The Canadian Paediatric Society has called for legislation mandating helmet use for all skiers and snowboarders. The Society says that through mandatory helmet legislation, governments can send a strong message that helmets are important and reduce the risk of brain injury and disability.

For the record, I am a strong advocate for helmets for skiers and snowboarders and have been so for years. I just do not support, with all its attendant issues and challenges, mandating their use. Public education and public awareness is more effective, cheaper, no public/user push-back, etc, etc. And with no taxpayer-funded inspectors roaming these facilities armed with citation books and empowered to hand out fines and other penalties.

Terrible tragedies, including the skiing death of actress Natasha Richardson at Quebec’s Mont Tremblant in 2009, always spark discussion and debate about wearing a helmet when skiing or snowboarding. Should skiers and snowboarders wear helmets?  Without question, the answer is yes!  Helmets are proven critical life-saving and injury -prevention equipment. A Norwegian study published in February 2006 in the Journal of the American Medical Association found that using a helmet was associated with a 60 percent reduction in the risk of head injury. Blows to the head are among the most devastating and lethal types of injury. Although head injuries are quite rare, an estimated 60 percent of skiing fatalities involve a head injury. Even if it is not fatal, such an injury can have lifelong consequences.

Some experts do question whether helmet use also prevent the most serious types of head injuries while skiing and snowboarding. Dr. Jasper Shealy, an American researcher who is recognized as an expert on the subject, supports helmet use but points out the rate of skiing fatalities has not dropped despite much greater helmet use on the slopes. In other words, helmets just cannot prevent catstrophic injuries in some ski hill accidents.

While children are most likely to wear a helmet, the recent surge in helmet use on Canadian hills, according to the Canada Safety Council, is reflected in all age groups. Today’s helmets are so light and stylish that many skiers consider them not only effective safety equipment but also as a fashion accessory. According to the Canadian Ski Council, helmet use has risen dramatically over the last few years for skiers and snowboarders. Nova Scotia, which recently passed legislation mandating helmet use,  already had one of the highest rates of helmet use on ski hills in Canada at 88 %.

The Canada Safety Council does not favour mandatory helmet use, which brings into question enforcement and its related challenges. Public education, public awareness, commonsense, adults and parents teaching by example, and working with operators to further educate skiers and snowboarders  are the way to go to get that many more skiers and snowboarders to wear helmets on the slopes.

Emile Therien,
Public Health and Safety Advocate,
Past President, Canada Safety Council,
326 Frost Avenue,
Ottawa. ON.
Tel:613-737-4965.

Related BJSM articles

Sports helmets now and in the future. 2011. Andrew Stuart McIntosh, Thor Einar Andersen, and Roald Bahr et al. 

The effectiveness of helmet wear in skiers and snowboarders: a systematic review. 2010. Michael D Cusimano, Judith Kwok.

Related BJSM Blogs

Injury prevention in high level snowboard: A need to return to first principles?

Is high level snowboard too dangerous to allow your children to participate?

Concussion: how do we reconcile risk-averse policies with risk-taking sports

We join the world in mourning Sarah Burke

Concussion Position Statement: Why it’s not a KO.

By @DrJohnOrchard

I have just started working in my 15^th season as a professional NRL (National Rugby League, Australia) team doctor but with respect to one injury feel as uneasy as I ever have at any stage of working in sports medicine. In theory I should be more experienced and therefore more relaxed at being able to cope with what the game can throw up at me. I am worried about one of my players suffering a minor concussion in a game, which is almost certainly going to happen in the next 6-8 weeks.

I’m not worried about one of my players suffering a significant concussion, which probably also will happen. By significant, I mean either than he is knocked out (for, say, >=10 seconds) or he is disoriented and reports are coming through that he doesn’t know where he is or what he is doing in the match. In this situation, the management will be simple – the player will come off the ground, I’ll recommend that he doesn’t come back on and the coaching staff for my team (who have a very responsible attitude towards injured players) will take my advice, with the player done for the day.

Why am I more worried about the so-called ‘minor’ concussion than the more serious one? Because the NRL has just brought in a rule that if a doctor assesses a player as having had a concussion (irrespective of whether he has been deemed to have recovered), then the player must not be allowed to return to play in that game. In bringing this zero-tolerance rule in, the NRL are following international trends and appearing to be doing the right thing by players. The problem is that the NRL haven’t really properly defined concussion (which doesn’t distinguish them too badly as even the consensus panels struggle to give a good definition) and, more importantly, haven’t defined a severity cut-off. I’ve seen players in the NRL before get knocked out cold for 60 seconds, come off on a Medicab, and 20 minutes later return to the field. I agree that this is not a good look and in the current climate we need to stop it happening with rule changes. So there is a part of me that is happy that the regulators are trying to stamp this sort of practice out.

The part of me that isn’t comfortable came out at an internal club meeting we had the other day. I told the coaching and training staff that the new official rule was that if I examined a player and determined that he had been concussed that day that, under the new rules, I couldn’t let him return to the field and the club couldn’t overrule me. However, it was quickly pointed out, if I didn’t examine the player, then the rules would allow him to continue. I think everyone can see where this is heading. An anonymous NRL player has blatantly recorded in the Sydney papers that players will avoid doctors and lie to them to make sure they aren’t removed from the field under the new rules.

Thus, I am either going to be put in one of the 3 uncomfortable positions very soon:

1. That I am going to be pulling players out of the game who I have been comfortable letting continue for many years, and possibly hurting our team’s chances of winning games.
2. That I am going to turn a blind eye and not examine or fully assess a player who looks as though he is fit to continue.
3.  That I am going to re-name something I used to call “mild transient concussion” something different like “traumatic migraine” so the player can be allowed to continue, even though deep down I think that the player has probably had a very mild concussion that has quickly recovered.

Over the past 14 years I have overseen about 10000 player games and have recorded approximately 250 concussions (about one in every 40 player games). I would also expect that maybe even second incident that could count as a concussion I wouldn’t even see/record (i.e. a player wouldn’t necessarily report symptoms to me). Of the 250 I did record, about 100 (less than half) left the field on the day, with 68 coming off for good and the other 32 being allowed to return to the game at some stage with a careful eye being kept on them by me and the on-field trainers. I am not aware of any of these players coming to long-term harm as a result of the concussions they have suffered – certainly none seemed to in the time that they were with the team.

I am aware that there is now a massive question mark over the long term effects of concussion, in that ex-footballers seem to have a higher rate than normal of erratic behaviour, including depression and suicide. The problem is whether you can pin these characteristics on concussion or simply playing professional team sport which attracts risk-taking, mood-swinging behaviour types. Cricketers are also renowned for having psychological issues post-retirement, yet the rate of concussion is very low. We obviously need some well conducted case-control studies (by well-conducted I mean where players with depression aren’t prompted to remember their previous concussions any more than players who are living happily). Sadly we aren’t going to get much further high quality research before we get the hysteria associated with the NFL concussion lawsuits, where retired players who have managed to blow their post-football life are going to have a crack at arguing that the concussions they received in the NFL were responsible. I’m not suggesting that they have no right to take action, but I think everyone can understand that in the absence of definitive scientific evidence that such a case will be decided by emotive arguments to a judge rather than a proven scientific link being established.

Will team doctors become the meat in the sandwich? Collision sports have rules which encourage a limited amount of violence and you win games by dominating the opposition players. If players are injured and come off the park, teams lose games. Perhaps there will be a trend for the leagues to pin the responsibility for player safety on the team doctors, yet the doctors get paid by the teams whose primary responsibility is to try to win games. One thing that the leagues can do, and which the NRL did very well last week, is crack down on high contact and increase penalties and suspensions to give a disincentive for players to tackle in such a way that concussions could result.

I was previously comfortable with a middle-ground approach to concussion – removing those who had moderate to severe symptoms from the game and watching those with mild symptoms which recovered quickly to make sure they didn’t get worse or become recurrent. It is probably a responsibility of the collision sports to ensure that players with moderate or severe concussions do not return to play on the same day (but to allow for enough substitutions so that teams aren’t disadvantaged by medically doing the right thing). A further dilemma for the contact sports is on how to handle the so-called ‘minor’ concussions where a player doesn’t get knocked unconscious but has transient symptoms lasting for less than a minute. Removing all of these players for the day is very problematic (and if it is mandated it becomes very difficult to police). No doubt it will be a major topic of discussion in the 4^th concussion in sport consensus statement conference  in Zurich this November.

Related BJSM Publications

International Olympic Committee’s special BJSM issue – Injury Prevention and Health Protection (IPHP): Read about that here.

BJSM publication of the proceedings of the 3rd International Conference on Concussion in Sport (Zurich 2008).

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John Orchard BA, MD, PhD, FACSP, FACSM, FFSEM (UK), is a Sports Physician, and an Adjunct Associate Professor at the University of Sydney, School of Public Health.

Concussion, concussion, concussion – has dominated the media over the past months. Major injuries to kids, research suggesting long-term problems, even the American Neurology Association updating their guidelines, now Sidney Crosby sits on the sidelines at millions of dollars a day.

BJSM afficionados will be aware but as we get new readers and blog followers daily, I don’t apologize for reminding you of free value in the following links:

The special issue of BJSM that followed the Zurich Concussion Consensus Meeting – this is the meeting that is driving the science – this was the evidence behind all the current change.

Particularly useful is Paul McCrory’s explanation of how to interpret the guidelines – via BJSM’s masterclass podcast.

Here’s the intro that goes with that podcast…

Part 3: You are the expert – you teach concussion to fellows and you can recite the SCAT2 even if you have profound headache and retrograde amnesia. Professor McCrory provides tips from the Consensus Statement that have you on the same page as the 27 experts in Zurich. And maybe you were one of them. Listen anyway, send any additional tips to the BJSM blog (http://blogs.bmj.com/bjsm/) and share the news of this practical podcast.

And then there is consensus statement itself – copublished in about 14 journals – a remarkable achievement in turning knowledge to action or ‘knowledge exchange’

As well as the practical forms to use on the sideline – the unfortunately named ‘SCAT2′ and ‘Pocket SCAT2′

Just  a short blog post today to alert you to lots of great free material on the home page. We didn’t get an Oscar for the ‘Mark Hutchinson’ physical exam videos but nomination can’t be far off. Learn to examine the knee, shoulder, hip/groin in this practical series. It’s free!

And in the blizzard of great free stuff on the internet it is easy to miss gems like the BJSM podcasts – there are about 15 interviews with leaders in sports medicine ranging across fields from ACL injuries and concussion to ‘exercise is medicine’.

The ACL series is particularly strong – hear from Engebretsen, Hewett and also the Scandinavian team who published in the NEJM last year – 3 different podcasts!

Paul McCrory walks you through the Zurich concussion consensus meeting – with 3 different podcasts customized to your level of experience.

And folks travel across the world to hear Stephen Blair explain why fit is more important than ‘thin’ – in a nutshell you need to exercise for health but carrying a few pounds is not a major health problem (other than for arthritis). Link to podcast here.

Please feel free to name who you would like to hear from via the comments section of this Blog or via direct emails to karim.khan@ubc.ca

We’ve had great feedback about the podcasts – try a recent one on your iPod, iPad or at the desk in the background while you take care of emails! Very convenient!

Concussion is certainly hot this week! Lots of news stories of variable quality. Today we review the International Consensus statement itself.

This practical resource was established, using a consensus-based approach, at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. It updates the recommendations of the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport. Click here to read the full document.

Key areas include:

• Management of acute simple concussion,
• complex concussion and long-term issues,
• Return to play,
• Paediatric concussion.

BJSMs podcasts also include 3 interviews with concussion guru Professor Paul McCrory, one of the leads on the Consensus statement.  See also this systematic review on helmets.

What do You Think? How has the Consensus Statement on Concussion in Sport shaped how you view and treat concussion?

Keep an eye on our homepage as an opinion poll will be posted shortly.

The American Association of Neurology has published a concussion position statement but the question is ‘Where is the reference to the international consensus’?

No-one would question that neurologists know about concussion but many of them would be the first to admit they are not experts in sport. How should an athlete train when returning to sport? Should a basketball player stay in the half-court or can she go full-court? When can a rugby player get back to the scrum? Definitely NOT in the NEUROLOGY CURRICULUM!

At a time when the credibility of medicine is being challenged on many fronts, disparate messages and silo thinking need to be minimized. Concussion was capably discussed at an international forum using NIH guidelines — relevant stakeholders were at the table and a consensus statement was published in numerous journals including Neurosurgery and also the Journal of Clinical Neuroscience.

The Consensus meeting represented 10 years of successful collaboration. The table of contents for this vibrant, multinational, interdisciplinary discussion highlights original data, debate and an overview that brought various disciplines under one roof.

We respectfully suggest the AAN position stand would have had even more credibility, and usefulness for a broad audience, if it had cited the 2009 Consensus Statement. As Heath and Heath suggest in their terrific book ‘Made to Stick‘, we need to provide clear, consistent, simple messages.

For those wanting more, listen to BJSM’s podcasts posted immediately after the Zurich meeting.