Protective Head Gear: How come this never caught on?

Corky Carroll (top), 1967 & 1969 World Champion; Larry Gephart. Photo Credit Fontannini LA Times

Corky Carroll (top), US Champion 66, 67, & 69; Larry Gephart (bottom). Photo Credit: Steve Fontanini / LA Times

We know surfing has a relatively low risk of injury in comparison to a range of other sports.  Nathanson et al. reported an acute injury rate of 0.9 injuries/person/year (1) in an observational, retrospective study of acute and chronic surfing-related injuries using a web-based multiple choice survey. In a later study by the same lead author an injury rate of 5.7/1000 athlete exposures, or 13/1000 hours of competitive surfing (2), was reported in a prospective study of competitive surfing injuries at 32 professional and amateur surfing contests worldwide between 1999 and 2005. Lowden et al. reported an acute injury rate of 3.5 injuries/1000 surfing days (3) and Taylor et al. 2.2 injuries/1000 surfing days (4). The latter suggesting a surfer could expect significant acute injury once every four years, deemed acceptable by the authors given the considerable exposure risk over the same period – median expected days of surfing: 400.

Master Noserider, David Nuuhiwa. Running the Huntington Beach Pier without a helmet was a no-no, now & back in the late 60s!

Master Noserider, David Nuuhiwa. Shooting the Huntington Beach Pier without a helmet is not to be recommended, now & back in 1966!

Although injury to all body regions is possible, head and facial injuries are commonly reported. Research suggests that head and facial injuries comprise somewhere between 25% and 37% of all surfing-related injuries (1–9), and 42% to 49% of surfing injuries treated in the emergency room (4,5). Nathanson et al (1) reported that the face and scalp were the most commonly implicated anatomy. Injuries vary from superficial head and facial injury to significant laceration, fractures, contusions, and closed head injury (1–9,13,14). Ophthalmic injury has also been reported (10–12). Whilst the above injuries may be significant in their own right, sequela (e.g. loss or change in level of consciousness) combined with the hazards arising from being in a maritime environment (e.g. drowning) must also be considered. A range of protective headgear is readily available for surfing. Yet, anecdotally, observation would suggest surfers decline its use. Published data appears to support this assertion. Figures of 1.9%, and 8%, have been reported by Taylor et al. (15), and Nathanson et al. (1), respectively, in relation to the proportion of surfers who routinely use protective headgear.

Bill Jones, Surfer's Medical Association (SMA) Director at Conference 2013

Bill Jones, EASD Mentor, Consiliari, & Surfer’s Medical Association (SMA) Director at Conference 2013

Exploring the use of protective headgear by surfers, perceptions of its usefulness, and barriers to its use, Taylor et al. (15) carried out a cross-sectional survey of surfers at eight of the most popular beaches in east and west Victoria, near Melbourne, Australia.  Over a 4-month period, surfers who were aged 18 years or older, and had been surfing actively for a minimum of one year, were invited to enroll.

What they found…

The response rate was 96.7%, equating to 646 surfers. Most participants were male (90.2%) and young (Mean Age: 28.2 years) with a mean surfing experience level of 11.6 years. Only 38.0% (95% CI 34.2–41.9) ranked the risk of head injury during surfing as moderate or high, and only 1.9% (95% CI 1.0–3.3) or 12 individuals reported using protective headgear routinely, believing that there was a greater risk of head injury in sports other than surfing (P<0.001). Most surfers (73.8%, 95% CI 70.2–77.1) did however hold the belief that the wearing of headgear was likely to reduce the risk of injury. Four hundred (62.1%, 95% CI 58.2–65.9) reported that they would rather surf without headgear on the basis that it restricted performance. The main reasons given for not using headgear were ‘no need’, discomfort, claustrophobia, and adverse effect on sensation and balance.

So, where does that leave us?

Romeo, the EASD's youngest member, and his Mom, Sabine

Romeo, the EASD’s youngest member, with Mom, Sabine, showing us how it’s done!

Taylor et al. (15) suggest ambivalence surrounding surfers’ relationship to protective headgear use, noting that one third of surfers surveyed in their research responded vaguely or gave ill-defined reasons for not using it. They speculate that such impediment to use may be perceived rather than actual in nature and that there is considerable potential for education and other strategies to affect opinion and behavioural change within the surfing world.

Further research is required to clarify head injury risk and the protective efficacy of headgear in surfing populations. Pending the emergence of such evidence, numerous authors (1,4,5,9,14–16) of the existing knowledge database advocate educational initiatives, increased wearing profile within surfing, and improved equipment design as a means to increase protective headgear use rates amongst surfers.

Dr.Terry Farrell

Dr. Terry Farrell

How can I find out more on this topic?

Dr. Terry Farrell will lecture on head trauma and traumatic brain injury seen in surfing with a review of the incidence, causes, classification, and consequences. Evaluation and management considerations in remote settings, clinical signs, and indications for immediate evacuations will be discussed. Furthermore, concussion management, and ‘return-to-play’ guidelines, as well as prevention in surfing will be explored.

References:

  1. Nathanson A, Haynes P, Galanis D. Surfing injuries. Am J Emerg Med. 2002;20:155–160
  2. Nathanson A, Bird S, Dao L, Tam-Sing K. Competitive Surfing Injuries: A Prospective Study of Surfing-Related Injuries Among Contest Surfers. Am J Sports Med. 2007;35:113–117
  3. Lowden BJ, Paterman NA, Pitman AJ. Surfboard-riding injuries. Med J Aust. 1983;2:613–616
  4. Taylor DMcD, Bennett DM, Carter M, Garewal D, Finch C. Acute injury and chronic disability resulting from surfboard riding. J Sci Med Sport. 2004;7:429–437
  5. Nathanson  AT. “Surfing Injuries” Adventure and Extreme Sports Injuries. Springer London. 2013;143–172
  6. Zoltan TB, Taylor KS. Health Issues for Surfers. Am Fam Physician 2005;71:2313–7, 2319–20
  7. Grenfell R. Beach-related injuries. Med J Aust. 1996;166:390
  8. Allen RH, Eiseman B, Straehley CJ, Orloff BG. Surfing injuries at Waikiki. JAMA. 1977;237:668–670
  9. Hay CSM, Barton S, Sulkin T. Recreational Surfing Injuries in Cornwall, United Kingdom. Wilderness and Environmental Medicine. 2009;20:335–338
  10. Zoumalan CI, Blumenkranz MS, McCulley TJ, Moshfeghi DM. Severe surfing-related ocular injuries: the Stanford Northern Californian experience. Br J Sports Med 2008;42:855–857
  11. Kim JW, McDonald HR, Rubsamen PE, Luttrull JK, Drouilhet JH, Frambach DA, Boyer DS, Lambrou FH Jr, Hendrick A, Weiss JN, Engstrom RE Jr, Ing M. Surfing related ocular injuries. Retina. 1998;18:424–429
  12. Lawless M, Pountney R, Porter W, Simpson M. Surfboard-related ocular injuries. Aust NZ J Ophthalmol 1986;14:55–57
  13. Taylor KS, Zoltan TB, Achar SA. Medical illnesses and injuries encountered during surfing. Curr Sports Med Rep 2006;5:262–267
  14. Sunshine S. Surfing injuries. Curr Sports Med Rep 2003;2:136–141
  15. Taylor DMcD, Bennett DM, Carter M, Garewal D, Finch C. Perceptions of Surfboard Riders Regarding the Need for Protective Headgear. Wilderness and Environmental Medicine. 2005;16:75–80
  16. Barucq G. 5 Reasons Why Surfers Should Wear a Helmet. The Inertia. [Posted Online Nov 19, 2013; Accessed Aug 22, 2014]

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