France, Le Tour, cycling injuries and cycle helmets
August 6, 2011 13 Comments
Welcome back following a short break in France, during which I spent a week in the Languedoc admiring the scenery and enjoying the French hospitality. Not everyone was as lucky as I was to be taking things easy, however, and Le Tour was in full swing during my time there, this being the 98th edition of the race since it was first held in 1903. The gruelling 21 stages run over 23 days covers a distance of 3430 km, and the race is a real test with a chequered and interesting history.
This year’s Tour was won by an Australian for the first time, Cadel Evans, who gained the lead on the penultimate day.
As usual, there were a number of casualties, mostly from crashes involving some high profile riders. These included Britain’s Bradley Wiggins who crashed out on stage 7 of Le Tour with a fractured clavicle during a pile-up which can be seen in this Guardian UK video footage . Others injured during the race included Andreas Klöden, Alexandre Vinokourov, Janez Brajcovic, Jurgen Van Den Broeck and Chris Horner who were all unable to continue the race due to their injuries.
Again this year, a large proportion of serious injuries were caused by collisions with vehicles, including an incident with a car involved with TV coverage which resulted in injuries to Juan Antonia Flecha and Johnny Hoogerland and led to Christian Prudhomme, Tour organiser, to say ‘It’s a scandal.’ Hoogerland’s dramatic lacerations following his collision with barbed wire can be seen in this image. In addition, Nikki Sorensen was struck by a photographer on his motorbike.
For a useful review of injuries associated with cycling, see this 2001 article by Thompson and Rivara published in American Family Physician.
Those of us who are perhaps more used to keeping safe whilst cycling in the streets might be more interested in this article published earlier this year in Injury Prevention by Lusk and colleagues, based on regional data from Montreal, which highlights the differences in injury rates between cycling on cycle tracks compared with comparable reference streets. The study found that the relative risk of injury on cycle tracks was 0.72 (95% CI 0.60 to 0.85) compared with cycling in reference streets, suggesting that the risk of injury from cycling on tracks is less than cycling in the streets.
A key element of road cycle safety surely has to be legislation for the mandatory use of helmets which still hasn’t found it’s way here in the UK. This is perhaps regretful – especially following the introduction of the London Cycle Hire Scheme which merely advises riders to consider wearing a cycle helmet . The British Medical Association currently supports the introduction of legislation, but this is opposed by the Transport and Health Study Group. Whether or not the position on mandatory laws for cycle helmets in the UK will change in the future may well depend on reaction following the recent publication of the ‘Health on the Move 2’ report .
Historically, Australia has taken the lead Internationally on compulsory cycle helmet laws which have been enforced there since 1990, with New Zealand following suit in 1994. Read more about issues related to cycle helmets in Australia and Internationally on this interesting Australian website.
A recent bmj.com poll on the compulsory wearing of helmets by adult cyclists resulted in 68% of respondents (n=1439) voting no to the idea of mandatory wearing of helmets. The BMJ blog led to a lively debate on the topic. Despite the controversy, I for one will continue to wear my cycle helmet whilst cycling on the roads.
Do you think that there should be world-wide mandatory legislation for cycle helmet wear for road cyclists? CJSM would like to hear your thoughts on this – feel free to post your comments on the blog.
Vote on our quick poll on the issue on our website front page here.
(Pictures from mIKL194FV and AFP)
About Chris Hughes
Clinical Journal of Sport Medicine Blog 
Yes I believe cycle helmets should be obligatory. An eminant A and E consultant once told me that they were lifesavers, particularly for the prevention of head injuries in children. If adults set a good example then kids on bikes will follow- and for that reason alone I think helmets should be mandatory.
Ann from Exercise Works!
The experience of countries where cycle helmets have been made mandatory has been the precisely the opposite. Just try asking anyone who has tried cycling in Australia or New Zealand. Then try talking to people who have cycled in Denmark or the Netherlands (the two countries with the worlds highest levels of cycling), and ask them how many people in those countries wear helmets? The answer is mostly tourists. The locals don’t, and yet these countries are not awash with cyclists suffering from head injuries.
The simple truth is cycling is not a particularly dangerous activity. Yes, we have all heard of an eminent Accident & Emergency Consultant who says that cycle helmets are lifesavers, and yet we never hear them advocating walking helmets, even though pedestrians are at a slightly greater risk of head injuries than cyclists (just check the figures). Nor do we hear them calling for compulsory motoring helmets, even though car occupants suffer a significantly greater risk of head injury! Why is this?
Why is it only cycling that gets such attention? A recent paper in the BMJ pointed out that the health benefits of cycling outweighed the risks by a factor of 77 to 1, and it is important to note that the ‘risks’ of cycling included deaths from air pollution and trauma, with the risk of death from air pollution being four times higher than the risk of death from trauma.
The risk of trauma is frequently exaggerated. I often hear that wearing a cycle helmet reduces the risk of head injury by 87%, but when I ask people where they get that figure from, they seldom know. It comes from Thompson, Rivara and Thompson 1987. No other authors have since come anywhere near this figure, including Thompson, Rivara and Thompson in their repeat study in 1996 (when using the same methodology, they came up with a figure of 64%). In the years since this paper, their methodology has been shown to be seriously flawed. There have also been a number of studies which have shown that cycle helmet can, under certain circumstances increase the risk of serious injury. Odd how the medical establishment is reluctant to quote these studies? An evidence based approach can be so inconvenient…
Absolutely not. The population studies on accident and injury prevention by cycle helmets indicate that they have doubtful benefit at best. In some instances cycle helmets can lead to greater injury than there would have been without. By all means continue to wear one if it makes you feel better, but there absolutely should not be any move towards compulsion. Cycling is not dangerous. You would save more lives by making pedestrians wear helmets. Or car drivers and passengers.
You would prevent more accidents and save more lives, if you simply got cyclists to look over their shoulders more often. Being safe (training/looking) and feeling safe (helmets/hi-vis) sit at opposite ends of the safety scale.
Cycling doesn’t have a head injury problem, so why are we trying to fix it? There are other more important health issues to worry about, and getting more people to cycle will go a long way to resolving those issues.
If you want to kill of cycling, by all means make helmets compulsory.
But then you need to come up with some plan for dealing with the vast increase in traffic casualties caused by the motor traffic that people will be forced to contribute to instead.
If you want to make cycling safer. increase the numbers cycling.
That is the only thing that has any provable benefit.
Since helmet promotion does the opposite (as it wrongly portrays cycling as dangerous, and has a provable effect in discouraging cycling), helmet promotion is actually bad for health.
There is still no evidence that it’s even possible (with current technology) to construct a helmet that is both wearable during extreme exertion and beneficial in reducing head injuries.
Certainly no current design has been shown to manage both in anything but an artificial laboratory test. The effect on actual head injury rates has been zero to negative.
Thanks for the invitation to participate in the discussion (via twitter). It is very nice to see a person who is himself leaning towards advocating helmet compulsion for cyclists, pointing to so many relatively high-quality sources that argue in a coherent and persuasive way against helmet compulsion.
This all leaves me with the question though : Having seen those arguments, where are the strong arguments that makes the author lean towards compulsion ?
Thanks for your comment, Morten. There is no doubt that this is a complicated subject. There is a heterogeneity of quality of evidence from studies available related to this issue, and there is limited applicability of the findings of different studies to different environments. The matter of legislation for the mandatory wearing of cycling helmets for cyclists using the roads remains a controversial one, and we are keen to hear everyone’s informed views on the topic. Bearing in mind the heirarchy of evidence and the limitations I have mentioned, Macpherson & Spinks published a Cochrane Systematic Review in 2008, concluding that bicycle helmet legislation appears to be effective in increasing helmet use and decreasing head injury rates in the populations for which it is implemented, although the authors did point out the limitations of their own conclusions.
As a Clinician who has spent some considerable time working in Accident and Emergency Departments, having to deal with the immediate consequences of a patient with a significant head injury sustained during road or recreational cycling acts as a powerful influencing factor on one’s own attitude. There are indeed many factors to consider when it comes to the safety of cyclists, and I am sure that most of us are very keen to maximise the safety of those of us (including myself) who choose this healthy mode of active travel. Having said that, it is important to remember that cycling is a relatively safe activity and associated with significant health benefits.It would be good to have definitive answers to the following questions :
1) Does wearing a cycle helmet reduce the risk of morbidity and mortality for cyclists on the roads (chiefly from head injuries)?
2) Does legislation for the mandatory wearing of cycle helmets ultimately lead to reduced morbidity and mortality for cyclists on the roads?
3) Are there definite adverse and / or unintended consequences of helmet wearing for cyclists on the roads, whether this is enforced or indeed encouraged?
4) If there are adverse and / or unintended consequences (either on an individual, or on a population level, for instance, a reduction in overall cycling participation), are these outweighed by any benefit to individual and population health from a mandatory enforcement policy?
Chris says, “… Macpherson & Spinks published a Cochrane Systematic Review in 2008, concluding that bicycle helmet legislation appears to be effective in increasing helmet use and decreasing head injury rates in the populations for which it is implemented …”
… but Alison MacPherson, one of the lead researchers in a number of related studies and a helmet law activist in Ontario, Canada, conceded in the journal Injury Prevention Sept 2010 that a decline in head injuries is not due to Canadian helmet laws as previously claimed.
You need to look skeptically at Canadian “research”. Activists are cherry-picking data and then publishing the results. The work you quote in the main article by Lusk et al concerning cycle tracks in Montreal lacks credibility since among other shortcomings it compares unlike streets and ignores confounding factors.
My second point would be that if we want to try to move forward in the debate, could we a agree on or at least discuss criteria that should be the most relevant for the helmet compulsion legislators ?
Very similar criteria would be pertinent for experts and professional bodies, cycling + road safety NGO’s , regarding recommendations on bicycle helmet compulsion.
Time and space does not permit me to be very thorough here, but here are some suggestions for important criteria :
1. Anecdotes and personal experience of crashes or, say, from the operating theatre are all but irrelevant for legislation and policy. The same goes for recommendations from professional bodies or even (other) NGO’s.
2. Peer reviewed reviews of studies of the net public health effect of helmet compulsion for cyclists would be amongst the strongest and most relevant decision foundations we could wish for. ( Some studies exists on the effects of compulsion laws, and evaluations of those studies have been done. )
3. A logical next step is to acknowledge that research on helmet efficiency not taking in the actual effects on public health in a compulsion setting, is close to irrelevant, if not firmly put in context with the compulsion studies.
4. Trying to establish if cycling is particularly dangerous is highly relevant. Compare risks to other groups, taking degree of seriousness and location + type of injury into account. (Informing this discussion : 1. Look at all-cause mortality for groups. [Research reviews strongly indicate those that cycle even short distances for transport get healthier and live longer. Dose-response effect confirmed ] 2. Does cycling pose risk to others, or is it chiefly the other way around ? )
5. What are the types of serious brain injuries, and what kinds of forces (or illnesses etc) cause them. How do they compare statistically
6. The standards of modern helmets. What are helmets built to ameliorate. What do forensic studies of bicycle helmets after accidents tell us ?
7. The civil liberties-, inconvenience- and scaremongering aspects are relevant to discuss, especially when comparing to other normal pursuits and modes of transport. Likewise victim-blaming (Not looking at the origin of the forces that cause the most serious injuries) and the (purported ?) culture of fear are relevant in the discussion. Finally and related to issues above : Are the societal benefits of cycling so great, that one should be more careful imposing restrictive measures than for other modes of transport (except walking) or sports activities ?
(Oops. That turned out more thorough , and long than I intended when I started. Sorry about that. )
I think it could be fruitful to discuss each of those points in turn, before reiterating, and be disciplined about it. (Possibly included with number 1 : A short discussion on the value + workings and shortcomings of science as a basis for societal decisions)
Your Questions, with answers from the published literature
1) Does wearing a cycle helmet reduce the risk of morbidity and mortality for cyclists on the roads (chiefly from head injuries)?
No. Available evidence strongly suggests ***increased risk*** of morbidity and mortality. We now have documented evidence of risk compensation. Drivers leave significantly less room when overtaking a helmeted cyclist[1]. The researcher, Dr Ian Walker, was hit twice when conducting this research – by a truck and a bus – both times when he was wearing a helmet! http://www.eurekalert.org/pub_releases/2006-09/uob-wah091106.php
Another study found that that cyclists accustomed to wearing helmets ride significantly faster (implying greater risk tolerance) when wearing helmets than without[2]. This is likely to increase the risk of crashing.
As discussed in the answer to Q2, evaluations of Australian helmet laws comparing cyclist and pedestrian injuries per km cycled shows that the number of head injuries post-law is higher than would have been expected without the law for observed post-law numbers of cyclists..
2) Does legislation for the mandatory wearing of cycle helmets ultimately lead to reduced morbidity and mortality for cyclists on the roads?
Helmet laws discourage cycling, so there are fewer people on the roads to get killed or injured. In order to answer this question, it is necessary to compare the change in injuries with the change in cycling.
In Victoria, post-law surveys counted 36% fewer cyclists (adult and children) at the same sites, observation periods and time of year[3]. Post-law surveys in New South Wales at the same sites, observation periods and time of year (available only for child cyclists) also showed a 36% reduction in numbers counted[3]. In Western Australia, the equivalent of 64% of adult cyclists said they would ride more except for the helmet law[4]. In New South Wales, 51% of schoolchildren owning bikes, who hadn’t cycled in the past week, cited helmet restrictions, substantially more than the numbers citing other reasons, including safety (18%) and parents (20%) [5]. Declines are also evident in census data on cycling to work. The 1.24% who cycled to work in 2006 (latest available data) is substantially less than the 1.68% who cycled before helmet laws were introduced[6]. Most people who dislike helmets probably gave up cycling, or (if too young to have cycled before the law) not seriously considered cycling as a means of transport. However, a national survey published this year reported that 16.5% of recent transport riders mentioned helmets as a barrier to cycling more often.[7]
After adjusting for the reduction in cycling, deaths and serious injuries to child cyclists increased from 43% to 65% of those for child pedestrians[3]. There is no reason to believe this would have happened without the law, suggesting a 51% increase in the risk of death or serious injury to child cyclists because of the helmet law.
A similar analysis comparing deaths and serious head injuries to pedestrians and cyclists (from crashes involving motor vehicles) in Victoria found a 26% reduction for pedestrians that was attributed to safer roads and increased use of speed cameras. Without the helmet law, a similar reduction would have been expected for cyclists. However, adjusting for the reduction in cycling, the reduction for cyclists was only 19% [8]. This again suggests that cyclists would have been safer without the helmet law.
Australia’s helmet laws therefore increased mortality and morbidity rates per km cycled, compared to what would have been expected without the law, perhaps because of risk compensation and reduced safety in numbers.
3) Are there definite adverse and / or unintended consequences of helmet wearing for cyclists on the roads, whether this is enforced or indeed encouraged?
Yes. An article in the British Medical Journal considered the health risks and benefits of users of the “Bicing” public bicycle sharing scheme in Barcelona, Spain. The researchers considered the 181,982 resident users of the bike share program and looked at deaths related to physical activity, road traffic incidents and exposure to air pollution. Compared with car users, the estimated annual change in mortality of the Barcelona residents using Bicing (n=181,982) was 0.03 deaths from road traffic incidents and 0.13 deaths from air pollution. As a result of physical activity, 12.46 deaths were avoided (benefit:risk ratio 77)[9].
A similar study in the Netherlands concluded that for individuals who shift from car to bicycle, the beneficial effects of increased physical activity are substantially larger (3–14 months gained) than the potential mortality effect of from increased risk of traffic accidents (5–9 days lost)[10]. Given the substantial evidence that helmet laws discourage cycling, this implies that they are detrimental to public health.
4) If there are adverse and / or unintended consequences (either on an individual, or on a population level, for instance, a reduction in overall cycling participation), are these outweighed by any benefit to individual and population health from a mandatory enforcement policy?
See answer to Q3.
Helmet legislation is controversial because governments and researchers would lose face if they admitted their mistakes. For example, the evaluation of Canadian helmet laws (by Alison Macpherson, author of the Cochrane Review you cite) doesn’t make sense if you read the companion paper showing that the law was not enforced and helmet wearing in Ontario returned to pre-law levels by 1999[11]. Since the law had no long-term effect on helmet-wearing rates, and the provinces that enacted bicycle helmet laws had greater declining trends in serious injuries to pedestrians (see graphs at http://www.bmj.com/content/332/7543/722.2.extract/reply#bmj_el_243531 ) Macpherson’s claims seems illogical.
Sadly, most people don’t take the time and trouble to look at the data, or piece together information that has to be gleaned from several publications. Well-meaning people often campaign for helmet laws thinking that helmets must do some good. Perhaps they do, but the statistics cited in the answer to Q3 show it is not enough to counteract the effects of risk compensation and reduced safety in numbers. If interested, http://www.cyclehelmets.org contains a lot of useful and relevant information.
Detailed references
1. Walker, I., Drivers overtaking bicyclists: Objective data on the effects of riding position, helmet use, vehicle type and apparent gender. Accident Analysis and Prevention, 2007. 39(2): p. 417-425.
2. Phillips, R.O., A. Fyhri, and F. Sagberg, Risk Compensation and Bicycle Helmets. Risk Analysis (epub published ahead of print), 2011.
3. Robinson, D.L., Head injuries and bicycle helmet laws. Accid Anal Prevent, 1996. 28: p. 463-475.
4. Heathcote, B. and G. Maisey, Bicycle use and attitudes to the helmet wearing law. Traffic Board of Western Australia, 1994, Traffic Board of Western Australia.
5. Blacktown City Council, Blacktown Bikeplan Study, Final Report. Sydney, 1993.
6. BHRF Changes in cycle use in Australia – http://www.cyclehelmets.org/1194.html (accessed August 2011).
7. Cycling Promotion Fund. Riding a bike for transport – 2011 survey findings. Canberra: Cycling Promotion Fund; 2011.
8. Robinson, D.L., Safety in Numbers in Australia: more walkers and bicyclists, safer walking and bicycling. Health Promotion Journal of Australia, 2005. 16(1): p. 47-51.
9. Rojas-Rueda, D., et al., The health risks and benefits of cycling in urban environments compared with car use: health impact assessment study. Bmj, 2011. 343.
10. de Hartog, J.J., et al., Do the health benefits of cycling outweigh the risks? Environmental Health Perspectives, 2010. 118(8): p. 1109.
11. Macpherson, A.K., et al., Economic disparity in bicycle helmet use by children six years after the introduction of legislation. Inj Prev, 2006. 12(4): p. 231-235.
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Further opinion and discussion on the topic of legislation on bicycle helmet wear can be found in this interesting Editorial by Ben Goldacre (of ‘Bad Science’ fame), with a linked Rapid Responses discussion, published in the British Medical Journal this month, entitled ‘Bicycle helmets and the law’ http://www.bmj.com/content/346/bmj.f3817
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