April 1, 2024 – Head injury cases among people riding electric bikes are increasing at an alarming rate while the odds of e-bike riders wearing a helmet are decreasing.
It’s a recipe likely to fuel the already skyrocketing number of people visiting the nation’s emergency rooms after mishaps on the popular and powerful bicycles, many of which can travel at more than 20 miles per hour.
New research shows that e-bike injuries in the U.S. increased by 30 times from 2017 to 2022, and hospitalizations rose by 43 times. During that 5-year period, there were more than 45,000 visits to emergency rooms stemming from e-bike injuries, and more than 5,000 hospitalizations. The findings were published in JAMA Surgery, and the researchers are also working on an analysis comparing e-bike injuries with those stemming from riding a traditional bicycle.
The head injury findings among e-bike riders was the most striking, particularly amid the decline in helmet usage, said lead author Adrian Fernandez, MD.
“We see so many people riding e-bikes around San Francisco that it was just an area of interest for us, and especially seeing people riding e-bikes without helmets got us interested in asking whether or not there had been more injuries,” said Fernandez, a resident doctor at the University of California San Francisco. “We saw a really explosive trend of increasing injuries and hospitalizations.”
From 2017 to 2022, the number of people being treated for e-bike injuries in the nation’s emergency rooms doubled annually, the researchers found. The number of people being admitted to the hospital for serious injuries also doubled each year during that 5-year period. The researchers were careful to exclude injuries from other forms of what has come to be known as "micromobility," such as electric scooters. The data was collected from the National Electronic Injury Surveillance System and included reports from about 100 emergency rooms nationwide.
Common injury types were those to the upper and lower extremities, such as a broken wrist or broken leg, Fernandez said. Blunt injuries were also common, such as those that might happen when hitting a car door or falling on hard ground. But also in the top tier of injuries were those to the head, such as a cut to the scalp or concussion.
The researchers warned that “the increasing proportion of head injuries in our study warrants further examination, as traumatic brain injuries are more severe in e-bicyclists than in traditional bicyclists.”
Helmets: A Tough Sell
The number of e-bikes sold in the U.S. quadrupled from 2019 to 2022, from 287,000 to 1.1 million, according to figures from the Light Electric Vehicle Association published by the U.S. Department of Energy. Metropolitan area e-bike sharing and rental programs targeting commuters have also been increasing.
Fernandez noted that most e-bike rental companies that allow people to simply unlock and hop on a bike using a mobile device app don’t also have a way to easily provide helmets. Improving helmet usage poses a significant opportunity to impact public health and usage of often already overloaded emergency rooms.
Not all bike helmets offer equal protection against head injuries, and the only requirement to market a bike helmet in the U.S. is that it must succeed in a pass-fail series of tests to show it can prevent a skull fracture or life-threatening head injury. The U.S. Consumer Product Safety Commission oversees the minimum protection requirements for bike helmets.
People who are looking for more than that basic protection can look to helmet ratings published by a special helmet testing lab in the Department of Biomedical Engineering and Mechanics at Virginia Tech in Blacksburg, VA.
“If the helmet passes those basic tests, the chances of you getting a skull fracture or dying are pretty low based on the test protocol that they’re using, so we supplement those pass-fail certifications with real-world, sport-specific helmet ratings,” said Barry Miller, PhD, MBA, director of outreach and business development for the Virginia Tech Helmet Lab. “So we figure out: How do people hit their heads riding a bike, how do they hit their heads snow skiing, how do they hit their heads coming off a horse, how do they hit their heads playing football?”
Miller said he isn’t surprised by the latest numbers on e-bike injuries, and his lab is considering creating a category of helmet ratings just for e-bikers.
“With old-fashioned pedal power, you have a lot of control when you’re generating the power and friction with the road, but when you’re just hitting the throttle button, and you’re going faster than you’ve ever gone before, people aren’t used to that. Your steering gets a little more tricky. It’s like driving your car at high speed; little movements have big results,” he said.
People selecting a helmet for e-bike riding may want to consider three questions:
- How often do they ride?
- How fast do they ride?
- What’s the ride environment?
Those who only ride now and then, don’t go fast, and are in controlled environments such as a recreational bike trail with few unexpected obstacles wouldn’t face the same level of risk as a daily commuter in a large city on traffic-filled streets.
Andy Powell of Charlotte, NC, grew up snowboarding and never wore a helmet. That habit continued when he started skateboarding as his main mode of transportation during college.
“I didn’t know I should wear a helmet. My parents didn’t make me wear one. I really wasn’t aware of the dangers at a younger age regarding helmet safety, and I didn’t hit my head, either,” said Powell, now co-owner of a shop called Rent EBoards Charlotte that rents and sells electric bikes and skateboards.
While in college, Powell admits he thought helmets were inconvenient and made people look awkward.
“These are the types of preconceptions that users who come into my store have. For whatever reason, our culture has bestowed upon them the idea that helmets are optional. Whereas they are, they’re still certainly recommended,” he said.
In all the shop’s rentals, Powell says they haven’t had a customer hit their head. The team spends a lot of time showing customers how the bikes work, discussing how important visibility and awareness are, and also discussing the importance of wearing a helmet. People who buy e-bikes or e-skateboards often ask whether they can wear a standard bike helmet, Powell said. He recommends helmets with what’s known as a MIPS certification, which means the helmet offers concussion protection during falls that may happen while the body is in rotation. His shop provides those high-end helmets to use during all rentals.
“The helmet debate is a big thing. A lot of times, people will defend their viewpoint on why they don’t wear a helmet and say, ‘I know how to fall,‘” Powell said. “When it’s your future, I try to impress on our customers that you do want to continue to ride. In order to do so, you have to take preventative measures.”
