Advertisement

The burden of unhelmeted motorcycle injury: A nationwide scoring-based analysis of helmet safety legislation

  • Arjun Ganga
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Eric J. Kim
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Oliver Y. Tang
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Joshua R. Feler
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Rahul A. Sastry
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Matthew N. Anderson
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Sharonda E. Keith
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Jared S. Fridley
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Ziya L. Gokaslan
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Deus J. Cielo
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Steven A. Toms
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
  • Patricia Zadnik Sullivan
    Correspondence
    Corresponding author at: Rhode Island Hospital, 593 Eddy St
    Affiliations
    Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

    Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
    Search for articles by this author
Published:January 03, 2023DOI:https://doi.org/10.1016/j.injury.2023.01.013

      Highlights

      • The stringency of motorcycle helmet safety legislation varies widely across the US.
      • States with more stringent laws had significantly lower unhelmeted fatalities per 100,000 people and 100,000 motorcycles.
      • Exemptions to helmet wearing for certain riders and motorcycle-like vehicles significantly predicted higher fatalities.

      Abstract

      Introduction

      Motorcycle collisions comprise a large portion of motor vehicle injuries and fatalities with over 80,000 injuries and 5,500 fatalities per year in the United States. Unhelmeted riders have poor medical outcomes and generate billions in costs. Despite helmet use having been shown to lower the risk of neurological injury and death, helmet compliance is not universal, and legislation concerning helmet use also varies widely across the United States.

      Methods

      In this study, we systematically reviewed helmet-related statutes from all US jurisdictions. We evaluated the stringency of these statutes using a legislative scoring system termed the Helmet Safety Score (HSS) ranging from 0–7 points, with higher scores denoting more stringent statutes. Regression modeling was used to predict unhelmeted mortality using our safety scores.

      Results

      The mean score across all jurisdictions was 4.73. We found jurisdictions with higher HSS's generally had lower percentages of unhelmeted fatalities in terms of total fatalities as well as per 100,000 people and 100,000 registered motorcycles. In contrast, some lower-scoring jurisdictions had over 100 times more unhelmeted fatalities than higher-scoring jurisdictions. Our HSS significantly predicted unhelmeted motorcycle fatalities per 100,000 people (β = -0.228 per 1-point increase, 95% CI: -0.288 to -0.169, p < .0001) and per 100,000 registered motorcycles (β = -6.17 per 1-point increase, 95% CI: -8.37 to -3.98, p < .0001) in each state. Aspects of our score concerning helmet exemptions for riders and motorcycle-type vehicles independently predicted higher fatalities (p < .0001). Higher safety scores predicted lower unhelmeted fatalities.

      Conclusion

      Stringent helmet laws may be an effective mechanism for decreasing unhelmeted mortality. Therefore, universal helmet laws may be one such mechanism to decrease motorcycle-related neurological injury and fatality burden. In states with existing helmet laws, elimination of exemptions for certain riders and motorcycle-type vehicles may also decrease fatalities.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ang B.H.
        • Chen W.S.
        • Lee S.W.H.
        Global burden of road traffic accidents in older adults: a systematic review and meta-regression analysis.
        Arch Gerontol Geriatr. 2017; 72: 32-38https://doi.org/10.1016/j.archger.2017.05.004
        • James S.L.
        • Lucchesi L.R.
        • Bisignano C.
        • Castle C.D.
        • Dingels Z.V.
        • Fox J.T.
        • et al.
        Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017.
        Inj Prev. 2020; 26: i46-i56https://doi.org/10.1136/injuryprev-2019-043302
        • Sharma B.R.
        Road traffic injuries: a major global public health crisis.
        Public Health. 2008; 122: 1399-1406https://doi.org/10.1016/j.puhe.2008.06.009
        • Chekijian S.
        • Paul M.
        • Kohl V.P.
        • Walker D.M.
        • Tomassoni A.J.
        • Cone D.C.
        • et al.
        The global burden of road injury: its relevance to the emergency physician.
        Emerg Med Int. 2014; 2014139219https://doi.org/10.1155/2014/139219
        • Adeloye D.
        • Thompson J.Y.
        • Akanbi M.A.
        • Azuh D.
        • Samuel V.
        • Omoregbe N.
        • et al.
        The burden of road traffic crashes, injuries and deaths in Africa: a systematic review and meta-analysis.
        Bull World Health Organ. 2016; 94: 510-521Ahttps://doi.org/10.2471/BLT.15.163121
        • Oltaye Z.
        • Geja E.
        • Tadele A.
        Prevalence of motorcycle accidents and its associated factors among road traffic accident patients in hawassa university comprehensive specialized hospital, 2019.
        Open Access Emerg Med. 2021; 13: 213-220https://doi.org/10.2147/OAEM.S291510
        • Ning P.
        • Schwebel D.C.
        • Huang H.
        • Li L.
        • Li J.
        • Hu G.
        Global Progress in Road Injury Mortality since 2010.
        PLoS ONE. 2016; 11e0164560https://doi.org/10.1371/journal.pone.0164560
        • Mohammadi E.
        • Azadnajafabad S.
        • Keykhaei M.
        • Shakiba A.
        • Ebrahimi Meimand S.
        • Hosseini Shabanan S.
        • et al.
        Barriers and factors associated with the use of helmets by Motorcyclists: a scoping review.
        Accid Anal Prev. 2022; 171106667https://doi.org/10.1016/j.aap.2022.106667
      1. Motorcycle Safety | NHTSA n.d. https://www.nhtsa.gov/road-safety/motorcycles (accessed June 9, 2022).

        • Sayyed Hoseinian S.H.
        • Ebrahimzadeh M.H.
        • Peivandi M.T.
        • Bagheri F.
        • Hasani J.
        • Golshan S.
        • et al.
        Injury Patterns among Motorcyclist Trauma Patients: a Cross Sectional Study on 4200 Patients.
        Arch Bone Jt Surg. 2019; 7: 367-372
        • Yun H.
        • Bae S.J.
        • Lee J.I.
        • Lee D.H.
        Epidemiology, injury characteristics and clinical outcomes of bicycle and motorcycle accidents in the under 20 population: south Korea.
        BMC Emerg Med. 2022; 22: 56https://doi.org/10.1186/s12873-022-00614-8
        • Yu X.
        • Logan I.
        • de Pedro
        • Sarasola I.
        • Dasaratha A.
        • Ghajari M.
        The protective performance of modern motorcycle helmets under oblique impacts.
        Ann Biomed Eng. 2022; https://doi.org/10.1007/s10439-022-02963-8
        • Adeleye A.O.
        • Ogun M.I.
        Clinical epidemiology of head injury from road-traffic trauma in a developing country in the current era.
        Front Neurol. 2017; 8: 695https://doi.org/10.3389/fneur.2017.00695
        • Liu B.
        • Ivers R.
        • Norton R.
        • Blows S.
        • Lo S.K.
        Helmets for preventing injury in motorcycle riders.
        Cochrane Database Syst Rev. 2004; CD004333https://doi.org/10.1002/14651858.CD004333.pub2
        • Singleton M.D.
        Differential protective effects of motorcycle helmets against head injury.
        Traffic Inj Prev. 2017; 18: 387-392https://doi.org/10.1080/15389588.2016.1211271
        • Khor D.
        • Inaba K.
        • Aiolfi A.
        • Delapena S.
        • Benjamin E.
        • Matsushima K.
        • et al.
        The impact of helmet use on outcomes after a motorcycle crash.
        Injury. 2017; 48: 1093-1097https://doi.org/10.1016/j.injury.2017.02.006
        • Lucci C.
        • Piantini S.
        • Savino G.
        • Pierini M.
        Motorcycle helmet selection and usage for improved safety: a systematic review on the protective effects of helmet type and fastening.
        Traffic Inj Prev. 2021; 22: 301-306https://doi.org/10.1080/15389588.2021.1894640
        • Bianco A.
        • Trani F.
        • Santoro G.
        • Angelillo I.F.
        Adolescents’ attitudes and behaviour towards motorcycle helmet use in Italy.
        Eur J Pediatr. 2005; 164: 207-211https://doi.org/10.1007/s00431-004-1604-9
        • Germeni E.
        • Lionis C.
        • Davou B.
        • Petridou E.T.
        Understanding reasons for non-compliance in motorcycle helmet use among adolescents in Greece.
        Inj Prev. 2009; 15: 19-23https://doi.org/10.1136/ip.2008.019356
        • Wiznia D.H.
        • Kim C.-.Y.
        • Dai F.
        • Goel A.
        • Leslie M.P.
        The effect of helmets on motorcycle outcomes in a level I trauma center in Connecticut.
        Traffic Inj Prev. 2016; 17: 633-637https://doi.org/10.1080/15389588.2015.1136059
        • Peng Y.
        • Vaidya N.
        • Finnie R.
        • Reynolds J.
        • Dumitru C.
        • Njie G.
        • et al.
        Universal Motorcycle Helmet Laws to Reduce Injuries: a Community Guide Systematic Review.
        Am J Prev Med. 2017; 52: 820-832https://doi.org/10.1016/j.amepre.2016.11.030
        • Mock C.N.
        • Maier R.V.
        • Boyle E.
        • Pilcher S.
        • Rivara F.P.
        Injury prevention strategies to promote helmet use decrease severe head injuries at a level I trauma center.
        J Trauma. 1995; 39 (discussion 34-35): 29-33https://doi.org/10.1097/00005373-199507000-00004
        • Nguyen H.T.
        • Passmore J.
        • Cuong P.V.
        • Nguyen N.P.
        Measuring compliance with Viet Nam's mandatory motorcycle helmet legislation.
        Int J Inj Contr Saf Promot. 2013; 20: 192-196https://doi.org/10.1080/17457300.2012.706617
        • Olsen C.S.
        • Thomas A.M.
        • Singleton M.
        • Gaichas A.M.
        • Smith T.J.
        • Smith G.A.
        • et al.
        Motorcycle helmet effectiveness in reducing head, face and brain injuries by state and helmet law.
        Inj Epidemiol. 2016; 3: 8https://doi.org/10.1186/s40621-016-0072-9
        • Hyder A.A.
        • Waters H.
        • Phillips T.
        • Rehwinkel J.
        Exploring the economics of motorcycle helmet laws–implications for low and middle-income countries.
        Asia Pac J Public Health. 2007; 19: 16-22https://doi.org/10.1177/10105395070190020401
        • Homer J.
        • French M.
        Motorcycle Helmet Laws in the United States From 1990 to 2005: politics and Public Health.
        Am J Public Health. 2009; 99: 415-423https://doi.org/10.2105/AJPH.2008.134106
        • Eltorai A.E.M.
        • Simon C.
        • Choi A.
        • Hsia K.
        • Born C.T.
        • Daniels A.H.
        Federally mandating motorcycle helmets in the United States.
        BMC Public Health. 2016; 16: 242https://doi.org/10.1186/s12889-016-2914-3
        • Fischer C.S.
        Paradoxes of American Individualism.
        Sociological Forum. 2008; 23: 363-372https://doi.org/10.1111/j.1573-7861.2008.00066.x
        • Hothem Z.
        • Simon R.
        • Barnes W.
        • Mohammad A.
        • Sevak S.
        • Ziegler K.
        • et al.
        Effects of repealing the motorcycle helmet law in Michigan.
        Am J Surg. 2017; 214: 407-412https://doi.org/10.1016/j.amjsurg.2016.09.052
        • Patel P.B.
        • Staley C.A.
        • Runner R.
        • Mehta S.
        • Schenker M.L.
        Unhelmeted Motorcycle Riders Have Increased Injury Burden: a Need to Revisit Universal Helmet Laws.
        J Surg Res. 2019; 242: 177-182https://doi.org/10.1016/j.jss.2019.03.023
        • Mertz K.J.
        • Weiss H.B.
        Changes in motorcycle-related head injury deaths, hospitalizations, and hospital charges following repeal of Pennsylvania's mandatory motorcycle helmet law.
        Am J Public Health. 2008; 98: 1464-1467https://doi.org/10.2105/AJPH.2007.123299
        • Bredikhina O.A.
        • Rafique S.
        • Fisher J.W.
        • Penmetsa P.
        • Wheeler L.M.
        • Li X.
        • et al.
        Ride-hailing with kids: who's got their back?.
        J Safety Res. 2021; 79: 117-124https://doi.org/10.1016/j.jsr.2021.08.012
        • Patel S.J.
        • Badolato G.M.
        • Parikh K.
        • Iqbal S.F.
        • Goyal M.K.
        Regional differences in pediatric firearm-related emergency department visits and the association with firearm legislation.
        Pediatr Emerg Care. 2021; 37: e692https://doi.org/10.1097/PEC.0000000000001779
        • Smith A.J.
        • Williams D.R.
        Father-friendly legislation and paternal time across Western Europe.
        J Comparative Pol Anal: Res Practice. 2007; 9: 175-192https://doi.org/10.1080/13876980701311604
        • Houston D.J.
        • Richardson Jr., L.E.
        Reducing traffic fatalities in the American States by upgrading seat belt use laws to primary enforcement.
        J Policy Anal Manage. 2006; 25: 645-659https://doi.org/10.1002/pam.20195
        • Nichols J.
        • Tippetts A.S.
        Strategies to increase seat belt use: an analysis of levels of fines and the type of law.
        National Highway Traffic Safety Administration, 2010
      2. CrashStats - NHTSA - DOT n.d. https://crashstats.nhtsa.dot.gov/#!/#%2F (accessed June 9, 2022).

      3. Bureau UC. 2019 US Population Estimates Continue to Show the Nation's Growth Is Slowing. CensusGov n.d. https://www.census.gov/newsroom/press-releases/2019/popest-nation.html (accessed June 9, 2022).

      4. Motorcycles registered in the United States, 2002-2021. IIHS-HLDI Crash Testing and Highway Safety n.d. https://www.iihs.org/topics/bibliography/ref/2225 (accessed June 10, 2022).

      5. Bureau UC. Geographic Levels. CensusGov n.d. https://www.census.gov/programs-surveys/economic-census/guidance-geographies/levels.html (accessed July 13, 2022).

      6. Statute | Kansas State Legislature n.d. http://www.kslegislature.org/li_2012/b2011_12/statute/008_000_0000_chapter/008_015_0000_article/008_015_0098_section/008_015_0098_k/ (accessed June 9, 2022).

      7. Michigan Legislature - Section 257.658 n.d. http://www.legislature.mi.gov/(S(m1qwtmvgwysqmwee4oegw0om))/mileg.aspx?page=GetObject&objectname=mcl-257-658 (accessed June 9, 2022).

      8. 2013 New Jersey Revised Statutes:: Title 39 - MOTOR VEHICLES AND TRAFFIC REGULATION:: Section 39:3-76.7 - Protective helmets. Justia Law n.d. https://law.justia.com/codes/new-jersey/2013/title-39/section-39-3-76.7 (accessed June 9, 2022).

      9. Helmets | Maine State Legislature n.d. https://legislature.maine.gov/lawlibrary/what-is-maines-law-on-helmets/9470 (accessed June 9, 2022).

      10. 2015 Nevada Revised Statutes:: Chapter 486 - Motorcycles and Similar Vehicles:: NRS 486.231 - Protective headgear and glasses: standards; when use required. Justia Law n.d. https://law.justia.com/codes/nevada/2015/chapter-486/statute-486.231/ (accessed June 9, 2022).

      11. 2010 Georgia Code:: TITLE 40 - motor vehicles and traffic:: chapter 6 - uniform rules of the road:: article 13 - special provisions for certain vehicles:: part 2 - motorcycles:: § 40-6-315 - Headgear and eye-protective devices for riders. Justia Law n.d. https://law.justia.com/codes/georgia/2010/title-40/chapter-6/article-13/part-2/40-6-315 (accessed June 9, 2022).

      12. 2019 Maryland Code:: Transportation:: Title 21 - Vehicle Laws – Rules of the Road:: Subtitle 13 - Operation of Motorcycles:: &sect; 21-1306 Equipment for riders – Motorcycles. Justia Law n.d. https://law.justia.com/codes/maryland/2019/transportation/title-21/subtitle-13/sect-21-1306/ (accessed June 9, 2022).

      13. 2016 Colorado Revised Statutes:: Title 42 -:: Vehicles and Traffic:: Regulation of Vehicles and Traffic:: Article 4 - Regulation of Vehicles and Traffic:: Part 15 -:: Motorcycles:: § 42-4-1502. Riding on motorcycles - protective helmet. Justia Law n.d. https://law.justia.com/codes/colorado/2016/title-42/regulation-of-vehicles-and-traffic/article-4/part-15/section-42-4-1502 (accessed June 9, 2022).

      14. New traffic law will require moped, scooter riders to wear helmets come Oct. 1. KLAS 2019. https://www.8newsnow.com/news/local-news/new-traffic-law-will-require-moped-scooter-riders-to-wear-helmets-come-oct-1/ (accessed July 6, 2022).

      15. 2010 Arkansas Code:: Title 27 - Transportation:: Subtitle 2 - Motor Vehicle Registration And Licensing:: Chapter 20 - Operation of Motorized Cycles and All-Terrain Vehicles:: Subchapter 1 - Motorcycles, Motor-Driven Cycles, and Motorized Bicycles:: § 27-20-104 - Standard equipment required. Justia Law n.d. https://law.justia.com/codes/arkansas/2010/title-27/subtitle-2/chapter-20/subchapter-1/27-20-104 (accessed June 27, 2022).

      16. Pennsylvania Code, Article VI, Chapter 107 - MOTORCYCLE HELMETS | Pennsylvania Code | Justia. Justia Law n.d. https://regulations.justia.com/states/pennsylvania/title-67/part-i/subpart-a/article-vi/chapter-107/(accessed June 27, 2022).

      17. 2006 Ohio Revised Code - 4511.53. Rules for bicycles, motorcycles and snowmobiles. Justia Law n.d. https://law.justia.com/codes/ohio/2006/orc/jd_451153-ebc5.html (accessed June 27, 2022).

      18. Motorcycles: Motorcycle helmet laws by state. IIHS-HLDI Crash Testing and Highway Safety n.d. https://www.iihs.org/topics/motorcycles/motorcycle-helmet-laws-table (accessed July 6, 2022).

      19. Boyd T. “Wanted to be home”: a record high, SC motorcyclist deaths devastate families. The Greenville News n.d. https://www.greenvilleonline.com/story/news/local/south-carolina/2022/01/25/motorcyclist-deaths-have-reached-record-high-south-carolina/6492620001/ (accessed June 9, 2022).

      20. Staff. South Carolina motorcycle deaths reach four-decade high point. Https://WwwWrdwCom n.d. https://www.wrdw.com/2022/01/28/sc-motorcycle-deaths-reach-four-decade-high-point/ (accessed June 9, 2022).

      21. Fatality Count n.d. https://fatality-count-scdps.hub.arcgis.com/ (accessed July 13, 2022).

      22. Bopp C. 2021 on track to be South Carolina's deadliest year on roadways. Https://WwwWrdwCom n.d. https://www.wrdw.com/2021/12/03/2021-track-be-south-carolinas-deadliest-year-roadways/ (accessed July 13, 2022).

      23. Missouri Code of State Regulations | Title 12 - DEPARTMENT OF REVENUE | Division 10 - Director of Revenue | Chapter 40 - Motorcycle Helmet Standards. Justia Law n.d. https://regulations.justia.com/states/missouri/title-12/division-10/chapter-40/ (accessed June 9, 2022).

        • Berrick J.
        • Gkritza K.
        Adolescent noncompliance with age-specific versus universal US motorcycle helmet laws: systematic review and meta-analysis.
        J Safety Res. 2021; 76: 166-175https://doi.org/10.1016/j.jsr.2020.12.011
        • Striker R.H.
        • Chapman A.J.
        • Titus R.A.
        • Davis A.T.
        • Rodriguez C.H.
        Repeal of the Michigan helmet law: the evolving clinical impact.
        The Am J Surg. 2016; 211: 529-533https://doi.org/10.1016/j.amjsurg.2015.11.004
        • Saunders R.N.
        • Adams N.S.
        • Chapman A.J.
        • Davis A.T.
        • Koehler T.J.
        • Durling L.T.
        • et al.
        The impact of the repeal of Michigan's universal helmet law on traumatic brain injury: a statewide analysis.
        The Am J Surg. 2018; 215: 424-427https://doi.org/10.1016/j.amjsurg.2017.09.033
        • Carter P.M.
        • Buckley L.
        • Flannagan C.A.C.
        • Cicchino J.B.
        • Hemmila M.
        • Bowman P.J.
        • et al.
        The impact of michigan's partial repeal of the universal motorcycle helmet law on helmet use, fatalities, and head injuries.
        Am J Public Health. 2017; 107: 166-172https://doi.org/10.2105/AJPH.2016.303525
      24. Missouri Statistical Analysis Home Page n.d. https://www.mshp.dps.missouri.gov/MSHPWeb/SAC/Compendium/TrafficCompendium.html# (accessed June 9, 2022).

        • Galanis D.J.
        • Castel N.A.
        • Wong L.L.
        • Steinemann S.
        Impact of helmet use on injury and financial burden of motorcycle and moped crashes in hawai‘i: analysis of a linked statewide database.
        Hawaii J Med Public Health. 2016; 75: 379-385
        • Kim C.-.Y.
        • Wiznia D.
        • Averbukh L.
        • Dai F.
        • Leslie M.
        The economic impact of helmet use on motorcycle accidents: a systematic review and meta-analysis of the literature from the past 20 years.
        Traffic Inj Prev. 2015; 16: 1-7https://doi.org/10.1080/15389588.2015.1005207
        • Croce M.A.
        • Zarzaur B.L.
        • Magnotti L.J.
        • Fabian T.C.
        Impact of motorcycle helmets and state laws on society's burden: a national study.
        Ann Surg. 2009; 250: 390-394https://doi.org/10.1097/SLA.0b013e3181b365a2
      25. Motorcycle injury prevention | health impact in 5 years | health system transformation | AD for Policy | CDC 2022. https://www.cdc.gov/policy/hst/hi5/motorcycleinjury/index.html (accessed June 11, 2022).

        • Boone E.M.
        • Rossheim M.E.
        • Krall J.R.
        • Weiler R.M.
        State helmet laws and helmet use among fatally injured moped riders in the United States, 2011-2015.
        Traffic Inj Prev. 2018; 19: 270-273https://doi.org/10.1080/15389588.2017.1383604
        • Hassan A.
        • Jokar T.O.
        • Rhee P.
        • Ibraheem K.
        • Kulvatunyou N.
        • Anderson K.T.
        • et al.
        More helmets fewer deaths: motorcycle helmet legislation impacts traumatic brain injury-related mortality in young adults.
        Am Surg. 2017; 83: 541-546
        • Notrica D.M.
        • Sayrs L.W.
        • Krishna N.
        • Davenport K.P.
        • Jamshidi R.
        • McMahon L.
        Impact of helmet laws on motorcycle crash mortality rates.
        J Trauma Acute Care Surg. 2020; 89: 962-970https://doi.org/10.1097/TA.0000000000002861
        • Powell J.M.
        • Ferraro J.V.
        • Dikmen S.S.
        • Temkin N.R.
        • Bell K.R.
        Accuracy of mild traumatic brain injury diagnosis.
        Arch Phys Med Rehabil. 2008; 89: 1550-1555https://doi.org/10.1016/j.apmr.2007.12.035
        • McKinlay A.
        • Lin A.
        • Than M.
        A comparison of emergency department medical records to parental self-reporting of traumatic brain injury symptoms.
        Concussion. 2018; 3: CNC52https://doi.org/10.2217/cnc-2017-0017