Introduction

Physical activity is an essential part of being healthy. In children, activity helps build strong bones and muscles, decreases the likelihood of developing obesity, and promotes positive mental health. Children are recommended to have 60 minutes or more of physical activity daily.

In the United States, more than 30 million children and teens participate in sports. Of that number, approximately 3.5 million children and adolescents ages fourteen and under are hurt annually while participating in recreational activities. In 2002, The National Safe Kids Campaign estimated that 13,700 children were treated in hospital emergency rooms for ice skating related injuries. Many of these are preventable head injuries if protective equipment, such as helmets or halos, is used.

Gliding across the ice, with the cool wind whipping across a skater’s face is an exhilarating feeling. One push can propel a skater far down the glistening, snowy surface. Worrying about a head injury is often far from a skater’s mind, as many participants are not aware of the possibility of head injury from ice skating. The goals of this article are to raise awareness about potential head injury from ice skating and to promote the use of helmets in skating, similar to what is required in cycling, skiing, and ice hockey.

Review of Injury Statistics

A concussion is a mild form of head injury, usually due to a blow to the head, which may cause disorientation, memory loss, or unconsciousness. Repeated concussions and loss of consciousness can result in traumatic brain injury or TBI.

An estimated 10% of all head and spinal cord injuries are due to sports related activities. Socially, athletes can feel undue pressure from family, coaches, and teammates to return to play quickly after a head injury. These influences can prevent an athlete from receiving the medical care he or she requires. In particular, parents and coaches can push their children too hard in an attempt to fulfill their own athletic aspirations. Athletes who return to play too soon or who suffer repeated injury to the head can develop chronic traumatic encephalopathy, or CTE, whose symptoms can include slowed speech, confusion, tremors, and mental deterioration. Most recently, CTE gained media attention when a settlement was reached with the National Football League, or NFL and thousands of players and families. The case, which involved more than 4,500 plaintiffs, calls for the NFL to pay for medical exams, compensation, and research related to head injuries sustained while playing professional football. Plaintiffs are committed to making the game safer at all levels and to educate the public; including parents of the four million children who play youth and high school football. Plaintiffs are committed to helping the focus on player safety trickle down to the youth level.

Awareness and education are key factors in injury prevention and return to play decisions. When an athlete suffers a head injury, a sideline assessment using the Standardized Assessment of Concussion should be completed by a medical professional. If a physician is not available, the coach can complete a basic assessment, until medical attention is available. The assessment includes tests of eye response, verbal response, and motor response. Telling a child to «shake it off» could have a grave impact on the child’s long term health.

Research concluded that safety measures in organized sports should include helmet requirements. There are approximately 230,000 cases of hospitalization due to traumatic brain injury annually of which 80,000 suffer long term disability and 50,000 result in fatalities. Five to twenty percent of these injuries are incurred during sports and recreational activities. Organized team sports, in particular football, soccer and ice hockey, have high instances of concussion annually in addition to recreational sports such as skating and bicycling. Helmets that are properly fitted and worn by participants of these activities can help reduce the risk of head injury among participants.

Sports and Helmet Rules

Cycling

In March 2003, professional cyclist Andrey Kivilev collided with two other riders during the Paris Nice ride. Kivilev was not wearing a helmet and catapulted head first off his bicycle. He fell immediately into a coma and was diagnosed with a serious skull fracture. Kivilev underwent surgery, but died shortly thereafter due to the severity of the head injury. He was 29 years old and the leader of the Cofidis cycling team. His death triggered the International Cycling Union, or UCI to implement compulsory wearing of helmets in all endorsed races.

Helmets protect the head by reducing the rate at which the skull and the brain are accelerated and decelerated during an impact effectively acting as a shock absorber between the force of the impact and the brain. Upon impact, the polystyrene liner of the helmet crushes thereby dissipating energy over a wider area. Instituting mandatory helmet policies in sports proves to be a divisive and controversial issue. Although research has demonstrated that helmets reduce injury in low speed crashes, helmet evidence is not conclusive with respect to high speed crashes. Kivilev’s accident occurred at approximately 35 kilometers per hour or about 22 miles per hour which is considered relatively low speed. At the time, he was ranked among the top 100 racers in the world.

Due to his high profile in the global cycling community, Kivilev’s death elevated the helmet debate into the media spotlight. Following this seminal UCI rule change, USA Cycling also revised their helmet policy to provide that in order to host an event sanctioned by USA Cycling, all participants are required to wear helmets.

In recreational cycling in the United States, bicycle helmet laws can vary widely. Currently, only twenty one states and the District of Columbia have instituted helmet laws for bicyclists below a certain age, which is generally 16 years-old. California requires helmets for riders 18 years and younger and only the Virgin Islands requires helmets for all riders. Twenty nine states have no bicycle helmet laws currently in place.

Researchers conducted a study which demonstrates helmet usage. This study directly observed 841 children in Texas who participated in bicycle riding, in line skating, skateboarding, and scooter riding over an eight week period. Whereas helmet rules vary county to county within Texas, most counties require helmets for riders age 16 years-old and younger. This study employed a randomly selected sample of children engaging in such activities from communities with populations equal to or greater than 1000. Children under 6 years-old, females and those riding on specified bike paths were found to wear helmets more frequently than other children.

Several factors often contribute to children not wearing helmets. During warmer months, children complain about high temperatures and accordingly are less inclined or willing to wear their helmets as riders feel they do not have proper ventilation inside the helmet. Parental knowledge and awareness is another contributing factor. Parents are often unfamiliar with applicable helmet laws nor are they informed of the potential risks of injury resulting from the failure to wear proper safety equipment. In a study examining data from1990 2005, there were in excess of 6,000,000 cases of children age 18 years-old and younger treated in emergency rooms for bicycle related injuries.

Skiing

In March 2009, actress Natasha Richardson sustained a head injury while taking a routine, beginner ski lesson. Initially she refused medical attention, however seven hours later, she was admitted to the hospital suffering from an epidural hematoma, a type of traumatic brain injury. She succumbed to her injuries and died the following day. Michael Kennedy, son of Robert F. Kennedy, died in 1997 following a skiing accident in Aspen, Colorado. A week later, Sonny Bono, television star and politician, died on the slopes of South Lake Tahoe. Richardson, Kennedy, and Bono were not wearing helmets.

Researchers studied injury rates at the three largest ski areas in Scotland during three winter seasons. The study found that first day participants are at an increased risk of injury due in part to low skill levels amongst the beginners. They concluded that first day participants should be targeted in educational programs about gear selection and protective equipment.

A study of skiers and snowboarders was conducted in Colorado where approximately 10 fatalities occur annually. Among the fatally injured, head injury proved the cause of death in 87.5% of the cases and none were wearing helmets. Of the 400 skiers and snowboarders admitted to the hospital with traumatic brain injuries, only five were wearing helmets. In the most serious case, the patient ascended off a 40 foot cliff, landed on his head, cracking his helmet in half. Whereas he sustained a severe concussion with unconsciousness, the computed topography, or CT scan proved negative and with inpatient rehabilitation, the patient has made a full recovery and is attending college.

In 2011, New Jersey Governor Chris Christie signed a bill into law requiring all skiers and snowboarders under 18 years to wear helmets with the intent to reduce head injuries on the slopes. California Governor Arnold Schwarzenegger signed a similar bill in 2010 however the measure was nullified following his veto of a companion bill that would have required California ski resorts to submit safety plans and reports to state officials. At the professional levels, the governing body of skiing, the Federation Internationale de Ski, requires a helmet as mandatory equipment for all downhill and Super G events.

Ice Hockey

In 1968, Bill Masterson of the Minnesota North Stars landed headfirst on the ice after being checked by two players from the Oakland Seals. He was not wearing a helmet and as a direct result died due to the severity of his head injury. Prior to this incident, the helmets use had been stigmatized which contributed to a lack of widespread use. However, as a consequence of this incident, the stigma surrounding the use of helmets began to diminish and ultimately in 1979, the National Hockey League, or NHL instituted a mandatory helmet policy. The policy did not apply uniformly at the outset as certain veteran players were grandfathered out of the new requirement. Such players elected to continue playing without helmets alongside new players who were subject the policy. Initially, the NHL and the players themselves faced harsh criticism from fans and the media. Despite the clear evidence of risks associated without helmets, some believed the policy harmed the integrity of the game and diminished the players’ masculinity.

Since the policy was first instituted more than three decades ago, significant research supporting the value and need for helmets has been documented. The hockey community has become supportive of the rule change particularly as a significant number of current hockey enthusiasts have never experienced the sport in which helmets were not employed and required. As with many elements of professional sports, the helmet policy was then instituted within youth hockey. The youth hockey governing board, USA Hockey, not only requires all players to wear helmets, they have mandated that all helmets employed by the players must be approved by the Hockey Equipment Certification Council, or HECC. Additionally, beginning in 2006, USA Hockey extended the helmet requirement to coaches who must wear helmets during on ice practice. The requirement for coaches provides the dual benefit of increased safety for all on ice participants as well as an opportunity for the authority figure to model appropriate safety practices. This continues to reinforce the value and importance of the use of safety equipment and in turn minimizes any residual stigma associated with wearing helmets on the ice.

In order to meet the requirements of the HECC, all helmets must undergo rigorous testing procedures including, without limitation, verifying the sufficiency of the coverage area, the quality of the protective material, and the degree of shock absorption. Aside from the specifications, the age, amount of use and type of each helmet all serve to impact the helmet’s effectiveness. The use of helmets with facial protection has proven effective in order to significantly decrease player injury at the amateur level. Whereas ice hockey is by nature a contact sport and checking is a significant cause of injury, the potential for injury is heightened further due to speed and surface tension. A study was conducted a study of 192 high schools in which 7,257 sports related injuries from 20 different sports were reported. From this total sample, 1,056, or 14.6% of injuries were concussions, 24% of which were sustained during boys’ ice hockey.

Ice Skating

In 1999, United Skates Pairs figure skaters, J. Paul Binnebose and Laura Handy were on track to make the 2002 Olympic team. While training at the University of Delaware, with Coach Ron Luddington, Binnebose fell on the ice, fracturing his skull. He suffered seizures, his heart stopped twice, and he was in a coma. Doctors removed a piece of his skull, allowing his brain to swell without pressure and heal. He was given a 10% chance of survival. Against the odds, he recovered.

Although the media widely publicizes celebrity sports related accidents, J. Paul Binnebose was not a well known star around the world. His story did not receive international media attention, but it is well known within the figure skating world. He and his coach have been working toward a helmet rule in skating for over a decade. They contend that many of the skating related injuries could be prevented or minimized with the use of a helmet.

Research suggests this notion is correct. An examination of pediatric skating related injuries was conducted in the years 1993-2003. The researchers sampled 1,235,467 children from emergency rooms with skating related injuries. Non random, purposeful sampling was used in this study. The data was collected from the National Electronic Injury Surveillance System, or NEISS, and the U.S. Consumer Product Safety Commission, known as CPSC.

The NEISS system has consumer product codes for each type of activity. Injuries were identified as ice skating, roller skating, or in line skating related, and coded accordingly. Ice hockey, roller hockey, and skateboarding were excluded from the study. Variables included the child’s gender and age, site of the injury, type of skating activity, mechanism of injury, use of protective equipment, and the injury diagnosis. Further, the injuries were categorized into 5 regions of the body.

The Centers for Disease Control report during the years 2001-2005, more than 200,000 emergency room visits for concussions and other traumatic brain injuries were recorded annually in the United States. Of those, 65% were found to be children ages 5 18 years-old who were participating in a sport or recreational activity. Children are at a greater risk for traumatic brain injuries with increased severity and a prolonged recovery. Thirty categories of sports and recreation head injuries were examined. Most of the sports demonstrated 2 7% annual emergency room visits for concussions and traumatic brain injuries. However, horseback riding, all terrain vehicle riding, and ice skating reported the highest instances of emergency room visits for traumatic brain injuries, with ice skating at 11.4%. Horseback riding and all terrain vehicle riding are activities where a secondary force carries the participant at a potentially high rate of speed; ice skating is a self propelled activity.

Researchers studied 419 children with injuries from ice skating, skateboarding, roller skating, and in line skating with the focus on head injury. Most injuries were to the face; 23 of 60 cases, 38.3%; and 12 additional injuries were to the head; 20%. Adult supervision was reported in 98.2% of the cases, and 78% reported no protective equipment use. The proportion of head injuries among ice skaters was greater than the participants in other types of skating, for which helmet use is recommended or required. Currently, there are no formal guidelines regarding the use of protective equipment in ice skating; however, studies show helmet use should be mandated for children.

A study of 80 patients who visited the Accident Service at John Radcliffe Hospital in Oxford for ice skating related injuries found that 56% were beginner skaters, defined as having skated less than 10 times. Eighty two and a half percent of the patients were 11 to 25 years-old. The study suggests that children who are beginner skaters are more likely to sustain injury than experienced skaters. Other research studies show similar results. In a study of 43 patients admitted to the Pamela Youde Nethersole Eastern Hospital with ice skating related injuries, 65% were first time skaters. The study found need for increased public awareness about the risk of potential injury from ice skating and for preventative measures to improve safety.

Insurance companies strongly urge skating facilities to post a warning potential of risks at the entrance of the buildings, which releases the facilities from general liability. However, people visiting ice skating rinks are not well informed about the potential risks of the activity before arrival. Often they do not read posted placards. If provided with the background knowledge, ahead of their visit to the ice skating rink, many guests would have the opportunity to bring safety equipment from home. A need exists for a public awareness campaign.

Positive Effect of Sports Involvement

An ice skating rink is a place for children to visit on a regular basis, during their out of school time, to engage in positive, fun exercise. The key to helping the child enjoy their experience, and continue to return to the ice skating rink, is to make sure they have a positive first experience. This may not mean becoming an expert skater, but becoming competent on the ice that he/she can have a positive social experience and be «ice safe.» In order for this to happen, the participants must learn to skate with the proper safety equipment, including helmets. Once they learn the skill, he/she will continue to return to the facility with their friends. Having a positive place to go during out of school time will help the children avoid risky behaviors.

Conclusion

Cycling, skiing, and hockey have made changes in their safety guidelines based on the trends and statistics of head injuries in the sport. As the governing body for skating, the International Skating Union, known as the ISU has to take action to require worldwide helmet use for skaters. Once the ISU takes the first step, member countries can incorporate helmet rules into basic training programs and begin a public awareness campaign. Reducing the incidents of head injury will improve the overall safety of the sport. As safety improves, more people will continue participating in the sport of ice skating.

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