Despite increased helmet use, the number of snow-sports-related traumatic brain injuries (TBIs) keeps rising, prompting calls by experts to implement a variety of targeted prevention strategies, with a special focus on educating parents about the protective value of helmets and the role modeling effect the parent's use has on their child's decision to wear a helmet.
Parents as role models
A 2012 study in the Clinical Journal of Sport Medicine found that, while 83% of children and teens surveyed at one Colorado ski resort always wearing a helmet, the odds of helmet use were 9.55 times higher if their parent wore a helmet than if they did not. Contrary to other published research, helmet-wearing behavior was not found to decline as age increased.
- The top reasons for wearing a helmet included safety (87.7%), parental advice (30.4%) and comfort/warmth (14.6%).
- The most common reasons for not wearing a helmet included comfort (48.6%) and inconvenience (25.7%).
- The importance of helmet use in the prevention of injuries was highlighted by the fact that among the participants who wear a helmet, 78.1% indicated that a helmet had protected them in the past during skiing/snowboarding.
On the basis of their findings, researchers at Children's Hospital Colorado and the University of Colorado said that "interventions and education targeted at increasing child helmet use during snow sports should be focused on educating parents about the protective value of helmets and the role modeling effect the parent's helmet use [has] on their child's decision to wear a helmet.
Traumatic brain injuries among teens on rise
The reasons prevention efforts are so important are clear from a recent study published in the journal Injury Prevention,  which found that teens are more likely to suffer snow-sports-related traumatic brain injuries (TBIs) than children, and that the teen injury rate had steadily increased over the period 1997-2010.
The study, by researchers at the Harborview Injury Prevention and Research Center at the University of Washington, is believed to be the first to use nationally representative data to examine snow-sports-related TBIs among children and adolescents.
While researchers were unable to directly determine the reasons for the increase, they speculated that it might be attributed in part to several factors, including:
- the rising popularity of snowboarding (which research suggests may have a greater risk of head injuries than skiing),
- the recent proliferation of terrain parks in resorts;
- the rapid growth of extreme sports, including freestyle snowboarding and skiing, which are characterized by high speeds and acrobatics, which has led to increased incidence of serious TBIs; and/or
- improved recognition of the clinical symptoms of TBI and increased reporting to EDs for head injuries incurred while skiing or snowboarding.
"Our results may have implications for targeted interventions involving helmet use in injury prevention," wrote lead author of the 2013 study, Janessa M. Graves, MD. Among the prevention techniques called for by Graves and her colleagues were:
- increased educational efforts to generate injury awareness and minimize hazards associated with snow sports for adolescents;
- considering mandatory helmet laws for minors, as some ski areas have done to improve compliance and ensure optimal safety;
- including free helmets with ski and snowboard rentals, as in Colorado;
- insurance incentives for ski resorts to encourage implementation of safety measures to improve infrastructure;
- conditioning access to terrain parks - which typically include jumps, half-pipes and harder surfaces that may contribute to head injury risk - on taking an educational module, as many resorts now require.
Helmets reduce injury risk
The use of helmets has been demonstrated to be extremely effective in reducing the incidence of serious head injuries during skiing and snowboarding;
- one study found that helmet use reduced the risk of head injury by 35%;
- another found that the relative risk among children younger than 13 years evaluated for ski/snowboard-related head injuries was more than 2 times higher for those without helmets compared to those with helmets;and
- Overall, helmet use has been associated with a 22% to 60% decrease in the rate of head injuries, specifically TBIs.
Despite these proven benefits, and the recommendations encouraging their use by governmental and medical organizations, the goal of near-universal use of helmets among child and teen skiers and snowboarders has proved elusive.
Head injury statistics
According to the 2013 University of Washington study
- From July 1996 to December 2010, there were an estimated 78,538 pediatric head injuries reported to U.S. emergency departments (EDs) for snowboarding or skiing during the winter seasons 1996-1997 to 2009-2010.
- Of these injuries, 33.8% were among children (4-12 years old) and 66.2% were among adolescents (13-17 years old)
- More head injuries were diagnosed as TBI among adolescents than children (82% v. 69%, respectively)
- Concussions and intracranial injuries represented the majority of TBI cases, with most other head injuries being attributed to scalp lacerations or contusions/abrasions.
- Most patients with head injuries were treated and released from the ED, rather than being transferred, admitted or held for observation. The proportion of TBI cases treated and released did not vary substantially over time.
- Among children, most TBIs were associated with skiing (55%), whereas for adolescents, the majority of TBIs were associated with snowboarding (62%)
- The average pediatric head injury rate was 3.14 per 10,000 resort visits.
- The rate for children did not vary significantly over the 14 seasons, but the TBI incidence among adolescents increased .19 percentage points per year.
- The average TBI rate was 2.42 per 10,000 visits: 1.59 per 10,000 visits for children, and 3.13 per 10,000 visits for adolescents
- The relative risk of snow-sports-related TBI in recent seasons was higher for both children and adolescents:
- The likelihood of TBI among children was 111% higher in 2009-2010 than it was in 1996-1997.
- The likelihood of TBI among adolescents was 250% higher in 2009-2010 than it was in 1996-1997.
Other studies have found that although the incidence of head injuries is relatively low, serious head injuries such as TBI and even death are reported each year in skiing and snowboarding. From 1980 to 2001, TBIs were the primary cause of 67% of skiing fatalities among children in Colorado and remain the leading cause of death in both skiing and snowboarding.[10,12,13]
Safety tips for kids
Lara McKenzie, a Principal Investigator in the Center for Injury Research and Policy at Nationwide Children's Hospital, offers these tips for parents on how to make sure their children don't need a trip to the emergency department after skiing or snowboarding:
- Always wear a helmet designed for skiing or snowboarding.
- Make sure boots fit properly and bindings are adjusted correctly.
- Do not ski or snowboard alone.
- Take a lesson - even experienced skiers and snowboarders can benefit from a review.
1. Provance AJ, Engelman GH, Carry PM. Implications of Parental Influence on Child/Adolescent Helmet Use in Snow Sports. Clin J Sport Med. 2012;22(3):240-243.
2. Graves JM, Whitehill JM, Stream JO, et al. Inj Prev 2013 (e pub March 19, 2013 as doi:10.1136/injuryprev-2012-040727.
3. Gilchrist JTK, Xu L, McGuire LC, et al. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤19 years-United States, 2001-2009. MMWR Morb Mortal Wkly Rep 2011;60:1337-42.
4. Bakhos LL, Lockhart GR, Myers R, et al. Emergency department visits for concussion in young child athletes. Pediatrics 2010;126:e550-6.
5. Faul MXL, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002-2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention
and Control, 2010.
6. Yang J, Phillips G, Xiang H, et al. Hospitalisations for sport-related concussions in US children aged 5 to 18 years during 2000-2004. Br J Sports Med 2008;42:664-9.7. Cusimano MD, Kwok J. The effectiveness of helmet wear in skiers and snowboarders: a systematic review. Br J Sports Med. 2010;44:781-786.
8. Russell K, Christie J, Hagel BE. The effect of helmets on the risk of head and neck injuries among skiers and snowboarders: a meta-analysis. CMAJ. 2010;182:333-340.
9. Macnab AJ, Smith T, Gagnon FA, et al. Effect of helmet wear on the incidence of head/face and cervical spine injuries in young skiers and snowboarders. In Prev. 2002;8:324-327.
10. Ackery A, Hagel BE, Provvidenza C, et al. An international review of head and spinal cord injuries in alpine skiing and snowboarding. Inj Prev. 2007;13:368-375.
11. Xiang H, Stallones L, Smith GA. Downhill skiing injury fatalities among children. Inj Prev. 2004;10:99-102
12. Levy AS, Hawkes AP, Hemminger LM, et al. An analysis of head injuries among skiers and snowboarders. J Trauma 2002;53:695-704.
13. Myles ST, Mohtadi NG, Schnittker J. Injuries to the nervous system and spine in downhill skiing. Can J Surg. 1992;35:643-648.
14. Fenerty L, Thibault-Halman G, Bruce BS, Landry J, Young J, Walling S, Clark DB. Helmets for skiing and snowboarding: who is using them and why. J Trauma Acute Care Surg. 2013;