BMJ 2000;321:1582-1585 ( 23 December )
Three lessons for a better cycling future
Malcolm J Wardlaw, business analyst.
92 Drymen Road, Bearsden, Glasgow G61 2SY
[22]A.Wardlaw@btinternet.com
Cyclists were the only group of road users in Britain whose death rate
increased sharply during the 1990s,[23]1 yet cycling was in decline
throughout the decade.[24]2 How could this happen, when attention on
casualties was the most intense in the history of the bicycle? Perhaps
a vision of the near future will be instructive^ . . .
Summary points
______________________________________________________________
Recent safety campaigns have destroyed faith in the bicycle as
a safe means of transport, reducing participation, compromising
public health, increasing the risks, and decreasing road skills
______________________________________________________________
Deaths of cyclists have increased since the introduction of
helmets
______________________________________________________________
Cyclists fare best when they act and are treated as drivers of
vehicles
______________________________________________________________
Promote cycling for a safer road environment
Safe walking
[25][uarrow.gif] Top
[dot.gif] Safe walking
[26][darrow.gif] Risks of cycling
[27][darrow.gif] Is driving safe?
[28][darrow.gif] Dangers of helmets
[29][darrow.gif] Do helmets protect the...
[30][darrow.gif] Lesson one: cyclists get...
[31][darrow.gif] Lesson two: cyclists fare...
[32][darrow.gif] Lesson three: promote cycling...
[33][darrow.gif] References
It began in America, as so many trends do, but for years no one in
Europe took any notice. American tourists wearing helmets around the
streets of London first drew media attention. And although public
response to walking helmets was initially amusement, the^ appeal of
extra safety drew some pioneers to the habit, especially academics and
competitive^ walkers.
The first case-control study of about 2000 injuries to pedestrians in
Britain (180 of whom had worn helmets) concluded that the risk of
serious head injury was reduced by 75% when a good^ walking helmet was
worn. Safety campaigners used the slogan "walkers need helmets" to
encourage parents to send their children to school in helmets. Several
high profile accidents focused public attention on the dangers of
walking. A well known television presenter was severely head injured
by a police van answering an emergency call. Doctors concluded that
her injuries would have been "substantially reduced" had she worn a^
helmet.
Walking helmets became widely available. The entire cabinet posed in
their helmets outside Number 10, the beaming prime minister urging:
"Let's go forward together into a new era of walking safety." Most
children now wore a helmet walking to school, although they were
otherwise not seen on the streets. They played at home, where^ many
injured themselves stunt walking in mountain boots. Safety campaigners
praised the courage of the 25% of adults who wore^ a walking helmet.
Safety campaigner Jean Keystone read her Walkers' Helmet Bill before
parliament: "As a society we are tired of the waste of^ lives in
walking accidents. Every year, around a 1000 pedestrians are killed in
walking accidents, and head injuries feature in 80% of these deaths.
Since research has shown that 75% of head^ injuries are prevented if a
good walking helmet is worn, legislation to compel wearing is
justified by the saving of lives that will result."
The bill wasn't passed, but time was on the campaigners' side. The pop
group Toyzone promoted walking helmets in their video Take a Walk on
the Mild Side. Safety campaigners founded the Helmet Youth. Only the
most antediluvian public figure would appear bareheaded^ in the media.
Compensation for injury was reduced if the pedestrian had not worn a
helmet. Pressure was mounting against those who still valued the
"dubious pleasure of walking with the wind in their hair."
However, safety did have its consequences. Not only had walking
declined, the aspiration to walk skilfully had disappeared. A
generation was growing up incapable of crossing the road. Young
walkers had become dependent on their helmets. Casualty rates were
increasing. Many otherwise capable adults were afraid to walk, having
been alarmed by the safety campaigns. As one chubby chap said from his
car: "It's got nothing to do with helmets. Walking is dangerous ---
why take the^ risk."
A new breed of walker had appeared, stern and serious about safety.
They wore £100 helmets, lighthouse jackets, eye protection, and spent
£1000 on footwear. But they were a rare breed. Gym clubs were
expanding their car parks, and the traffic had never been so bad.
Risks of cycling
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[35][uarrow.gif] Safe walking
[dot.gif] Risks of cycling
[36][darrow.gif] Is driving safe?
[37][darrow.gif] Dangers of helmets
[38][darrow.gif] Do helmets protect the...
[39][darrow.gif] Lesson one: cyclists get...
[40][darrow.gif] Lesson two: cyclists fare...
[41][darrow.gif] Lesson three: promote cycling...
[42][darrow.gif] References
You think I am being facetious? Let us examine the facts. The inherent
risks of road cycling are trivial.[43]3 Of at least 3.5 million
regular cyclists in Britain, only about 10 a year are killed in rider
only accidents. This compares with about 350^ people younger than
75 killed each year falling down steps or tripping.[44]4 Six times as
many pedestrians as cyclists are killed^ by motor traffic, yet travel
surveys show annual mileage walked^ is only five times that cycled; a
mile of walking must be more^ "dangerous" than a mile of cycling. In
both cases, of course, the activity itself is harmless --- but it's in
the way. Although a mile of driving is ten times safer than a mile of
cycling, a^ mile of urban driving is ten times more likely to kill a
pedestrian than such a mile^ cycled.
Is driving safe?
[45][uarrow.gif] Top
[46][uarrow.gif] Safe walking
[47][uarrow.gif] Risks of cycling
[dot.gif] Is driving safe?
[48][darrow.gif] Dangers of helmets
[49][darrow.gif] Do helmets protect the...
[50][darrow.gif] Lesson one: cyclists get...
[51][darrow.gif] Lesson two: cyclists fare...
[52][darrow.gif] Lesson three: promote cycling...
[53][darrow.gif] References
One problem with comparing the safety of driving and cycling is that
the population that cycles differs from that which drives. The average
driver is trained, tested, will have about two decades of experience,
and is to a degree regulated. The average cyclist is young, male,
untutored, unregulated, not wealthy, riding a^ badly equipped machine
on busy urban streets, and in the minority. Nearly half of all
cyclists ride only occasionally, and most regular cyclists will do so
for only a few years. Clearly there are potent risk factors here that
confound comparisons based on averages. Adults aged 17-20 in the
United Kingdom are probably less likely to be killed per hour cycled
than hour driven,[54]5 and the danger inflicted on others will be
fractional. Experienced cyclists, like experienced drivers, have far
better accident rates, suggesting that a given individual should not
be at greater risk of death or serious injury per hour cycled than
driven. There are not enough skilful, experienced cyclists on
Britain's roads, however.
[warm4664.f3.gif]
As the Cabinet donned walking helmets, the prime minister urged the
nation to "go forward together into a new era of walking safety"
Notwithstanding the above, it still takes at least 8000 years of
average cycling to produce one clinically severe head injury and
22 000 years for one death. A recent study in Glasgow estimated^ that
150 000 people are admitted to hospital annually with head^ injuries
in the United Kingdom[55]6; road cyclists account for only 1% of this
total, yet 6% of the population are regular cyclists and a further 5%
are occasional cyclists; 60% of admissions were^ alcohol related. Do
we need revelling helmets?
Dangers of helmets
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[57][uarrow.gif] Safe walking
[58][uarrow.gif] Risks of cycling
[59][uarrow.gif] Is driving safe?
[dot.gif] Dangers of helmets
[60][darrow.gif] Do helmets protect the...
[61][darrow.gif] Lesson one: cyclists get...
[62][darrow.gif] Lesson two: cyclists fare...
[63][darrow.gif] Lesson three: promote cycling...
[64][darrow.gif] References
The statistical wrangle over the effectiveness of helmets is actually
a side issue; what we need people in authority to understand^ is that
cycle helmets inevitably damage public health. Even for cyclists on
Britain's roads, the health benefits exceed the risks by a factor of
20.[65]7 The health benefits of cycling are so great --- and^ the
health injuries from driving so great[66]8 --- that not cycling is
really dangerous. By telling people that they need helmets for an
activity that for a century has been regarded as "safe" --- and^ in
fact has a fine safety record --- you inevitably engender the
impression that cycling must have become more dangerous than driving
and^ walking. That deters cycling. That reduces cyclists' presence^ on
the roads. That increases the risk of death. And if wild claims about
helmets saving lives are published in the media,[67]9 helmet users are
bound to feel overly secure, thus compromising their one vital safety
feature --- a sense of caution. [68]10 [69]11 In addition, over time
most people --- and especially parents --- will come to believe^ that
it is wearing a helmet that matters, not acquiring skilful
technique.[70]12 These effects have been noted in every country where
helmets have come into general use, including the United^
Kingdom.[71]13 Millions will die early because they did not cycle.
Do helmets protect the head?
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[73][uarrow.gif] Safe walking
[74][uarrow.gif] Risks of cycling
[75][uarrow.gif] Is driving safe?
[76][uarrow.gif] Dangers of helmets
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[77][darrow.gif] Lesson one: cyclists get...
[78][darrow.gif] Lesson two: cyclists fare...
[79][darrow.gif] Lesson three: promote cycling...
[80][darrow.gif] References
Experience shows helmets give only limited head protection. Studies in
Australia show some prevention of superficial injuries (such as scalp
lacerations) but only marginal prevention of "mild" head injuries and
no effect on severe head injuries or death.[81]14^ When helmets were
made compulsory in Australia, admissions from head injury fell by
15-20%, but the level of cycling fell by 35%. [82]15 [83]16 Ten years
later, cycling levels in western Australia are still 5-20% below the
level they were before the introduction of the^ law[84]17 yet head
injuries are only 11% lower than would be expected^ without
helmets.[85]18 Incidentally, 17 times more motorists than cyclists
died of head injuries in Australia during 1988.[86]19
The situation in New Zealand is poorly documented, but even
sophisticated analysis reveals either no reduction in head injury with
increased helmet use[87]20 or a modest reduction (19%) when
superficial injuries are included in the definition.[88]21
Misreporting of the cause of injury among people cycling without
helmets after the law made cycling compulsory must have influenced the
figures. The United States and Canada have had similar experiences to
Britain. [89]1 [90]22
Many articles have been published claiming that a helmet will prevent
60-90% of serious head injuries while neglecting to evaluate the risks
of cycling versus driving.[91]23 But in 1988^ the largest survey of
cycling casualties ever undertaken concluded^ that helmets did not
prevent injury; indeed, increased use correlated^ with increased risk
of death.[92]24 How could real world experience^ diverge so enormously
from the savings promised by clinical research? The trouble was,
researchers did not compare like with like. If^ you compare a helmeted
minority who fell off in parks with an unhelmeted majority injured in
collisions with motor vehicles, it is no surprise that people wearing
helmets have much less severe^ injuries. Other studies did focus on
road accidents but drew conclusions from a small group of helmeted
cyclists, typically 10% of the^ sample. In the early days, those who
wore helmets were cautious, mature, educated, life long cyclists.
Researchers failed to consider that this group would be more likely to
attend accident and emergency after receiving a head injury or that
they would have better anticipation, thereby reducing the risk of an
accident or the risk of serious injury in a given accident. In fact,
the case-control studies confirm what experienced cyclists already
know --- that skill and^ a sense of caution cut the risk of serious
injury by 80-90%.
Our tarmac world is stuck in the Dark Ages; if you get hurt, you're
wrong. The assault on cycling has vandalised the appeal of the safest,
cleanest, most efficient, healthy, and fun means of personal transport
that exists --- right at the time we most need^ it. Cyclists don't
need helmets, they need^ priority.
Lesson one: cyclists get ahead when left alone
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[94][uarrow.gif] Safe walking
[95][uarrow.gif] Risks of cycling
[96][uarrow.gif] Is driving safe?
[97][uarrow.gif] Dangers of helmets
[98][uarrow.gif] Do helmets protect the...
[dot.gif] Lesson one: cyclists get...
[99][darrow.gif] Lesson two: cyclists fare...
[100][darrow.gif] Lesson three: promote cycling...
[101][darrow.gif] References
Cyclists gain more from improvements in road safety than other road
users; hence the risk of death per mile cycled fell by 60% between
1971 and 1994 (fig [102]1). The number of reported accidents has not
changed much in the past 40 years (see BMJ 's website^ for details).
The fall in the number of deaths is due to accidents getting less
lethal rather than there being fewer accidents. The^ lethality of
cycling accidents dropped faster than the average^ for all road users
(fig [103]2). By 1994, the risk of death in a cycling accident was
only 75% of what it would have been had the trend^ followed the
average. This will surprise those who see cyclists as "vulnerable" and
drivers as "safe." However, cycling accidents got more lethal in the
second half of the 1990s, when helmets became generally popular.
[104][warm4464.f1.gif]
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Fig 1. Indices of cycling mileage and deaths (index year
1970)[107]1
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View larger version (15K):
[109][in this window]
[110][in a new window]
Fig 2. Index of lethality (number of deaths per number of
accidents) of cycling accidents and all traffic accidents,
1970-98 (index year 1970)[111]1
Lesson two: cyclists fare best when they act and are treated as
drivers of vehicles[112]25
[113][uarrow.gif] Top
[114][uarrow.gif] Safe walking
[115][uarrow.gif] Risks of cycling
[116][uarrow.gif] Is driving safe?
[117][uarrow.gif] Dangers of helmets
[118][uarrow.gif] Do helmets protect the...
[119][uarrow.gif] Lesson one: cyclists get...
[120][uarrow.gif] Lesson two: cyclists fare...
[121][uarrow.gif] Lesson three: promote cycling...
[122][uarrow.gif] References
It is widely thought that cyclists should be segregated from the
traffic for safety's sake. This appears logical, since most road
cycling injuries are due to motor traffic. It is a naive^ conclusion.
Segregation protects the cyclist from only a rare^ accident --- being
hit from behind --- at the expense of increasing other risks and
reducing convenience. International research shows that segregation
multiplies the risks threefold to fivefold, [123]26 [124]27 even in
countries such as the Netherlands, where it is traditional. The
promotion of danger has scared many cyclists out of the traffic,
merely to put them at greater risk on pavements and "safe" cycle^
routes.
Experienced cyclists already know that the road system is by far the
safest national cycle network that will ever exist. Cyclists and
drivers are not enemies; each has something to offer the other in a
civilised road environment. Cyclists should tackle the risks just as
in a car, by acquiring a high standard of road^ craft.
Lesson three: promote cycling for a safer road environment
[125][uarrow.gif] Top
[126][uarrow.gif] Safe walking
[127][uarrow.gif] Risks of cycling
[128][uarrow.gif] Is driving safe?
[129][uarrow.gif] Dangers of helmets
[130][uarrow.gif] Do helmets protect the...
[131][uarrow.gif] Lesson one: cyclists get...
[132][uarrow.gif] Lesson two: cyclists fare...
[dot.gif] Lesson three: promote cycling...
[133][darrow.gif] References
Increasing the number of cyclists is a straightforward way of making
cycling much safer. It is a method we can be sure of, because it has
already worked.
It is worth pausing here to consider the meaning of "road safety." The
roads can get more dangerous, yet total deaths still fall. Compulsion
to wear a seatbelt cut deaths among drivers and^ front seat passengers
by 25% in 1983. But in the subsequent years, the long established
trend of declining deaths in car accidents reversed, and by 1989 death
rates among car drivers were higher than they had been in
1983. Evidently the driving population "risk compensated" away the
substantial benefits of seatbelts by taking extra risks, putting
others in more danger. This period saw a^ jump in deaths of cyclists
(fig [134]1). Although temporary, the jump can be explained fully only
by cyclists having adapted to a more^ dangerous road environment
through extra caution, retreat, or giving up. Is it coincidence that
the long decline in cycling began in 1983?
Many drivers today surge about aggressively, accelerating and braking
hard. They don't achieve a high average speed but touch peaks of
50-60 mph, at which pace the vehicle is a frightening menace to the
most experienced cyclist. That kind of behaviour is the consequence
of, among other things, compelling seatbelts, and it is a massive
deterrent to cycling. Difficult though it may be, it is time that
those who control road safety legislation faced the facts; reducing
casualties is not the same as reducing danger. Give thought to the
real cause of danger and how it can be^ reduced.
Between 1974 and 1982 cycling mileage in Britain increased 70%, but
there was no increase in fatalities until the seatbelt law was
introduced in 1983 (fig [135]1). The more cyclists there are, the more
presence they have, the less individual danger there^ is. This truth
is confirmed by experience in the Netherlands and^ Denmark, where
cycling is far safer despite a tradition of segregation. All road
users should gain. Pedestrians benefit because (skilful) cyclists are
little threat to them and because a large increase^ in cycling should
reduce traffic speeds and thus risks to all. Then there are the health
benefits.
Cycling has slipped off the political agenda. The vital need to change
attitudes is nowhere in sight. Doctors must press for recognition that
in a civilised society, those who create danger will be held
responsible for the consequences. Getting hurt doesn't make you wrong.
Promote the positive aspects of cycling: speed, fitness, pride in
learning a new skill. Focus on getting adults to cycle a few trips
they currently drive --- later they can teach their children. Promote
cycling, not helmets. Get out there and^ enjoy the dubious pleasure of
the wind in your hair.
Footnotes
Competing interests: None^ declared.
[bmjcom.f1.gif] A figure giving details of accident rates is available
on the BMJ's website
References
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[137][uarrow.gif] Safe walking
[138][uarrow.gif] Risks of cycling
[139][uarrow.gif] Is driving safe?
[140][uarrow.gif] Dangers of helmets
[141][uarrow.gif] Do helmets protect the...
[142][uarrow.gif] Lesson one: cyclists get...
[143][uarrow.gif] Lesson two: cyclists fare...
[144][uarrow.gif] Lesson three: promote cycling...
[dot.gif] References
1. Department for the Environment, Transport, and the Regions. Road
accidents in Great Britain; the casualty report. London: DETR, 1998.
2. Department for the Environment, Transport, and the Regions.
National travel survey. London: DETR, 1998.
3. Gilbert K, McCarthy M. Deaths of cyclists in London: the hazards of
motor traffic. BMJ 1994; 308: 1534-1537[145][Abstract/Free Full Text].
4. National Statistics Office. Death by injury and poisoning. London:
NSO, 1997.
5. Morgan JM. Risk in cycling. Crowthorne: Transport and Road Research
Laboratory, 1988. (TRRL Working Paper WP/RS/75.)
6. Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI.
Disability in young people and adults one year after head injury: a
prospective cohort study. BMJ 2000; 320: 1631-1635[146][Abstract/Free
Full Text].
7. Hillman M. Cycling towards health and safety. London: BMA, 1994.
8. Carnall D. Cycling and health promotion. BMJ 2000; 320:
888[147][Free Full Text].
9. Mullins J. Hard headed choice. New Scientist 2000 July 22:16-7.
10. Mills NJ. Protective capability of bicycle helmets. Br J Sports
Med 1990; 24: 55-60[148][Abstract].
11. Halliday, White, Finch, Ward. Attitudes to cycle helmets --- a
qualitative study Crowthorne: Transport and Road Research Laboratory,
1996. (TRRL Report 154.)
12. Kifer K. Is cycling dangerous?
[149]kenkifer.com/bikepages/health/risks.htm
13. Franklin J. Enabling and encouraging people to cycle. Paper
presented to Cambridge Cycling Campaign AGM, October
1999. [150]www.ccdc.cam.ac.uk/camcycle/campaigning/JohnFranklinAGM1999
.html (accessed 29 Nov 2000).
14. Robinson D. Head injuries and bicycle helmet laws. Accident
Analysis and Prevention 1996; 28:
463-475[151][CrossRef][152][Medline].
15. Robinson B. Is there any reliable evidence that Australian helmet
legislation works? Proceedings of the Velo Australis Conference,
Perth, 1996. Freemantle, Promaco Conventions, 1996.
16. Robinson D. Cycle helmet laws --- facts, figures and consequences.
Proceedings of the Velo Australis Conference, Perth, 1996. Freemantle,
Promaco Conventions, 1996.
17. Gillham C. Compulsory bicycle helmets endanger public health.
[153]http://members.iinet.net.au/~property/bicycle_helmets.html
(accessed 12 Dec 2000).
18. Australian Road Accident Prevention Research Unit. An economic
evaluation of the mandatory helmet legislation. Nedlands: University
of Western Australia, ARAPRU, 1999.
19. Attewell RG, Dowse MJ. Fatal crash types. Analysis of
1988 fatality file. Canberra: Federal Office of Road Safety, 1992.
(Report CR105.)
20. Scuffham P, Langley JD. Trends in cycle injury in New Zealand
under voluntary helmet use. Accident Analysis and Prevention 1997; 29:
1[154][CrossRef][155][Medline].
21. Scuffham P, Alsop J, Cryer C, Langley JD. Head injuries to
bicyclists and the New Zealand helmet laws. Accident Analysis and
Prevention 2000; 32: 565-573[156][CrossRef][157][Medline].
22. Burdett A. Cyclist fatalities in Canada 1975 to
1997. [158]www.globalx.net/ocbc/fatals.html
23. Henderson D. The effectiveness of bicycle helmets: a review.
Sydney: Motor Accidents Authority of New South Wales, 1995.
24. Rogers GB. Reducing bicycle accidents: a re-evaluation of the
impact of the CPSC bicycle standard and helmet use. J Product
Liability 1988; 11: 307-317.
25. Forester J. Effective cycling. 6th ed. Boston: MIT Press, 1986.
26. Franklin J. Cycling skill and its relation to infrastructure and
safety. VeloCity Conference paper, Graz, April
1999. [159]ourworld.compuserve.com/homepages/quinze/digest/VC99.htm
(accessed 29 Nov 2000).
27. Franklin J. Casualties on cycle paths. Open letter to Sustrans,
June
1998. [160]ourworld.compuserve.com/homepages/quinze/digest/cy_sustr.ht
m (accessed 29 Nov 2000).
_________________________________________________________________
[161]© BMJ 2000
This article has been cited by other articles:
[162]Home page
[163]J Epidemiol Community Health Home page
D A Lawlor, A R Ness, A M Cope, A Davis, P Insall, and C Riddoch
The challenges of evaluating environmental interventions to increase
population levels of physical activity: the case of the UK National
Cycle Network
J. Epidemiol. Community Health, February 1, 2003; 57(2): 96 - 101.
[164][Full Text] [165][PDF]
_________________________________________________________________
[166]Home page
[167]Can Med Assoc J Home page
M. Wardlaw
Butting heads over bicycle helmets
Can. Med. Assoc. J., August 1, 2002; 167(4): 337 - 338.
[168][Full Text] [169][PDF]
_________________________________________________________________
Rapid responses:
Read all [170]Rapid responses
All helmets are not created equal
Robert Arthurson
bmj.com, 26 Dec 2000 [171][Full text]
Further information from the author on reference 18
M Wardlaw
bmj.com, 30 Dec 2000 [172][Full text]
Don't blame the helmet
Ian Wacogne
bmj.com, 1 Jan 2001 [173][Full text]
Future for Cycling
Andy Horton
bmj.com, 3 Jan 2001 [174][Full text]
Web Link Update
Avery Burdett
bmj.com, 3 Jan 2001 [175][Full text]
Doctor Guthrie's Ten Essential Cycling Survival Lessons
Colin Guthrie
bmj.com, 4 Jan 2001 [176][Full text]
Safer drivers needed
Edwin R van Teijlingen
bmj.com, 4 Jan 2001 [177][Full text]
Setbelt legislation: Additional information
Shane Foran
bmj.com, 8 Jan 2001 [178][Full text]
Urban cycling and safety
Edwin Moore
bmj.com, 11 Jan 2001 [179][Full text]
Author's reply
M Wardlaw
bmj.com, 15 Jan 2001 [180][Full text]
A better cycling future
A A Faraj
bmj.com, 16 Jan 2001 [181][Full text]
Cycle Helmets
Michael Laverick
bmj.com, 16 Jan 2001 [182][Full text]
Re: Author's reply - Where did helmets come from?
Peter James
bmj.com, 19 Jan 2001 [183][Full text]
from the US
De Clarke
bmj.com, 20 Jan 2001 [184][Full text]
A footnote Re: from the US
De Clarke
bmj.com, 27 Jan 2001 [185][Full text]
Hard vs soft shell
Chris Bitmead
bmj.com, 10 May 2001 [186][Full text]
Cycling has to be as simple as it really is!
Giselle Xavier
bmj.com, 11 May 2001 [187][Full text]