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Most studies find strong evidence that motorcycle helmets protect against injury, but a small number of controversial studies have reported a positive association between helmet use and neck injury. The most commonly cited paper is that of Goldstein (1986). Goldstein obtained and reanalyzed data from the Hurt Study, a prospective, on-scene investigation of 900 motorcycle collisions in the city of Los Angeles. The Goldstein results have been adopted by the anti-helmet community to justify resistance to compulsory motorcycle helmet use on the grounds that helmets may cause neck injuries due to their mass. In the current study, we replicated Goldstein's models to understand how he obtained his unexpected results, and we then applied modern statistical methods to estimate the association of motorcycle helmet use with head injury, fatal injury, and neck injury among collision-involved motorcyclists. We found Goldstein's analysis to be critically flawed due to improper data imputation, modeling of extremely sparse data, and misinterpretation of model coefficients. Our new analysis showed that motorcycle helmets were associated with markedly lower risk of head injury (RR 0.40, 95% CI 0.31-0.52) and fatal injury (RR 0.44, 95% CI 0.26-0.74) and with moderately lower but statistically significant risk of neck injury (RR 0.63, 95% CI 0.40-0.99), after controlling for multiple potential confounders., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: The "risk compensation" hypothesis suggests that individuals offset perceived gains in safety by increasing their risk-taking behavior to maintain a stable or "homeostatic" level of risk. If this is true for motorcyclists, then helmet use, which reduces the risk of brain injury and death, may lead helmet users to take more risks when they ride. Thus, increased risk-taking by helmet users should show up as overrepresentation in crashes, and accident reconstruction should reveal risky behaviors in the seconds just before the crash. This article examines data from two separate studies involving the on-scene, in-depth investigation and reconstruction of motorcycle crashes: 900 in Los Angeles (1976-1977) and another 1082 in Thailand (1999-2000)., Methods: Each crash was investigated on scene within minutes of its occurrence by teams of specially trained researchers and later reconstructed in order to identify precrash and crash events, verify helmet use/nonuse, etc. "Exposure" data on helmet use and other readily visible factors were also collected for the population-at-risk by observing riders who passed by each accident scene some time after a crash that had been investigated by the team. In this article, helmeted and unhelmeted accident-involved riders are compared to each other as well as to the population-at-risk., Results: In Thailand, helmeted riders did not differ significantly from unhelmeted riders in alcohol use, precrash speed, being the primary or sole cause of the crash, or unsafe speed or lane positioning for the traffic conditions; they were no more likely to be in a single-vehicle accident, to crash by running off the road, or to lose control. In Los Angeles, drinking riders were half as likely to wear a helmet as nondrinkers. However, when drinkers and nondrinkers were segregated, helmeted riders were no more likely to cause their crash, run stop signs or red lights, commit other traffic code violations, or run off the road. They did not differ in speed or single-vehicle crash rates. In both studies, helmeted riders were underrepresented in crashes compared to helmet use in the population-at-risk, and helmet use was associated with greater distances traveled., Conclusions: The data fail to support the hypothesis that the increased safety provided by motorcycle helmet use is offset by more risk-taking while riding. The only evidence of risk compensation was that helmet use increased with greater amounts of travel.

Objective: To compare the effectiveness of motorcycle helmets seen in prospective on-the-street motorcycle accident investigations. The data are drawn from two detailed, in-depth studies of motorcycle accidents, in which trained investigators collected extensive accident evidence on-scene immediately after the crash. This article compares helmeted and unhelmeted motorcycle riders on a per-accident basis for fatality rates, the rate of serious (AIS > 2) brain injuries among survivors, or an outcome that involved either of the two., Methods: Nine hundred motorcycle crashes in Los Angeles and 969 crashes in Thailand were investigated in detail at the accident scenes, including photos of vehicles, skids, damage, and sometimes the rider. Helmets were collected and injury information was obtained from riders and care providers. This evidence was then used to reconstruct collision events to identify speeds, precrash motions, collision contacts, injury causation, and helmet performance., Results: In both studies, approximately 6% of riders were killed and 20-25% were hospitalized. Overall, unhelmeted riders were two to three times as likely to be killed, and three times as likely to suffer either death or survival with AIS > 2 brain injury. Unhelmeted survivors had three to four times as many AIS > 2 brain injuries as helmeted riders on a per-crash basis. Nearly 100% of riders with AIS > 4 somatic injuries died. Such injuries were 30% of Thailand fatalities and 57% of L.A. fatalities, but only about 2-3% of the overall accident population. Among the 97-98% of riders with AIS < 5 somatic injuries, helmet use could prevent about three-fourths of fatalities and brain injuries., Conclusions: Helmets were extremely effective in preventing brain injury and death in 97% of the accident population in less-than-extreme crashes. Helmet use cannot prevent all fatalities because many of those killed succumb to below-the-neck injuries that a helmet cannot prevent.

In order to identify motorcycle accident cause factors and countermeasures in Thailand, a large prospective study was undertaken. Researchers conducted on-scene, in-depth investigation and reconstruction of 969 collisions involving 1082 motorcycle riders. Accidents were randomly sampled and included all levels of injury severity. Alcohol proved to be the most outstanding cause factor, with 393 drinking riders in crashes. Alcohol accidents were distinctly different from non-alcohol crashes. Alcohol accidents were more frequent on weekends and particularly at night, usually when the rider was on his way home. Drinking riders were more likely to lose control of the motorcycle, usually by running off the road. They were more likely to be in a single vehicle accident, to violate traffic control signals, and to be in non-intersection collisions. Males were far more likely to drink and ride than females. Drinking riders were far more likely to be inattentive to the driving task just before they crashed, and to be the primary or sole cause of the accident. One-fourth of all riders did not go to the hospital, and another 42% needed only treatment in the emergency room. Drinking riders were more likely to be hospitalized and far more likely to be killed. The higher hospitalization and fatality rates of drinking riders resulted from the kinds of accidents in which they were involved, not from the minimal differences in speeds and helmet use. Problems with balance and coordination were about equally rare among drinking and non-drinking riders. Inattention was a far greater contributing factor.

Detailed layer-by-layer autopsy of the head and neck was performed on a prospective series of 73 fatally injured motorcyclists in order to identify occult injuries, particularly soft tissue neck injuries such as hemorrhage of vertebral and carotid arteries. The fatal cases were gathered as part of a larger study of 1,082 on-scene in-depth motorcycle crash investigations in Thailand. Detailed neck dissection was done on nearly all fatal cases. Injuries were coded using the 1990 revision of the Abbreviated Injury Scale (AIS 90) and an Injury Severity Score (ISS) was determined for each case. Additional AIS codes are proposed for neck injuries that were often identified during the detailed autopsy procedures, but which are not listed explicitly among existing AIS codes. Helmet use was determined based on analysis of injury patterns and helmet damage with consideration also given to witness statements. Both helmeted and unhelmeted motorcyclists showed a high frequency of occult neck injuries such as hemorrhages in the carotid sheath or surrounding the vertebral arteries, phrenic nerve, or brachial plexus. These soft tissue neck injuries sometimes accompanied more obvious injuries to cervical vertebrae or spinal cord, but about one-third of riders had no obvious injury to suggest the presence of occult neck injury. Twenty-eight motorcyclists had been wearing a helmet at the start of the collision sequence, but only nine helmets remained in place through the entire collision event. Helmeted riders showed more severe somatic (below-the-neck) injuries than unhelmeted riders, suggesting helmeted riders are less likely to die in low-threat accidents with somatic injuries below AIS-3. The most significant finding of this study was the identification of serious internal neck injuries despite the absence of external physical evidence of trauma to the neck. Virtually all riders with significant head injuries showed some of these soft tissue neck injuries. Approximately one-third of the critically injured riders who survived at least a few hours before death showed serious occult soft tissue neck injuries.

Detailed layer-by-layer autopsy of the head and neck was performed on a series of seventy-three fatally injured motorcyclists in order to identify occult soft tissue injuries such as subluxation of the cervical spine or hemorrhage of vertebral or internal carotid arteries. The fatal cases were gathered as part of a larger study of 1082 on-scene in-depth motorcycle crash investigations in Thailand. Injuries were coded using the 1990 Abbreviated Injury Scale (AIS 90) and an Injury Severity Score (ISS) was determined for each case. Twenty-eight motorcyclists had been wearing a helmet at the start of the collision sequence, but only nine helmets remained in place through the entire collision event. Both helmeted and unhelmeted motorcyclists showed a high frequency of neck injuries such as hemorrhages in the carotid sheath compressing the vagus nerve, hemorrhages surrounding the phrenic nerves or the brachial plexus, or hemorrhages surrounding the vertebral arteries. The most significant finding of this study was the identification of serious internal neck injuries even when there was no external physical evidence of trauma to the neck. Virtually all riders with significant head injuries showed some of these soft tissue neck injuries. This may be important for trauma physicians, who are presented with critically injured motorcyclists with complex multiple trauma, which may include occult soft tissue neck injuries.