Can head protectors make injuries WORSE?
From cycling to skiing and rugby, the experts’ view isn’t always as clear cut as you might think
Last week’s call for a ban on tackling in school rugby because of injuries will have sent a frisson of fear through many parents. there’s no doubt that rugby can potentially cause harm; as well as fractures, torn ligaments and dislocated shoulders, there is the risk of concussion and head and spinal cord injuries.
In December, Lily Partridge, a 23-year- old who played for the Exonian Ladies Rugby team in Devon, died after colliding with another player in a training match.
Of course, rugby is not the only sport where such injuries can occur; there is a risk with any activity that involves contact with another person or an object (such as a hard ball or the ground) — these include skiing, cycling, boxing, hockey and horseriding.
But could helmets protect against this, whatever the sport?
Do helmets prevent concussion?
thE short answer is probably no. But depending on the sport, they can help prevent fractures and brain bleeds.
Most sports helmets are designed to protect the bones and the soft tissue — such as the scalp and ears.
When it comes to the brain itself, it’s more complicated. ‘the brain is a gelatinous mass of tissue effectively floating inside the cranium,’ explains Michael Grey, a specialist i n motor neuroscience at the University of Birmingham.
‘It’s fixed at a point near the base of the skull and when the skull gets hit — or the body gets hit causing a whiplash effect — the brain rotates back and forth inside the cranium.
‘If you banged on the side of a bowl of jelly, the jelly would shake — that’s what’s happening with the brain and the head when knocked.’
One of the main risks is concussion, a mild form of brain injury, and common in rugby. ‘Concussion is basically a temporary disruption of brain function, and can occur when the wobbling of the brain damages nerve cells and their ability to communicate,’ says Dr Grey.
symptoms include confusion, nausea and headaches, and somet i mes l oss of consciousness, although there may be no obvious symptoms initially.
a one- off concussion is unlikely to cause serious harm, but there are concerns that repeated concussions can trigger long-term problems such as chronic traumatic encephalopathy, a progressive degenerative brain disease seen in athletes after repeated trauma to the brain (such as boxers and american football players).
another concern is the rare, but serious, ‘second impact’ syndrome, where a second concussion occurs before the brain has recovered from the first. ‘the theory is that there’s not enough energy reserved to deal with a second insult, and that can lead to cell death and is potentially fatal,’ explains Dr Grey.
Ben Robinson, 14, from Co. antrim, was found to have died this way after a rugby match in January 2011.
Playing on while concussed also increases the risk of having a second injury on the pitch, such as a musculoskeletal one.
Can a helmet prevent this? ‘With really big impacts, as in a skiing or cycling injury, the helmet takes some of the force, so can help protect against catastrophic injuries,’ says Dr Grey.
Colin shieff, a consultant neurosurgeon and trustee of the brain injury charity headway, adds: ‘a helmet will reduce the likelihood of any surface injury — to the scalp, skull and layers immediately beneath the skull, where big blood clots can occur if the skull is fractured, and occasionally even when it’s not.’
It’s this bleeding that puts pressure in the brain and can prove fatal. this is the type of injury that actress Natasha Richardson died from in 2009 after a fall on a ski slope. she was not wearing a helmet.
What about rugby scrum caps?
thE soft-shelled scrum caps worn by some rugby players would only provide minor protection against such serious impacts, and none against concussion, says Mike Loosemore, a consultant in sport and exercise medicine at University College hospital, London.
their main purpose is to protect players from ‘cauliflower ears’ — deformed ears associated with the ‘rubbing’ experienced in a scrum.
Indeed, a recent major study by the University of Ulster suggested that, when protective headgear was worn by schoolboy rugby players in Northern Ireland, it didn’t reduce concussion risk.
the skull is a ‘pretty good helmet itself ’, adds William stewart, a consultant neuropathologist at the Queen Elizabeth University hospital in Glasgow. ‘By adding more layers on top, you are providing protection for the skull, but not saving the brain from rotating.
‘When it comes to the kind of collisions you might have on a rugby field, a helmet or headgear makes no difference whatsoever.’
Occasionally, a rugby player might suffer a serious bleed in the brain if the impact is large, says Dr Grey. ‘While a helmet could potentially provide some protection, you’re less likely to be exposed to those sorts of knocks in rugby.’
this is partly because the ground is likely to be relatively soft, unlike with skiiing or cycling.
When they may make things worse
thERE are suggestions that protective headgear could cause more problems in sports such as rugby. One argument i s that wearing a helmet increases the wobbling of the brain.
‘If you take a glancing blow at the side of the helmet rather than on the head itself, you are increasing the “moment arm” — the distance from the centre of the head to where you are applying the force,’ says Dr Grey. ‘this will increase the amount the head rotates, making the brain wobble more, increasing the concussion risk.’
similarly it would be easier to turn someone’s head if you grabbed the rim of their sombrero than if you grabbed their ear, for example.
But with activities where there is the risk of more serious impact injuries, such as cycling, concerns about this effect are outweighed by the greater dangers of the highimpact forces, says Dr Grey.
Does headgear make you take risks?
thIs is the so-called risk compensation theory, the idea that an increased sense of safety causes people to alter their behaviour and take more risks.
In a study published in January in the journal Psychological science, researchers from the University of Bath found that people who wore cycle helmets while taking part in a gambling task took more risks than those who wore baseball caps.
the task involved inflating an animated balloon on a screen — more points were earned as the balloon got closer to popping.
Critics say this doesn’t relate to how someone might behave when in a real cycling situation.
But Ian Walker, who led the study and who specialises in traffic psychology, says: ‘It was the first demonstration that helmets could change your behaviour in a completely unrelated way to what you’re using the helmet for.’
a similar phenomenon has been observed in boxing. Dr Loosemore, medical adviser to the British boxing team, helped get headguards removed from men’s boxing in 2014 after finding that boxers who wore them had more signs of concussion.
since headguards were removed, the style of boxing has changed — boxers hold their heads further back and throw fewer punches, he says.
another example of this is american football. ‘they wear helmets, yet there are still high rates of con- cussion, head injuries and chronic traumatic encephalopathy,’ says allyson Pollock, a professor of public health policy and author of tackling Rugby, What Every Parent should Know about Injuries.
In fact, the introduction of helmets into american football resulted in a ‘systematic change of behaviour’, adds John hardy, a clinical neuroscientist at University College London, who is jointly conducting a study into concussion in rugby (where the saracens rugby team is being tested for biomarkers of concussion in their blood, urine and saliva after games, to develop a test to identify players who need help).
‘tactics started to change when they wore helmets, shoulder pads and protective gear. they started using their heads as a battering ram. there is a danger that if you introduced them into rugby, the same could happen.’
Even scrum caps could have a similar effect, by lessening the pain that could otherwise put people off i njuring themselves, suggests neuropathologist William stewart.
Cars get closer to cyclists in helmets
It’s not just helmet wearers who may take more risks — some controversial research suggests that those around them do, too.
two years ago, henry Marsh, recently retired as a senior consultant neurosurgeon at st George’s hospital, in London, attracted criticism when he said he never wears a bike helmet: ‘I see lots of people in bike accidents and these flimsy helmets don’t help.’
he also drew on research from the University of Bath, which suggests that drivers get around 3in closer to cyclists wearing helmets because they subconsciously view them as safer.
Ian Walker, who conducted the research, would not go so far as to advocate cycling without a helmet. But he says that those who call for cycle helmets to be compulsory are missing a serious point.
‘Rather than letting people be hit, let’s tackle the danger at source — let people cycle in complete safety, in completely separate areas.’
Children should wear ski helmets
hIGh-PROfILE incidents such as Michael schumacher’s catastrophic fall have brought the issue of ski safety to the fore.
however, the risk of serious head injury is low — one for every 25,000 days spent skiing or snowboarding, and one death for every 1.85 million people on the piste, explains Dr Mike Langran, president of the International society for ski safety.
While he says helmets do reduce the incidence and severity of head injuries, the risks are not high enough to make it mandatory for everyone to wear one. But for children the argument f or helmets is stronger as ‘the risks are higher’.
‘the brain has some ability to protect itself when it sustains an injury — those processes are still developing in a child,’ says Dr Grey.
another issue is that children’s heads are disproportionately large compared with their body. ‘an adult head won’t move as much as they will have proportionately bigger neck muscles.’
Unfortunately, there are no clear-cut answers as to how much protection a helmet can provide.
‘Genetics are an important point, too — if you expose two people to the same mechanical force, one may experience concussion and the other may not,’ says Dr Grey.
‘It’s a complex issue and we don’t have all the answers yet.’