Assessing the Prevalence of Traumatic Head Injury amongst Recreational Surfers in the United States

Abstract

Surfing is a popular recreational sport that carries a substantial risk of injury. Although head injuries are frequently documented in the surfing population, an in depth assessment of the prevalence of surfing-related head injury has not been reported. A web-based survey was conducted in May of 2015. Participants were asked a series of questions regarding surfing-related injuries and demographic characteristics. A total of 50 responses were obtained, of which 35 (70%) reported sustaining a head injury. The most common injury was laceration of the head/face (n=27), followed by concussion (n=13). Other injuries, such as skull fracture and broken nose, were also reported. Only 2 of the 50 participants reported wearing a protective helmet. Neurosurgical intervention was required in 2 instances. Increased emphasis on preventative measures by the medical community may reduce the future incidence of such injuries. Medical professionals should be aware of the most common forms of injury sustained by the surfing population in order to better recognize and treat these conditions.

Introduction

Surfing is a popular recreational sport in the United States. This is particularly true in the Hawaiian Islands, where the sport has great cultural and historical significance. However, there are many dangers inherent to the sport, leading to a significant risk of injury. A recent study found head injuries to be the most commonly sustained injury amongst surfers, comprising 24% of all injuries.¹ In the United States, sports-related injuries, such as those from surfing, account for more than 10% of the staggering 2 million traumatic brain injuries that are reported each year.² Other studies also found that lacerations, regardless of body part, are another common injury among surfers.^3,4 To-date, most published studies have been general in focus and no investigations specific to surfing related head injury have been conducted. Thus, an investigation into the prevalence of such injuries is warranted. The purpose of this study is to assess the prevalence of traumatic head injury and the use of protective equipment in a sample of surfers living in the United States. This study may provide the medical community with a better understanding of how to best prevent and treat this potentially devastating form of morbidity.

Methods

Data was obtained using an anonymous interactive web-based survey that was made available to multiple surf associations and clubs in the United States throughout the month of May 2015. Initially, a google search was conducted to identify United States-based surfing organizations and clubs. Those that had an online section, including either an online directory with member email addresses or an online forum through which members could be contacted, were eligible. In the former situation, all members in the online directory were invited to participate. In the latter setting, any registered member logging into the online forum during the study period could respond to the survey. The web-based survey application ensured that each member could only respond once to the questions. Thus, responses were obtained from members with online involvement who accessed the associated websites during the study period.

The study consisted of 10 multiple choice questions with an option to write in “other” responses. The survey was original and not based off previously published questionnaires. No incentives were offered. Demographic characteristics, including age group, gender, and surfing experience, were obtained. Age was categorized into 5 subgroups: 18–24, 25–34, 35–44, 45–55, and 56–64. Surfing experience was defined based on individuals' self-reported years of experience. Possible categorizations included less than 1 year, 1–5 years, and greater than 5 years of experience. Participants were then asked about their history of surf-related head injuries, diagnostic measures taken, treatments received, and preventative measures taken to prevent head injury. Any surfer over the age of 18 was considered eligible for this study. No other inclusion or exclusion criteria were applied. Data was initially collected utilizing a web-based survey service. It was then compiled and analyzed using Microsoft Excel 2010. A 2 sample homoscedastic t-test was used to compare the rate of head injury between age groups.

Results

A group of 50 individuals participated in this study. Demographic data is displayed in Table 1. Most responders were between 18 and 34 years old (51%) and male (88%), with more than 5 years surfing experience (76%). Of the 50 participants, 35 (70%) reported sustaining a head injury (Table 2) which did not differ by age group (P>.05). The most common head injury was laceration of the head/face (77%), followed by concussion (37%). Other head injuries included skull fracture (6%), loss of consciousness (9%), broken nose (9%), and severe traumatic brain injury (3%). Four participants reported wearing a protective helmet. Two participants, neither of whom wore a helmet, also reported sustaining an injury that required neurosurgical intervention.

Table 1.

Demographic Characteristics of Participants, United States, May 2015

	Participants (N= 50)	%
Age Group
18–24	11	22.0
25–34	15	30.0
35–44	9	18.0
45–54	6	12.0
55–64	9	18.0
Gender
Male	42	87.5*
Female	6	12.5*
Not Disclosed	2
Surfing Experience (years)
<1	0	0
1–5	12	24.0
>5	38	76.0

^*Percentages exclude unknown values.

Table 2.

Characterization of Reported Surfing-Related Head Injuries, United States, May 2015

	Participants Reporting a Head Injury (N=35)	%
Type of Injury
Concussion (Mild Traumatic Brain Injury)	13	37.1
Severe Traumatic Brain Injury	1	2.9
Skull Fracture	2	5.7
Head/Face Laceration	27	77.1
Loss of Consciousness	3	8.6
Broken Nose	3	8.6
Received Diagnostic Assessment (CT/MRI/X-Ray)	4	11.4
Required Neurosurgical Intervention	2	5.7

Discussion

A recent article by Woodacre and colleagues established that head injuries are common amongst surfers.¹ While this study has many merits, it does not provide specific details regarding the types of head injuries sustained. Furthermore, it does not include athletes from the United States who may surf in distinct environmental conditions, which may lead to a unique pattern of injury. Thus, a study focusing on specific head injuries relevant to surfers in the United States is needed.

Injuries to the head and face were common within the present study's cohort, reported by 70% of participants. These findings suggest that lacerations, which have been reported to be the most common injury that surfers experience in general,^3,4 are also the most common form of injury sustained specifically to the head region. While lacerations do not often produce functional neurological deficits, they are still a significant health concern. Even simple lacerations have the potential to lead to serious infections.⁵ Additionally, inadequate healing of lacerations may lead to permanent disfiguration and cosmetic defects.

More severe injuries were also reported. Thirteen participants, 26% of all subjects, reported experiencing a concussion/mild traumatic brain injury while surfing. This is alarming given the potential long term impact of concussive injuries, which have been reported to impair recall, cognitive function, and academic performance.⁶ Although less common, skull fractures, a potentially deadly injury, were also reported in 2 instances. Such injuries put athletes at risk for a variety of dangerous complications, such as epidural hematoma, a neurosurgical emergency. Multiple forms of head protection are available to surfers, including helmets, surf hoods, and goggles. Of note, there are lightweight helmets (Gath Sports, Margaret River, Australia) that are specifically designed for surfing and other water sports. However, head protection, which has been reported to decrease the incidence of head injury in athletes,⁷ was only worn by 2 individuals in this study. This underutilization may be due to a lack of awareness of potential injury, as well as aesthetic concerns. It is reasonable to conclude that an increased emphasis on preventative measures, such as helmet use, by the medical community has the potential to decrease the frequency of surfing-related head injury.

While the nature of this study, an anonymous online survey, was effective at maximizing the response rate, there are certain limitations that should be acknowledged. Notably, patient responses could not be cross-referenced with actual medical records, making it impossible to confirm the validity of the reported diagnoses. The study also operates under the assumption that the sample population is representative of the United States surfing population as a whole. However, no comprehensive study characterizing the demographic and geographic distribution of United States surfers currently exists. Thus, the extent that this sample is truly representative of all surfers in the United States, including those in Hawai‘i, is unknown. The study's small sample size also limits the generalizability of our findings. Using a web-based survey may have also unintentionally excluded older members of these organizations, who may be less likely to utilize the internet and online membership components. Similarly, it should be noted that some surfing organizations may not have an online component, excluding them from consideration.

Going forward, additional studies with a larger sample size and focus in preventative strategies are warranted. This study establishes that head injury is a serious problem for the surfing population, but the literature is lacking when it comes to the efficacy of specific preventative measures. Additionally, a longitudinal assessment could provide insight into trends in head injury over time, as the current study captures a single moment in time.

Conclusion

This study establishes the notable prevalence of surfing related head injury, as well as the lack of utilization of protective headgear. Future initiatives should focus on increasing the use of preventative measures to reduce morbidity. Medical professionals should be aware of the most common forms of injury sustained by the surfing population in order to better recognize and treat these conditions. Increasing awareness of surfing related head injuries and encouraging preventative measures, such as the use of helmets and exercising caution during adverse weather conditions, has the potential to reduce both the incidence and severity of surfing related injury. This is particularly relevant in the Hawaiian Islands and Pacific Rim, where surfing continues to be a popular activity amongst both recreational and professional athletes.

Conflict of Interest

The author does not identify any conflict of interest.