Are helmets effective in preventing or reducing ski/snowboard head and neck injury?

Two researchers – Hagel and Pless - have recently published a fairly exhaustive study that examines the effectiveness of ski and snowboard helmets. Persons with head or neck injuries came from 19 ski areas in Quebec, Canada. One thousand eighty two skiers and snowboarders (cases) with head and neck injuries reported by the ski patrol and 3,295 skiers and snowboarders (controls) with non-head or non-neck injuries were matched to cases at each hill.

Answer: Helmets may reduce the risk of head injuries in skiers and snowboarders.
For every 10 skiers or snowboarders wearing a helmet, three to six (29% to 56%) may avoid head injury. The authors say if the helmets were worn incorrectly or were in poor condition, this may even be an underestimate.

Inadequate evidence: The effect of helmet use on neck injuries is unclear.
The small number of neck injuries precluded control for more than a few covariates. A sensitivity analysis suggested an increased risk of neck injury with helmet use.

Commentary
In another paper reviewing the Hagel and Pless study, McKeag praises the authors for their study methodology but says the “downfall” of their research is due to the nature of public health. “It is extremely difficult in an epidemiologic study to demonstrate that a piece of equipment will prevent injury.” For example he questions:

1. Does the behavior of the person wearing the helmet bias and change the study? Studies have shown some wearers use more caution, some less than they would without a helmet.
2. Is any helmet as good as any other? In this study many different types of helmets were used with no apparent distinction of whether they had been tested or not.
3. Does wearing a helmet decrease the severity, rather than the incidence, of injury? Severity of injury was defined as requiring ambulance evacuation, which was determined by many different ski patrol members.

McKeag suggests that a better approach than case-control and case-crossover, might be to do an analysis of the snow sport crashes in terms of biomechanics in an effort to determine whether a helmet might have prevented head and/or neck injury.

References
Hagel BE, Pless IB, Goulet C, Platt RW, Robitaille Y, Effectiveness of helmets in skiers and snowboarders:case-control and case crossover study. BMJ 2005. Online citation: BMJ,doi:10.1136/bmj.38314.480035.7C(published 4 January 2005)

McKeag DB. Does wearing a helmet affect the risk of head and neck injuries in snow sports? Clin J Sport Med 2005; 15(6): 464-5. See also above online citation.

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