, resulting in a general recommendation to wear a helmet while skiing or snowboarding. Aim To determine the effect of the expected increased helmet wear on the risk of head injury one decade after the recommendation. Methods Ski patrols reported injury cases in major Norwegian alpine ski resorts. Injury type, helmet use and other risk factors were recorded. A multiple logistic regression analysis was used to assess the relation between individual risk factors and the risk of head injuries by comparing head injured skiers (cases) with skiers and snowboarders who reported other injuries (controls). Results Helmet use was associated with improved odds for head injuries (OR: 0.45, 95% CI 0.34 to 0.60; p<0.001) in 2002; this effect was attenuated in 2010 (OR: 0.79, 95% CI 0.63 to 0.98; p=0.02), and not significant in 2011 (OR: 0.80, 95% CI 0.60 to 1.06; p=0.12). For potentially severe head injuries, the protective effect of using a helmet was better sustained over the observation period, from an OR of 0.44 (95% CI 0.28 to 0.68, p<0.001) in 2002 to an OR of 0.74 (95% CI 0.57 to 0.97, p=0.02) in 2010 and 0.67 (95% CI 0.47 to 0.96; p=0.03) in 2011. Conclusions We observed an unexpected reduction in the protective effect of a skiing helmet. This may be due to new skiing trends in the alpine resorts. INTRODUCTION Helmet use in alpine skiing and snowboarding has been a contentious issue for many years. Haid first introduced the issue of wearing a safety helmet while skiing in 1955. 1 Mandatory helmet use for children up to 17 years was first advocated in 1983. 2 Still, helmet use among adults did not become common until the current decade, after several studies had led to the same conclusion that head injury risk among skiers and snowboarders is reduced by wearing a helmet and with no evidence of increased risk of neck injury. 3–8 In 2005, Hagel et al 4 reported a 29% reduction in head injury risk for skiers and snowboarders wearing a helmet at 19 ski areas in Quebec, Canada. On the basis of a case–control study in eight major Norwegian alpine resorts during the 2002 winter season, comparing 3277 injured skiers and snowboarders with 2992 non-injured controls, we concluded that using a helmet was associated with a 60% reduction in the risk for head injury (57% for severe head injuries). 3 In 2008, Mueller et al 9 reported a 15% reduction in head injuries with helmet use. Another study looked at head, face and neck injuries among children, and found an increased risk among those who did not wear a helmet. 5 A retrospective cohort study by Greve et al 10 showed a 5.8-fold decreased incidence in loss of consciousness when hitting the head when using a skiing helmet. Rhugani et al, 11 in a retro- spective study of skiers with skull fractures, reported that the risk of a skull fracture was 10.5-fold higher among those not wearing a helmet compared with helmet users. On the basis of self- reported injury data from 2986 neck injured skiers and snowboarders in Quebec covering the period from 1995–1996 to 2004–2005, Hagel et al 12 con- cluded that helmets did not increase the risk of neck injuries or cervical spine fractures in skiers and snowboarders. On the basis of the above studies, recent reviews have also concluded that safety helmets decrease the risk and severity of head injuries in alpine skiing and snowboarding by roughly 40%, without increasing the risk of neck injuries or risk-taking behaviour. 6 7 13 According to the 2012/2013 National Ski Areas Association (NSAA) National Demographic Study, 70% of skiers and snowboarders wore helmets, a dramatic increase from the 2002/2003 season, when only 25% wore helmets. 14 We therefore wanted to repeat our study on Norwegian skiers and snow- boarders, 3 expecting to find a similar increase in the proportion of helmet users and hypothesising that, as a consequence, there would be a substantial reduction in head injuries. METHODS Ski patrols at major Norwegian ski resorts registered injuries during the 2002, 2010 and 2011 winter seasons. This study was based on anonymised data from the Norwegian Ski Lift Association injury and marketing research databases. An injury was recorded when a skier or snow- boarder was treated by or consulted the ski patrol or first aid room staff after an injury in the skiing/ snowboarding area during skiing/snowboarding or lift transport. To qualify for the ski patrol, the per- sonnel are required to go through a structured pro- gramme of first aid education. A standard form was used to record personal data (age, gender, national- ity), as well as information about equipment used (alpine skis, telemark skis (turning with free heel lift), snowboard, sleigh or other), the use of helmet (yes/no), rented or own equipment (yes/no), previ- ous ski school attendance (yes/no) and skiing Sulheim S, et al. Br J Sports Med 2017;51:44–50. doi:10.1136/bjsports-2015-095798 1 of 7 Original article on November 26, 2021 by guest. Protected by copyright. http://bjsm.bmj.com/ Br J Sports Med: first published as 10.1136/bjsports-2015-095798 on 16 August 2016. Downloaded from