Cycling and Concussions

Broken collarbones and road rash are the most common injuries in bicycle racing but there is growing concern about concussions. With the advancing mentality that the general audience watches for huge impacts, and more risk, this motivates the athletes to go bigger, higher, and faster than ever before. Crashing is part of bicycle racing and most riders say you can’t worry about it. Every rider in the Tour de France has been concussed from a fall during their bicycle riding careers, without exception. Cycling’s hard-man culture still exists, and it is far more powerful than any UCI bylaw or laminated card. When a rider crashes during a race, the immediate reaction is to remount and continue racing. A great example was the crash at the TDF involving Fabian Cancellara. This happened when a rider crossed wheels while descending at over 60 km/hr (35 mph). More than twenty riders went down after a rider crossed wheels. Just about everyone continued racing but it is a good bet that many had minor head injuries. Fabian Cancellara was reported to feel “groggy.” This is probably an understatement. Everyone knows Fabian is a tough individual but being tough has nothing to do with recognizing a brain injury.

With all the publicity about concussions and Chronic Traumatic Encephalopathy (CTE) in the news, doctors and medical personnel are making more decisions to hold athletes from competing in order to do the right thing for their heads. I work with several athletes who race bicycles and motorcycles professionally. One thing I help them with is to make sure they take care of their heads. I make sure they are active in head injury prevention through nutrition, mental exercises, circadian rhythm optimization, vitamins, and more.

There have been many recent examples of cycling and concussions lately. Tom Skujins of the Cannondale-Drapac team crashed descending Mount Hamilton in this year’s Tour of California. When he attempted to remount, he remained wobbly and fell again to the ground. He continued for a while and Jonathan Vaughters (team director) communicated with the race organizer and had him pulled out of the race. Riders who have all sustained concussions: Fabian Cancellara, Tom Boonen, Kiel Reijnen, Amanda Miller, Evelyn Stevens, Mara Abbott, Andrew Talansky, Taylor Phinney, Chris Horner, Ian Boswell and countless others.

A cyclist shaking off a crash while lying on the side of the road has a split-second choice: get up fast because the peloton is speeding away, or quit. While event rules and protocols vary, the decision to start pedaling again is made by the athlete or the team manager, who is trailing behind in a support vehicle. I was in this very situation during the 2009 Tour of California. As team doctor for Fly V Australia cycling team, I was looking after our GC rider, Ben Day after he crashed in the feed zone on the way to Big Bear summit. I was not present for the crash itself. The information was radioed to me and we sped through the caravan to get to Ben. He was already riding again, well behind the peloton. When I got to him, he was pedaling just fine but bloodied all over his face. I asked him neurological questions, like time, person, place, and situation, and he mumbled and repeated words. It is a hard thing to do to have to take your GC rider out of their biggest race of the year. But it was obvious and we stopped his race and put him in the ambulance.

The increased frequency of concussions prompted organizations like USA Cycling to develop protocols for assessing athletes with head injuries. Most use some form of an online neurologic test where you follow a dot with a mouse and you get a score. When a rider gets a concussion, they can retake the test to assess if they are ready to return to competition. It’s more complicated than this, as it is difficult to determine if an athlete is emotionally ready to re-enter the sport after a head injury. Bicycle races at the professional level are chaotic, high-speed chess matches. Regaining the confidence to ride aggressively in a tight peloton or descend winding fast roads takes time after a crash. The emotional stress caused by a concussion slows that process.

The UCI has adopted the Standardized Assessment of Concussion (SCAT 3) guidelines. Many teams now carry laminated note cards that explain how to assess a rider for a head injury. Members of USA Cycling’s national team who suffer head injuries must take an online cognitive test before returning to racing. Many of these protocols were created at medical meetings and are far from perfect but they are a step in the right direction. Another thing that could change are the helmets worn. Racing helmets are only designed to guard riders against a 14 mph crash onto a flat surface, or a fall from approximately six feet. But even the latest technology can’t prevent all head injuries. There are new technologies coming out such as MIPS–Multi-Directional Impact Protection System. It is a slip-plane technology inside the helmet designed to reduce rotational forces resulting from an impact.

The physiology of a head trauma is pretty straight forward. You fall off your bicycle and when your head hits the ground, the brain is literally floating inside the skull. The shaking that occurs with the hit causes a concussion. Sometimes it is just an instantaneous daze, or it can be lights out. Entire weeks of memory can be erased by a head trauma. The damage sustained, if not allowed to heal properly can lead to problems with brain function. Namely, the proteins that allow for neural processing. What is ironic, is that the athletes with chronic head trauma can often perform their respective sports without difficulty. It is their everyday lives that become difficult. These insults to brain tissue result in problems of neurotransmission; the way your brain sends and gathers information. Head injuries are tricky because they are not like a broken bone, where you have a definitive timeline for return. You can’t just get a head x-ray or MRI that will tell you the brain is healed.

Head injuries and their outcomes range widely—from concussions that fully heal, to a condition called post-concussion syndrome that can take months or years to resolve, to more serious traumatic brain injuries and CTE. Research shows it doesn’t take much for a concussion to cause problems. A study in the Journal of Orthopaedic Journal of Sports Medicine analyzed over four million emergency room visits over ten years. They reported a rising number of concussion injuries in seven sports: surfing, mountain biking, motocross, skateboarding, snowboarding, snowmobiling, and skiing. Snowboarding was the most concussive activity with 42,811 concussions over that ten-year period.

One thing I see missing from concussion management is treatment after the fall. Usually a rider just rests, gets more sleep, hydrates and calls it good. They should be doing much more than that and being proactive in their recovery. The important thing is to be proactive and know it is happening. This is why it is so important to have a good team around you. Having a bunch of people who are your “cheerleaders” who applaud your every move are not the ones who will point out the symptoms of concussion or CTE. It is a hard thing to tell someone they are acting different, losing memory, or they are just off. Typical symptoms of brain dysfunction consistent with CTE include memory loss, disequilibrium, headaches, depression, irritability, nausea–for days to weeks and even months.

There are many stories of athletes who suffered head injuries and kept riding, sometimes to their own detriment. They came back to the sport too soon and suffered the consequences. The only thing that will further concussion injury management is a change in culture. Changing culture takes years to accomplish. Riders may need to consider to re-train themselves to react differently after a fall, rather than checking themselves over and frantically remounting the bicycle to continue. The teams and the UCI definitely do not have an answer, but time will tell. Due to the speed and size of the peloton, there will always be head injuries and concussions. The real question: what are we going to do and how are we going to prevent them?

 

**The main page for concussion information at the USA Cycling website, titled Concussions in Cyclists for Team Managers and Coaches, links to some important resources, including several concussion and cognitive-baseline-assessment tests.