Downloaded from http://injuryprevention.bmj.com/ on November 17, 2015 - Published by group.bmj.com
IP Online First, published on February 13, 2015 as 10.1136/injuryprev-2014-041425 Brief report
Implementation of an all-ages mandatory helmet policy for ice skating Ginette Thibault-Halman,1 Lynne Fenerty,1 Kathie Wheadon-Hore,2 Simon Walling,1 Michael D Cusimano,1 David B Clarke1 1
Division of Neurosurgery, Dalhousie University, Halifax, Canada 2 Athletics and Recreational Services, Dalhousie University, Halifax, Canada Correspondence to Dr David B Clarke, Division of Neurosurgery, Dalhousie University/Capital Health, Halifax Infirmary, 1796 Summer Street, Halifax, NS B3H 3A7; [email protected] Received 12 September 2014 Revised 19 December 2014 Accepted 21 January 2015
ABSTRACT Ice skaters sustain a significant number of head injuries each winter. We are the first to implement an all-ages helmet policy at a university-based Canadian arena. We report our experience from a cross-sectional observational study as well as the policy’s consequences on helmet use and skating participation. Educational programming was provided prior to policy implementation. Observations of helmet use, falls and skater demographics were conducted prior to education/ implementation and after policy implementation. The number of skaters observed was essentially unchanged by the policy; 361 skaters were observed preimplementation, while 358 were observed postimplementation during the same number of observationhours. Pre-implementation, helmet use ranged from 97% among children under 12 to 10% among adults; postimplementation use in all skaters was 99%. Falls were observed among all age groups, with preponderance among those aged 4–12. An all-ages helmet policy was successful both in achieving helmet use among all skaters and in maintaining participation rates. INTRODUCTION
To cite: Thibault-Halman G, Fenerty L, Wheadon-Hore K, et al. Inj Prev Published Online First: [ please include Day Month Year] doi:10.1136/injuryprev2014-041425
In Canada, ice skating forms part of the national identity and is an important means to maintain fitness. However, injury associated with ice skating is significant: between 2006 and 2011, more than 4000 Canadians were admitted to hospital for injuries suffered while ice skating.1 Ice skating poses an especially high risk for traumatic brain injuries (TBIs) due to the slippery ice surface;2 13.3% of ice skaters who present to the emergency department have sustained a TBI and 4.3% experience concussions.3 Helmets have been shown to reduce the risk of TBI.4 Although helmet use is the norm in hockey and is mandated for virtually all hockey players in Canada, usage rates in other types of ice skating have been less consistent. Most TBIs (68%) due to ice skating occur in arenas,5 providing an opportunity to significantly reduce these injuries through policy. Dalhousie University’s Division of Neurosurgery Injury Prevention Program and Dalhousie Memorial Arena established a partnership, with the goal of developing and implementing an all-ages helmet policy. Effects on helmet use and arena attendance were examined before and after implementation of the new helmet policy.
METHODS This study was conducted in three phases at Dalhousie University Memorial Arena in Halifax, Nova Scotia, Canada. During Phase I (October
2009), nine naturalistic, 30 min interval observations were conducted over a 1-month period during public skating sessions held prior to the implementation of the mandatory helmet policy. Each 30 min observation session consisted of a 15 min helmet observation followed by a 15 min falls observation. Observers worked in teams of two; one team member counted skaters and the other member acted as a transcriptionist. This was done to minimise double-counting errors. To establish per cent agreement (age and gender), two teams, each consisting of one observer and one scribe, conducted observations simultaneously on the same group of skaters. Observation times were divided a priori into morning and evening periods on weekdays and weekends. Primary variables of interest were helmet use and number of falls occurring on the ice. Secondary variables of interest included estimated age (by category), gender, proper helmet and proper helmet fit. All hockey helmets sold in Canada meet Canadian Standards Association (CSA) standards and are labelled with a prominently displayed approval sticker on the outside of the helmet. A ‘proper’ helmet was considered to be a CSA-approved hockey helmet. Incorrect helmet use captured issues such as unfastened or malpositioned helmets. For each observed fall, data for age, number of persons in collision, area of bodily impact, whether the skater resumed skating immediately or sat out and whether first aid was required were recorded. Phase II was conducted over a 2-month period (November–December 2009) and focused on helmet education and raising awareness for the upcoming policy. No skater-related data were collected during this transition phase. Educational sessions were held for rink staff. Rink-side helmet and TBI prevention displays were attended by trained senior nursing students during public skating sessions. Information regarding the policy change, ballots for a helmet draw and coupons towards helmet costs were distributed. Promotional posters for the use of helmets were placed throughout the arena, the policy change was promoted on the university athletics’ website, and a ‘Frequently Asked Questions’ document (available at http://tinyurl.com/DalHelmetFAQ) was posted on the site. On 1 January 2010, the helmet policy, based on national recommendations,6 went into effect. During Phase III ( January and February 2010) or post-implementation of policy, all skaters were mandated to wear a CSA-approved hockey helmet; those arriving without a helmet were turned away, but were provided with a free skate pass as well as the helmet discount coupon. Post-implementation data collection occurred in nine observation periods over a 2-month
Thibault-Halman G, et al. Inj Prev 2015;0:1–3. doi:10.1136/injuryprev-2014-041425
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://injuryprevention.bmj.com/ on November 17, 2015 - Published by group.bmj.com
Brief report period using the same protocol as for Phase I. Educational efforts continued during Phase III. Descriptive statistics were used to characterise the data. Grouped data were compared using χ2 analyses (GraphPad InStat software V.3.10). Age-based trends in helmet use were analysed using the Cochran–Armitage test. Comparisons were considered significant at p60 Total
16 270 5 3 1 295
0 266 1 4 0 271
16 536 6 7 1 566
0 0 0 0 0 0
2 51 0 1 0 54
10 129 0 2 0 141
0 23 1 1 1 26
0 61 0 1 0 62
4 261 5 2 0 272
0 1 0 0 0 1
0 10 0 0 0 10
Falls were observed among all age groups, with most falls observed among those under age 12.
majority of falls in our study were seen among children, falls were observed in all age categories. In our pre-implementation observations, adults were the least-protected skaters. Not only do all-ages policies prevent injuries among adults, but they have also been shown to raise compliance with helmet regulation among youth.10 Skaters from all age groups continued to participate at Dalhousie Arena. This study was conducted at a single arena in an urban academic setting, and generalisability of the results remains to be determined. Skating is associated with a significantly elevated risk of TBI, and we have shown that an all-ages mandatory helmet policy can be successfully implemented in an arena without affecting overall participation in skating. The authors hope that their experience will encourage other centres to explore all-ages helmet policies.
What is already known on this subject
Contributors GT-H contributed to study design, data analysis and manuscript preparation. LF contributed to overall study design, implementation and coordination, training and supervision of educators/observers, data acquisition and writing and editing of the manuscript. KW-H contributed to study design and implementation and review of the manuscript. MDC and SW contributed to study design and review of the manuscript. DBC generated the study’s conceptual framework and design and contributed to writing the manuscript. Competing interests None. Ethics approval Capital Health Research Ethics Board. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3
▸ A significant number of head injuries are attributable to ice skating. ▸ Helmets can help prevent brain injuries, but the impact of arena helmet policies on participation is unknown.
4 5 6 7
What this study adds 8
All-ages helmet policies can be successfully implemented with no significant impact on overall participation.
9 10
Acknowledgements We would like to thank Jessica Heaton and Lisa Sangster (senior students, Dalhousie School of Nursing) for help with education and data collection, Kelly Boyd and Jacob Landry (senior student interns, Dalhousie Health Promotion Program) for help with the literature review, Julian Young (coordinator, Injury Prevention and Control, Nova Scotia Department of Health and Wellness) and the Nova Scotia Department of Health and Wellness for support in providing funding for helmets and Nelofar Kureshi for assistance with editing of the manuscript.
Thibault-Halman G, et al. Inj Prev 2015;0:1–3. doi:10.1136/injuryprev-2014-041425
11 12
13
Canadian Institute for Health Information. Number of hospitalizations due to winter sports and recreational activities, by cause and fiscal year, 2006–2007 to 2010– 2011 [Canadian Institute for Health Information web site] 2011. http://www.cihi.ca/ CIHI-ext-portal/internet/en/document/types+of+care/specialized+services/trauma +and+injuries/release_17jan12_tab12012 Knox CL, Comstock RD. Video analysis of falls experienced by paediatric ice skaters and roller/inline skaters. Br J Sports Med 2006;40:268–71. Knox CL, Comstock RD, McGeehan J, et al. Differences in the risk associated with head injury for pediatric ice skaters, roller skaters, and in-line skaters. Pediatrics 2006;118:549–54. Al-Habib A, Attabib N, Hurlbert RJ. Recreational helmet use as a predictor of noncranial injury. J Trauma Acute Care Surg 2012;72:1356–62. Merrick M. Head injuries by sport/activity: statistics from the IWK Emergency Dept CHIRPP Database, 1999–2003 (inclusive). 2007. ThinkFirst Canada. Which helmet for which activity? 2011. http://www.thinkfirst.ca/ documents/ThinkFirst_WHWA_English_2011.pdf Haider AH, Saleem T, Bilaniuk JW, et al. An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders. J Trauma Acute Care Surg 2012;73:1340–7. Tator CH. Catastrophic injuries in sports and recreation: causes and prevention—a Canadian study. Toronto: University of Toronto Press Incorporated, 2008. de Jong P. The health impact of mandatory bicycle helmet laws. Risk Anal 2012;32:782–90. Dennis J, Potter B, Ramsay T, et al. The effects of provincial bicycle helmet legislation on helmet use and bicycle ridership in Canada. Inj Prev 2010;16:219–24. Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database Syst Rev 2008;3:CD005401. Fenerty L, Thibault-Halman G, Bruce BS, et al. Helmets for skiing and snowboarding: who is using them and why. J Trauma Acute Care Surg 2013;74:895–900. Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev 1999;5:203–7.
3
Downloaded from http://injuryprevention.bmj.com/ on November 17, 2015 - Published by group.bmj.com
Implementation of an all-ages mandatory helmet policy for ice skating Ginette Thibault-Halman, Lynne Fenerty, Kathie Wheadon-Hore, Simon Walling, Michael D Cusimano and David B Clarke Inj Prev published online February 13, 2015
Updated information and services can be found at: http://injuryprevention.bmj.com/content/early/2015/02/13/injuryprev2014-041425
These include:
References
This article cites 8 articles, 4 of which you can access for free at: http://injuryprevention.bmj.com/content/early/2015/02/13/injuryprev2014-041425#BIBL
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Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
IP Online First, published on February 13, 2015 as 10.1136/injuryprev-2014-041425 Brief report
Implementation of an all-ages mandatory helmet policy for ice skating Ginette Thibault-Halman,1 Lynne Fenerty,1 Kathie Wheadon-Hore,2 Simon Walling,1 Michael D Cusimano,1 David B Clarke1 1
Division of Neurosurgery, Dalhousie University, Halifax, Canada 2 Athletics and Recreational Services, Dalhousie University, Halifax, Canada Correspondence to Dr David B Clarke, Division of Neurosurgery, Dalhousie University/Capital Health, Halifax Infirmary, 1796 Summer Street, Halifax, NS B3H 3A7; [email protected] Received 12 September 2014 Revised 19 December 2014 Accepted 21 January 2015
ABSTRACT Ice skaters sustain a significant number of head injuries each winter. We are the first to implement an all-ages helmet policy at a university-based Canadian arena. We report our experience from a cross-sectional observational study as well as the policy’s consequences on helmet use and skating participation. Educational programming was provided prior to policy implementation. Observations of helmet use, falls and skater demographics were conducted prior to education/ implementation and after policy implementation. The number of skaters observed was essentially unchanged by the policy; 361 skaters were observed preimplementation, while 358 were observed postimplementation during the same number of observationhours. Pre-implementation, helmet use ranged from 97% among children under 12 to 10% among adults; postimplementation use in all skaters was 99%. Falls were observed among all age groups, with preponderance among those aged 4–12. An all-ages helmet policy was successful both in achieving helmet use among all skaters and in maintaining participation rates. INTRODUCTION
To cite: Thibault-Halman G, Fenerty L, Wheadon-Hore K, et al. Inj Prev Published Online First: [ please include Day Month Year] doi:10.1136/injuryprev2014-041425
In Canada, ice skating forms part of the national identity and is an important means to maintain fitness. However, injury associated with ice skating is significant: between 2006 and 2011, more than 4000 Canadians were admitted to hospital for injuries suffered while ice skating.1 Ice skating poses an especially high risk for traumatic brain injuries (TBIs) due to the slippery ice surface;2 13.3% of ice skaters who present to the emergency department have sustained a TBI and 4.3% experience concussions.3 Helmets have been shown to reduce the risk of TBI.4 Although helmet use is the norm in hockey and is mandated for virtually all hockey players in Canada, usage rates in other types of ice skating have been less consistent. Most TBIs (68%) due to ice skating occur in arenas,5 providing an opportunity to significantly reduce these injuries through policy. Dalhousie University’s Division of Neurosurgery Injury Prevention Program and Dalhousie Memorial Arena established a partnership, with the goal of developing and implementing an all-ages helmet policy. Effects on helmet use and arena attendance were examined before and after implementation of the new helmet policy.
METHODS This study was conducted in three phases at Dalhousie University Memorial Arena in Halifax, Nova Scotia, Canada. During Phase I (October
2009), nine naturalistic, 30 min interval observations were conducted over a 1-month period during public skating sessions held prior to the implementation of the mandatory helmet policy. Each 30 min observation session consisted of a 15 min helmet observation followed by a 15 min falls observation. Observers worked in teams of two; one team member counted skaters and the other member acted as a transcriptionist. This was done to minimise double-counting errors. To establish per cent agreement (age and gender), two teams, each consisting of one observer and one scribe, conducted observations simultaneously on the same group of skaters. Observation times were divided a priori into morning and evening periods on weekdays and weekends. Primary variables of interest were helmet use and number of falls occurring on the ice. Secondary variables of interest included estimated age (by category), gender, proper helmet and proper helmet fit. All hockey helmets sold in Canada meet Canadian Standards Association (CSA) standards and are labelled with a prominently displayed approval sticker on the outside of the helmet. A ‘proper’ helmet was considered to be a CSA-approved hockey helmet. Incorrect helmet use captured issues such as unfastened or malpositioned helmets. For each observed fall, data for age, number of persons in collision, area of bodily impact, whether the skater resumed skating immediately or sat out and whether first aid was required were recorded. Phase II was conducted over a 2-month period (November–December 2009) and focused on helmet education and raising awareness for the upcoming policy. No skater-related data were collected during this transition phase. Educational sessions were held for rink staff. Rink-side helmet and TBI prevention displays were attended by trained senior nursing students during public skating sessions. Information regarding the policy change, ballots for a helmet draw and coupons towards helmet costs were distributed. Promotional posters for the use of helmets were placed throughout the arena, the policy change was promoted on the university athletics’ website, and a ‘Frequently Asked Questions’ document (available at http://tinyurl.com/DalHelmetFAQ) was posted on the site. On 1 January 2010, the helmet policy, based on national recommendations,6 went into effect. During Phase III ( January and February 2010) or post-implementation of policy, all skaters were mandated to wear a CSA-approved hockey helmet; those arriving without a helmet were turned away, but were provided with a free skate pass as well as the helmet discount coupon. Post-implementation data collection occurred in nine observation periods over a 2-month
Thibault-Halman G, et al. Inj Prev 2015;0:1–3. doi:10.1136/injuryprev-2014-041425
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://injuryprevention.bmj.com/ on November 17, 2015 - Published by group.bmj.com
Brief report period using the same protocol as for Phase I. Educational efforts continued during Phase III. Descriptive statistics were used to characterise the data. Grouped data were compared using χ2 analyses (GraphPad InStat software V.3.10). Age-based trends in helmet use were analysed using the Cochran–Armitage test. Comparisons were considered significant at p60 Total
16 270 5 3 1 295
0 266 1 4 0 271
16 536 6 7 1 566
0 0 0 0 0 0
2 51 0 1 0 54
10 129 0 2 0 141
0 23 1 1 1 26
0 61 0 1 0 62
4 261 5 2 0 272
0 1 0 0 0 1
0 10 0 0 0 10
Falls were observed among all age groups, with most falls observed among those under age 12.
majority of falls in our study were seen among children, falls were observed in all age categories. In our pre-implementation observations, adults were the least-protected skaters. Not only do all-ages policies prevent injuries among adults, but they have also been shown to raise compliance with helmet regulation among youth.10 Skaters from all age groups continued to participate at Dalhousie Arena. This study was conducted at a single arena in an urban academic setting, and generalisability of the results remains to be determined. Skating is associated with a significantly elevated risk of TBI, and we have shown that an all-ages mandatory helmet policy can be successfully implemented in an arena without affecting overall participation in skating. The authors hope that their experience will encourage other centres to explore all-ages helmet policies.
What is already known on this subject
Contributors GT-H contributed to study design, data analysis and manuscript preparation. LF contributed to overall study design, implementation and coordination, training and supervision of educators/observers, data acquisition and writing and editing of the manuscript. KW-H contributed to study design and implementation and review of the manuscript. MDC and SW contributed to study design and review of the manuscript. DBC generated the study’s conceptual framework and design and contributed to writing the manuscript. Competing interests None. Ethics approval Capital Health Research Ethics Board. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3
▸ A significant number of head injuries are attributable to ice skating. ▸ Helmets can help prevent brain injuries, but the impact of arena helmet policies on participation is unknown.
4 5 6 7
What this study adds 8
All-ages helmet policies can be successfully implemented with no significant impact on overall participation.
9 10
Acknowledgements We would like to thank Jessica Heaton and Lisa Sangster (senior students, Dalhousie School of Nursing) for help with education and data collection, Kelly Boyd and Jacob Landry (senior student interns, Dalhousie Health Promotion Program) for help with the literature review, Julian Young (coordinator, Injury Prevention and Control, Nova Scotia Department of Health and Wellness) and the Nova Scotia Department of Health and Wellness for support in providing funding for helmets and Nelofar Kureshi for assistance with editing of the manuscript.
Thibault-Halman G, et al. Inj Prev 2015;0:1–3. doi:10.1136/injuryprev-2014-041425
11 12
13
Canadian Institute for Health Information. Number of hospitalizations due to winter sports and recreational activities, by cause and fiscal year, 2006–2007 to 2010– 2011 [Canadian Institute for Health Information web site] 2011. http://www.cihi.ca/ CIHI-ext-portal/internet/en/document/types+of+care/specialized+services/trauma +and+injuries/release_17jan12_tab12012 Knox CL, Comstock RD. Video analysis of falls experienced by paediatric ice skaters and roller/inline skaters. Br J Sports Med 2006;40:268–71. Knox CL, Comstock RD, McGeehan J, et al. Differences in the risk associated with head injury for pediatric ice skaters, roller skaters, and in-line skaters. Pediatrics 2006;118:549–54. Al-Habib A, Attabib N, Hurlbert RJ. Recreational helmet use as a predictor of noncranial injury. J Trauma Acute Care Surg 2012;72:1356–62. Merrick M. Head injuries by sport/activity: statistics from the IWK Emergency Dept CHIRPP Database, 1999–2003 (inclusive). 2007. ThinkFirst Canada. Which helmet for which activity? 2011. http://www.thinkfirst.ca/ documents/ThinkFirst_WHWA_English_2011.pdf Haider AH, Saleem T, Bilaniuk JW, et al. An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders. J Trauma Acute Care Surg 2012;73:1340–7. Tator CH. Catastrophic injuries in sports and recreation: causes and prevention—a Canadian study. Toronto: University of Toronto Press Incorporated, 2008. de Jong P. The health impact of mandatory bicycle helmet laws. Risk Anal 2012;32:782–90. Dennis J, Potter B, Ramsay T, et al. The effects of provincial bicycle helmet legislation on helmet use and bicycle ridership in Canada. Inj Prev 2010;16:219–24. Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database Syst Rev 2008;3:CD005401. Fenerty L, Thibault-Halman G, Bruce BS, et al. Helmets for skiing and snowboarding: who is using them and why. J Trauma Acute Care Surg 2013;74:895–900. Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev 1999;5:203–7.
3
Downloaded from http://injuryprevention.bmj.com/ on November 17, 2015 - Published by group.bmj.com
Implementation of an all-ages mandatory helmet policy for ice skating Ginette Thibault-Halman, Lynne Fenerty, Kathie Wheadon-Hore, Simon Walling, Michael D Cusimano and David B Clarke Inj Prev published online February 13, 2015
Updated information and services can be found at: http://injuryprevention.bmj.com/content/early/2015/02/13/injuryprev2014-041425
These include:
References
This article cites 8 articles, 4 of which you can access for free at: http://injuryprevention.bmj.com/content/early/2015/02/13/injuryprev2014-041425#BIBL
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
