Helmets for recreational skiing and other winter sports in children and adolescents

Note: This report represents information and AMA policy on this subject as of December 1997.

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Resolution 418, introduced by the Resident Physicians Section at the 1996 Annual Meeting and referred to the Board of Trustees, asks: "That the American Medical Association (AMA) encourage recreational and competitive winter sports organizations to mandate the use of protective headgear by children and adolescents during their participation in winter sports including, but not limited to, skiing." Headgear (helmet) use is mandated for participants in amateur and professional ice hockey and for most professionals and amateurs who participate in alpine ski racing and other competitive winter sports. However, no mandate exists currently for recreational winter sports such as skiing or snowboarding. In considering a policy mandating that children and adolescents use helmets for recreational winter sports, the Council on Scientific Affairs (CSA) reviewed the medical literature on the incidence of serious and fatal head injuries from recreational skiing and snowboarding, evidence for the level of protection provided by currently available helmets, and the estimated cost-benefit ratio if such a mandate were enacted.  

Methods  

In-depth information on the incidence of recreational skiing injuries comes predominantly from an ongoing surveillance of injuries at a ski area in Vermont.^1-3 Sugarbush is a major ski resort in northern Vermont. Over a 25-year period, all injuries diagnosed at the resort's medical center have been monitored and categorized according to type, severity, and cause. Of relevance to this report are the number of people who had what Shealy and associates¹ termed, "Potentially Serious Head Injuries (PSHI)," which they defined as fatal head injuries, concussions, severe brain injury, and skull fracture.  

Information on the frequency of ski injury also comes from a 9-year study conducted at Mammoth-June ski resort in California.⁴ In this study, data were collected from accident reports provided by ski patrol and first-aid room staff, whereas in the Sugarbush study injuries were diagnosed by physicians in a medical clinic.^1-3 In addition, all head injuries were included in the analysis from Mammoth-June, rather than only potentially serious head injuries as was done in the study from Vermont.  

Using national estimated figures for the overall number of skiers (T. White, National Ski Areas Association. Personal communication, July 1997), and the rate of injury reported at Sugarbush,1 the estimated national rate of serious head injury per 1,000 skiers was calculated. The Sugarbush data used in this segment of the analysis included skiers of all ages.  

Other data from Sugarbush distinguish the number and rate of head injury between skiers under the age of 17 from those who are age 18 and older.² These data, however, do not classify the type of head injury. In order to estimate the frequency of the different categories of serious head injuries among young skiers, an assumption was made that the distribution of PSHI categories among this population is proportional to the distribution of categories described for skiers of all ages.¹  

Cost estimates for providing ski helmets to children and adolescents were calculated by using an estimate of the number of skiers under the age of 17 who would need helmets (either rental or purchase) at any one time. This figure was then multiplied by the discounted cost of purchasing an existing ski helmet.  

Estimates of the acute care and lifetime costs of managing skiers who suffered traumatic brain injuries (TBI) come from the American Re-Insurance Company (ARI).⁵ These estimates are based on the assumption that patients with TBI have a severe enough injury to be initially treated in a neurotrauma intensive care unit. ARI estimates both first year acute medical (including hospital care, physician costs, attendant care, behavior management, equipment, and home alteration) and annual lifetime costs (including costs for physician management, attendant care, home care, supplies and drugs, therapeutics, equipment, and hospital care costs) for the management of people with mild, moderate, and severe TBI. The health care costs of skiers who died were not included in these analyses. In that the classification of PSHI reported from Sugarbush¹ was not equivalent with the level of TBI, as defined by ARI,⁵ two assumptions were made in order to correlate the two sets of data. First, skiers who were classified as having a mild concussion were assumed to suffer a mild TBI. The second assumption was that skiers with the PSHI categories of moderate to severe concussion, severe brain injury, and skull fracture could not be classified as either moderate or severe TBI without further information. These groups were, therefore, collapsed and the resultant number used to estimate both moderate and severe TBI cost figures.  

In addition to reviewing the scientific literature on recreational ski and snowboarding injuries and on the use of helmets to prevent head injury from these sports, AMA staff also consulted with medical, engineering, and epidemiological experts and with the National Ski Areas Association. Finally, staff contacted 13 professional organizations and ski associations to determine their policy on mandating helmets for children and adolescents for recreational winter sports.  

Results  

Incidence and severity of head injuries in the general population  

Over a period of 15 ski seasons (1981 to 1997), a total of 11,795 injuries were diagnosed among skiers at Sugarbush.¹ As shown in   Table 1, 309 people (2.6 percent) were diagnosed as having PSHI. Three people (1 percent of PSHI cases) died, 10 (3.4 percent) had skull fractures, 8 (2.6 percent) had severe brain injuries, and 288 (94 percent) suffered concussions. Because there were 4,322,589 skier visits during the 15 ski seasons, the overall incidence of ski injuries was 2.7 per 1,000 ski visits, while the incidence for PSHI was 0.07 per 1,000 ski visits. These figures can be compared with results from the study of ski injuries that occurred at the Mammoth-June ski resort in California.⁴ In this study, the overall injury rate was 2.6 injuries per 1,000 ski visits, while the rate of head injuries was 0.24 per 1,000 ski visits.  

Epidemiological data suggest that although the incidence of ski injuries declined during the 1970s and 1980s, during the past decade the rate has remained stable, or possibly even increased slightly.^1,3,4,6 Over a 25-year period, the rate of serious head injuries at Sugarbush decreased by 10 percent from 0.79 to 0.70 injuries per 1,000 ski visit.¹ Because the overall rate of injury declined by 48 percent, however, the proportion of head injuries has actually increased. Among males, for example, serious head injuries increased from 1.5 percent to 2.9 percent of total injuries, while for skiers under 17 years of age the change was from 2.6 percent to 4.9 percent.  

There are an estimated 54 million ski visits annually in the United States (T. White, National Ski Areas Association. Personal communication, July 1997). Using this figure, and the rate of head injuries from Sugarbush,¹ an estimated 135,000 skiing-related injuries occur each year, of which 3,537 would be PSHI (Table 1). According to these calculations, an estimated 34 people die annually from skiing-related head injuries.  

Incidence and severity of head injuries among children and adolescents  

The epidemiological data discussed previously relate to skiers of all ages. Data on injuries to children and adolescents come from another study also conducted at Sugarbush.² In this study, a total of 5,748 skiers had an injury over 8 ski seasons, of which 175 (3 percent) were diagnosed as PSHI. Skiers under the age of 17 experienced 1,101 injuries (19 percent of the total number of injuries), of which 54 (4.9 percent) were diagnosed as PSHI. In contrast, 4,657 injuries were incurred by skiers age 18 years and older, 121 (2.6 percent) of which were PSHI. During the study interval, there were 381,702 skier visits by children and teenagers (14 percent of total visits) and 2,342,299 visits by skiers 18 and older. Thus, the incidence of PSHI was over twice as great for young skiers (0.14 PSHI per 1,000 ski visits) compared to older skiers (0.062 PSHI per 1,000 ski visits). Neither the specific type of head injuries nor the number of deaths were reported for either age group. Results from other studies, however, suggest that deaths among children and adolescents from recreational skiing are rare.^2,7  

Snowboarding is a popular winter sport, especially among adolescents. Approximately 15% to 18% of skiers at Sugarbush and other ski resorts are now snowboarders (T. White, National Ski Areas Association. Personal communication, July 1997; J.E. Shealy, Rochester Institute of Technology. Personal communication, July 1997). Data from several studies suggest that although injuries occur somewhat more frequently among snowboarders than among skiers, head, neck, and face trauma account for approximately equal proportions of snowboarding injuries and skiing injuries.^8-10 There are no current data on the incidence or severity of snowboarding injuries to children and adolescents.  

Protection provided by helmets  

The purpose of a helmet for skiers is to prevent or lessen the severity of head injuries that occur when the head strikes a fixed object. An appropriately designed helmet dissipates the energy of impact and protects the head from absorbing the total force of the blow. Although skiing injury results from a variety of mechanisms, such as falls, ski lift mishaps, and equipment failure, most serious injuries result from collisions with stationary objects.^7,11  

Based on the preventive health model of promoting helmets for the reduction of injury from bicycle accidents, a similar model for reducing injury during recreational skiing has an intrinsic logic. Results from case-controlled studies suggest that bicycle helmet use is associated with a reduction in severe brain injury of over 70%.^12-14 Unlike existing standards for bicycle helmets, however, there are no current biomechanical standards for the construction of helmets for recreational skiers. Also, in contrast to bicycle injuries, there are no epidemiological data on the degree of protection provided by currently available ski helmets.  

In January 1997 a subcommittee of the American Society for Testing and Materials (ASTM) examined a proposal to set performance specifications for protective headgear (helmets) used for recreational snow skiing and snowboarding. At present, this performance standard exists only as a proposal.¹ The proposed ASTM specification would ensure that a head inside an approved helmet would not experience peak accelerations more than 250 times the force of gravity when the helmet impacts a solid steel anvil at a velocity of 12.2 mph.¹ Data from studies using cadavers suggest that helmets with the proposed ASTM standards may prevent or ameliorate brain trauma that occurs from a direct impact at speeds below 12 mph or that results from an indirect or glancing blow.¹  

As noted by Shealy et al, 1 "To provide greater protection, such as a motorcycle helmet, that might cope with higher impact velocities, the helmet would be about three times as massive, and cost $200 to $500 each, and then would only raise the impact velocity target from 12.2 mph to 17 mph." Because the majority of the head injuries in recreational skiing are the result of glancing rather than direct blows, some degree of protection would be offered by the proposed ASTM standard helmet for recreational skiing and snowboarding--but for an indeterminate number of skiers.¹ For these skiers, helmet use might reduce the frequency and severity of mild or moderate concussion. Because most severe and fatal head injuries occur as a result of a direct impact with a fixed object at speeds greater than 20 mph (a speed reached by most skiers), the currently proposed ASTM standard would provide minimal protection for such injuries.^{1 ,7}  

Cost estimate of mandating the use of helmets  

Comparing the estimated cost of preventing a serious head injury with the estimated cost of treating the consequences of a serious head injury is one way to assess the benefit of a regulation mandating helmet use for recreational skiing. Although no such study has been done, the following analysis provides a rough estimate of the financial benefit that may occur from helmet use by children and adolescents.  

Of the estimated 11 million skiers in the United States (T. White, National Ski Areas Association. Personal communication, July 1997), 16% are under 17 years of age.¹ Assuming that a pool (rental and private) of 500,000 helmets is needed at any one time for this population and that ski helmets in the United States sell for a discounted retail cost of $105,¹ the total financial outlay for helmets would be an estimated $52.5 million. Given that the typical half-life for skiing equipment is 5 years, the total benefits of this financial outlay should be spread over a 5-year interval. A total of 5,482 PSHI can be projected to occur over a 5-year period among skiers under age 17 (31 percent of PSHI are to young skiers² x 3,537 estimated PSHI per year nationally to skiers of all ages x 5 years). Dividing the estimated cost for helmets ($52.5 million) by the number of skiers under age 17 projected over a 5-year period to suffer a head injury (5,482) yields an average cost of approximately $9,600 per injury avoided. This figure assumes that ski helmets are 100 percent effective in preventing serious head injuries. Using the more conservative figure of 70 percent effectiveness that is found with bicycle helmets,^12,13 a total of 3,837 head injuries would be avoided, resulting in an estimated cost of approximately $13,700 per injury avoided.  

Using data from Sugarbush, 17.2% of skiers with serious brain injuries,¹ or an estimated 607 skiers each year in the United States, would be initially diagnosed with either a moderate-to-severe concussion, a severe brain injury, or a skull fracture and would likely be transferred to a trauma center for evaluation and management. Assuming that skiers under age 17 constitute 31 percent of all serious head injuries² and assuming the type of head injury among younger skiers occurs in a distribution pattern similar to older skiers, an estimated 188 individuals under age 17 would have been initially diagnosed with a moderate-to-severe concussion, a severe brain injury, or a skull fracture. Applying these estimates to the cost estimates developed by ARI5 provides an estimate of the financial impact of serious head injuries nationally   (Table 2). First-year acute care costs for all skiers under age 17 range from an average of $1.5 million ($94,000 to $3 million) for patients with mild TBI, to $33.8 million for those with moderate TBI, to $82 million for those with severe TBI. Annual lifetime care costs, excluding first year costs, range from an average of $329,000 ($188,000 to $470,000) for mild TBI, to $2.8 million ($1.25 million to $4.4 million) for moderate TBI, to $8.96 million ($6.1 million to $11.8 million) for severe TBI.  

Recommendations of other national organizations  

The following national medical and ski organizations were contacted and questioned regarding their policy on mandating helmet use for children and adolescents in recreational skiing or snowboarding: The American Academy of Neurology, the American Association of Neurological Surgeons, the American Academy of Orthopaedic Surgeons, the American Academy of Osteopathic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Pediatrics, the American Academy of Physical Medicine and Rehabilitation, the American College of Emergency Medicine, the American Osteopathic Academy of Sports Medicine, the Brain Injury Association, the National Ski Patrol, the National Ski Areas Association, and the United States Consumer Product Safety Commission.  

As of July 1997, none of these organizations has any policy or recommendation regarding mandating helmets for winter recreational sports for children or adolescents.  

Discussion  

The results of data from two major ski areas indicate that injuries occur at a rate of approximately 2.7 per 1,000 ski visits. Head injuries comprise approximately 2.6 percent of all injuries, and occur at a rate of between 0.071 to 0.244 injuries per 1,000 ski visits. The range in rates probably depends on whether the head injury was diagnosed by medical staff or by people less well trained (eg, ski patrol or first aid staff). Although potentially serious head injury (PSHI) among recreational skiers and snowboarders under 17 years of age is relatively rare (an estimated 1,096 nationally per year), this population has about twice the risk of sustaining a PSHI as do older skiers (0.14 injuries vs 0.062 injuries per 1,000 ski visits).² The increased risk of PSHI among younger skiers may be due to faster speeds, reckless behavior, or less well-developed skills. Nationally, an estimated 34 skiers die annually from head injury; few of these, however, are children or adolescents.⁷ While improved and safer ski equipment and modern slope grooming techniques might have reduced the risk of certain injuries (eg, ankle, lower leg, and lacerations), the data also indicate that the rate of serious head injuries per 1,000 ski visits has declined less during the past 25 years than has the overall injury rate.¹ Possible explanations include the increased risk of collision with other skiers due to the growing popularity of the sport and an increase in speeds due to better equipment.  

Evidence presented in this report suggests that use of helmets by children and adolescents during recreational skiing and snowboarding might have some benefit in preventing serious head injury. The magnitude of risk reduction for the more severe injuries (ie, moderate-to-severe concussion, skull fracture, etc), is likely to be small because most skiers travel at speeds in excess of 20 mph and the proposed ASTM standards for ski helmets likely would offer protection only at speeds up to 12 mph.¹ Use of ski helmets in recreational skiing would, therefore, have the greatest effect in preventing mild concussions among skiers traveling at low speeds or in reducing the severity of potentially more serious head injury that results when skiers at a faster speed suffer a glancing blow (as opposed to direct impact with a stationary object).  

The success of the public health model in promoting helmets to reduce injuries from bicycle accidents raises the question of whether a similar model could be used to reduce head injuries among recreational skiers. From a cost perspective this approach is logical. The estimated cost per injury avoided with use of helmets by skiers under age 17 would be $13,700. This figure is substantially smaller than the acute ($8,150 to almost $500,000) or annual lifetime costs ($1,750 per year to $47,650 per year) for treating a skier with TBI. However, promoting helmet use through mandates is not currently practical due to the lack of strong public support. Reasons for the difference between public support for the use of helmets to prevent bicycle injuries compared to recreational skiing injuries include: (1) head injuries constitute a far greater percent of bicycle accident injuries (as much as 32%¹⁴ ) than of skiing injuries (under 5%⁶ ); (2) head injuries from bicycle accidents are more often associated with death (over 60%¹³ ) than are head injuries from skiing accidents (1%^1,5); and (3) standards for bicycle helmets are established and appear effective in reducing serious head injury, which is in contrast to ski helmets for which there are no current standards or data on effectiveness.  

A major limitation to the current analysis is the lack of in-depth data on skiing and snowboarding injuries among children and youth. Most data in the analysis comes from one ski area. It is unknown how these data compare to injuries elsewhere. In addition, because the type of serious head injuries that occur to young skiers is not known, various extrapolations and assumptions had to be made from data on skiers of all ages in order to provide national estimates and to calculate cost estimates. When interpreting these results, therefore, care must be taken to understand how both the cost per injury avoided and the cost for managing skiers with traumatic brain injury were determined.  

Summary  

The total number of serious head injuries suffered by young skiers and snowboarders is small compared to other skiing injuries. Young skiers do, however, have a greater risk for suffering a head injury than do older skiers. Although there are limited data on the effectiveness of helmets to prevent head injury among recreational skiers or to reduce the severity of injury, the experience with bicycles suggests that helmets may be beneficial. A cost analysis also suggests a potential benefit from helmet use when the estimated cost of injury avoided is compared to the estimated cost of either first year, acute medical management, or annual long-term care of skiers with traumatic brain injury. Because of the lack of data on children and youth, however, these cost results must be interpreted cautiously.  

Taken as a whole, there are insufficient data for the CSA to conclude that the AMA should adopt policy in support of mandatory helmet use for recreational skiing or snowboarding. This position is consistent with the position of other major medical and ski organizations.  

Recommendations  

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1997 AMA Interim Meeting.

1. The AMA supports the voluntary use of helmets and protective headgear for children and adolescents during recreational skiing and snowboarding. As of September 1997, there is insufficient scientific evidence to support a policy of mandatory helmet use.    
2. The AMA encourages further research into the epidemiology and outcome of head injuries to children and adolescents from recreational skiing and snowboarding and research on the development of helmets to prevent or reduce the severity of these injuries.    
3. The AMA encourages the American Society for Testing and Materials to finalize standards for ski helmets and study the effectiveness of ski helmets in preventing serious brain trauma.

References 

1. Shealy JE, Johnson RJ, Ettlinger CP. Helmets for recreational skiers and snowboarders: an idea whose time has come? Presented at the 1997 spring meeting of the International Society for Skiing Safety (XII International Congress on Skiing Trauma and Safety) in Whistler. BC.  
2. Delbert MC, Aronsson DD, Johnson RJ, Ettlinger CF, Shealy JE. Skiing injuries in children, adolescents, and adults. J Bone Joint Surgery. In press.  
3. Johnson JR, Ettlinger CF, Shealy JE. Skier injury trends--1972-1994. In: Johnson RJ, ed. Skiing Trauma and Safety: Ninth International Symposium . ASTM STP 1289. American Society for Testing and Evaluation. In press.  
4. Davidson TM, Laliotis AT. .Alpine skiing injuries-a nine year study. West J Med. 1996;164:310-314.  
5. American Re-Insurance Company. Guidelines for Reserving Traumatic Brain Injury. Princeton, NJ (undated).  
6. Shealy JE. Comparison of downhill ski injury patterns--1978-81 vs. 1988-90. In: Johnson RJ, Mote CD, Zelcer J, eds. Skiing Trauma and Safety. Ninth International Symposium. ASTM STP 1182. Philadelphia:American Society for Testing and Evaluation; 1993:23-32.  
7. Tough SC, Butt JC. A review of fatal injuries associated with downhill skiing. Am J Forensic Med Pathol. 1993;14:12-16. 
8. Shealy JE: Snowboard vs. downhill skiing injuries. In: Johnson RJ, Mote CD, Zelcer J, eds. Skiing Trauma and Safety: Ninth International Symposium. ASTM STP 1182. Philadelphia:American Society for Testing and Evaluation; 1993; 241-254.  
9. Prall JA, Winston KR, Brennan R. Severe snowboarding injuries. Injury. 1995;26:539-542.  
10. Bladin C, McCrory P. Snowboarding injuries-an overview. Sports Med. 1995;19:358-364.  
11. Shorter NA, Jensen PE, Harmon BJ, Mooney DP. Skiing injuries in children and adolescents. J Trauma. 1996;40:997-1001. 
12. Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries: a case control study. JAMA. 1996;276:1968-1973. 
13. Thompson DC, Nunn ME, Thompson RS, Rivara FP. Effectiveness of bicycle safety helmets in preventing serious facial injury. JAMA. 1996;276:1974-1975.  
14. Sacks JJ, Holmgreen P, Smith SM, Sosin DM. Bicycle associated head injuries and deaths in the United States from 1984 through 1988: how many are preventable? JAMA. 1991;266:3016-3018.

Table 1. Potentially Serious Head Injuries (PSHI) at Sugarbush, Vermont:
1981 through 1997²

Type of Injury	N*	Percent of PSHI	Percent of All Injuries	National Estimate of PSHI**
All Injuries	11,795		100%	135,000
All Injuries, Excluding PSHI	11,486		97.4%	131,463
All PSHI	309	100%	2.6%	3,537
Fatal head injuries	3	0.97%	0.04%	34
Skull Fracture	10	3.2%	0.08%	114
Severe brain injury	8	2.59%	0.07%	92
Concussion: moderate to severe	35	11.33%	0.3%	401
Concussion: mild	238	77%	2%	2,724
Concussion: unclassified	15	4.85%	0.13%	172

* Injuries include skiers of all ages
** National estimate is based on the rate of head injuries (number per 1,000 ski visits) from Sugarbush multiplied by the estimated number of ski visits nationally.

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Table 2. Estimated acute and lifetime costs of traumatic brain injury to skiers under age 17*

	Acute, first year medical care	Acute, first year medical care	Annual lifetime care	Annual lifetime care
	Per Person (ave)	Total Injured Population (ave)	Per Person (ave)	Total Injured Population (ave)
Mild TBI	$500-15,800 ($8,150)	$94,000-3M ($1.5M)	$1,000-2,500 ($1,750)	$188,000-470,000 ($329,000)
Moderate TBI	$179,000	$33.8M	$6,700-23,340 ($15,020)	$1.25M-4.4M ($2.8M)
Severe TBI	$435,950	$82M	$32,250-63,050 ($47,650)	$6.1M-11.8M ($8.96)

* Data from references 1, 2, and 14. Total population figures are based on an estimated 188 skiers under the age of 17 who have a serious head injury (moderate-to-severe concussion, severe brain injury, and skull fracture as defined in reference 1).

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