“I didn’t take con­cus­sion se­ri­ously un­til I had a bad one last Feb­ru­ary. It’s an is­sue all sports should be aware of. Our team doc­tor has worked on a pro­to­col us­ing VR to work out if riders who have crashed are at risk. MC ”

Procycling - - CONLCUSION CONTROL - Writer: Richard Abra­ham Il­lus­tra­tion: Tim Marrs

The Ger­man foot­baller Christoph Kramer can­not re­mem­ber 14 min­utes of the big­gest game in his life. He took a blow to the head when he col­lided with an Ar­gen­tinian op­po­nent not long into the 2014 World Cup fi­nal, but was al­lowed to carry on. He then ap­proached the ref­eree and asked: “Ref, is this the fi­nal?” The stunned of­fi­cial told the Ger­man cap­tain but Kramer was al­lowed to play on for 14 min­utes

– of which he has no rec­ol­lec­tion - be­fore he slumped to the ground and was helped off the pitch.

This sort of thing will sound fa­mil­iar to any­one who fol­lows pro­fes­sional cy­cling. Re­mem­ber Chris Horner cross­ing the fin­ish line of stage 7 of the 2011 Tour de France bab­bling in­co­her­ently and Toms Sku­jin dizzily dodg­ing the on­com­ing pelo­ton as he re­trieved his bike com­puter from the mid­dle of the road, be­fore re­mount­ing with a bro­ken col­lar­bone at the 2017 Tour of Cal­i­for­nia.

Play­ing on with con­cus­sion is ev­i­dently not a good thing to do. Foot­ball, box­ing, rugby, Amer­i­can foot­ball - fol­low­ing a huge class ac­tion law­suit from for­mer play­ers who ar­gued that the NFL in­ten­tion­ally left them un­aware of the health risks of re­peated con­cus­sions - and ice hockey are tak­ing steps to ad­dress that fun­da­men­tal is­sue. But ac­cord­ing to Dr Helga Riepen­hof, a doc­tor at the BG Clinic in Ham­burg who spe­cialises in trau­ma­tol­ogy and has worked with a range of pro­fes­sional foot­ball and cy­cling teams, in­clud­ing Di­men­sion Data, cy­cling is not.

“It’s re­ally bad how the man­age­ment still is,” he says. “Cur­rently there is noth­ing they do when riders crash to make an ob­jec­tive de­ci­sion on the road as to whether this rider can con­tinue or not. And from my point of view that’s a ter­ri­ble sit­u­a­tion. “We know that if a se­cond im­pact had oc­curred, he [Christoph Kramer] could have died. Eng­land and English foot­ball is very good, and so is box­ing, but in sports like cy­cling there has not been a lot hap­pen­ing.”

Mark Cavendish is one of the riders who knows full well the im­pact of con­cus­sion. Hav­ing worked on and off with Dr Riepen­hof at T-Mo­bile, Highroad and Quick-Step, Cavendish sought the Ger­man’s help fol­low­ing a se­ries of crashes in 2018. It be­gan with an in­nocu­ous spill on the open­ing stage of the Abu Dhabi Tour on 21 Feb­ru­ary.

“I was sat in the se­cond or third row in the neu­tralised sec­tion, be­hind the car. Next thing, the guy in front stopped and I’m up his arse,” Cavendish tells Pro­cy­cling. “I didn’t know what hap­pened in front, but my wheel got locked on his skewer. I kind of fell and we were only go­ing dead slow. But I landed on the wheel of the guy next to me, boomf. And I didn’t even hit my head. My neck hit the wheel.

“I didn’t have a scratch on me. I stood up and I was like… like… out of the game. Prop­erly. It was like be­ing drunk.

You know when you are so drunk that ev­ery­thing is just a haze? I could see ev­ery­thing but…it was oth­er­worldly. Like I wasn’t re­ally there.” Cavendish im­me­di­ately got back on his bike and re­sumed the race, a sit­u­a­tion so com­mon in cy­cling that it is al­most un­ques­tion­able. ‘Put me back on my bike’ is just what you say, and get­ting back on your bike is just what you do.

“I was like, woah, I don’t feel so good, man. I got back, we started the race and I re­mem­ber peo­ple talk­ing to me. I re­mem­ber ev­ery­thing, but it was weird. You know what they are say­ing, but…I couldn’t re­ally re­act to them. I went back to the team doc­tor after about a kilo­me­tre and said, I’m not f*ck­ing right, man. He was a good team doc­tor and he said im­me­di­ately, ‘Get off your bike.’”

There are thou­sands of rea­sons why cy­cling still keeps this self­de­struc­tive stiff up­per lip. The sport is still chron­i­cally in­se­cure – riders crave re­sults and shun time off the bike – and the mar­gins are finer than ever. And cru­cially, cy­cling glo­ri­fies suf­fer­ing. Its struc­ture en­cour­ages it. In grand tours it’s a case of bat­tle on and get bet­ter by the se­cond rest day, we can’t lose an­other team-mate, and be­sides, it’s the Tour de France! In one­day races, it goes: grit your teeth and carry on, you have to wait a whole year for an­other shot, and it’s Paris-Roubaix, it’s sup­posed to be tough!

Yet in this in­stance, and per­haps in dozens of oth­ers that came be­fore it, Cavendish should not have got back on his bike. He was lucky that he and his doc­tor could spot his symp­toms be­fore it was too late.

Some of this is blind­ingly ob­vi­ous; a dizzy, punch-drunk rider is a clear dan­ger to them­selves and the rest of the pelo­ton. At other times, the symp­toms can oc­cur a long time after the ini­tial trauma. “From my point of view, you see things hap­pen at the races and you can’t ex­plain them,” says Riepen­hof. “When some­thing like [a crash] hap­pens with­out a rea­son, I would won­der whether some­thing hap­pened be­fore, a day be­fore, and whether it might be the re­sult of con­cus­sion. And that’s why we have to take it more se­ri­ously.”

After get­ting off the bike, Cavendish went to hos­pi­tal in Abu Dhabi to check for skull frac­tures and bleeds. He then spent six days in a dark room – the best treat­ment for con­cus­sion is to rest the brain, as you would rest a bro­ken bone or torn lig­a­ment - be­fore get­ting bored, re­turn­ing home and train­ing on the turbo. Two weeks after his crash he fell again in the team time trial at Tir­renoA­dri­atico, this time after his sad­dle dropped out. He landed on his face and broke a rib, although he didn’t re­port the same symp­toms as in Abu Dhabi. He got back up, fin­ished out­side the time cut and went home. Ten days later, he started Mi­lan-San Remo and crashed

' Put me back on my bike’ is just what you say, and get­ting back on your bike is just what you do

again, som­er­sault­ing into the air at high speed after hit­ting a bol­lard just be­fore the Pog­gio climb.

“I went to San Remo and to this day my wife says I shouldn’t have gone,” Cavendish says. “She thinks that [the con­cus­sion] is why I crashed in San Remo, but I say no.”

Fur­ther down the line, ath­letes who have suf­fered a con­cus­sion have re­ported mood changes, fa­tigue, dif­fi­culty con­cen­trat­ing and lin­ger­ing headaches. Re­cov­ery pe­ri­ods range from days to months. Re­peated con­cus­sions bring with them deeper and more pro­found changes; for­mer Eng­land cap­tain Alan Shearer ex­plored the link be­tween head­ing foot­balls and longterm brain ill­ness in a doc­u­men­tary re­cently: De­men­tia,Foot­bal­landMe.

“No­body took this se­ri­ously, but

I tell you there’s a lot of de­pres­sion which stems from re­peated con­cus­sions,” Cavendish says. In de­fence of the sport, it’s not as sim­ple as a bro­ken bone. It’s dif­fi­cult to spot ev­ery head trauma over a spread-out pelo­ton, and it’s al­most im­pos­si­ble to at­tribute cer­tain symp­toms to one in­ci­dent. Some in­juries show no im­me­di­ate symp­toms. Later in the 2018 sea­son Cavendish un­der­went a brain scan; it showed lit­tle white spots on his brain, each one in­di­cat­ing a small scar. “I didn’t take con­cus­sion se­ri­ously. Turns out I’ve had sh*tloads in my ca­reer,” he says. “I got checked and there are loads of spots in my head. Mas­sive signs of a lot of hits to the head and it freaks you out.”

“We know they are likely re­lated to con­cus­sion but there can be other rea­sons why they are there,” Riepen­hof ex­plains. “That’s why you can’t sim­ply screen for­mer cy­clists and see how many white spots are there, be­cause it could be down to things like blood pres­sure or sim­ple changes in pro­teins in your body, and it shows the same thing. There will def­i­nitely be cases of long-term ill­ness too, but that is also hard and com­pli­cated to prove.”

Cavendish’s team, Di­men­sion Data, now has a con­cus­sion pro­to­col. At the start of the sea­son, riders com­plete a 30 to 40 minute test of cog­ni­tive func­tion and then, if they suf­fer any sort of head in­jury, they are ob­li­gated to re­peat it and com­pare the re­sults. Any de­cline in per­for­mance is taken as ev­i­dence of a con­cus­sion.

It’s a start, but it’s far from fool­proof. It re­lies on the rider to self-re­port or

“I went to San Remo and to this day my wife says I shouldn’t have gone. She thinks that [the con­cus­sion] is why I crashed there”

some­body else to no­tice any symp­toms. Pro­fes­sional ath­letes, Dr Riepen­hof says, are also likely to have higher cog­ni­tive func­tion than the av­er­age per­son for whom the tests were de­signed, ef­fec­tively help­ing them to trick it. “If you look at a foot­ball or a rugby player who has had mul­ti­ple con­cus­sions, for them the test is a joke,” he says. “Even after hav­ing more than a mild trau­matic brain in­jury they are able to com­plete the tasks.”

It has also been re­ported that some ath­letes in the NFL, which has a sim­i­lar test­ing pro­to­col, have de­lib­er­ately un­der­per­formed in their base­line test to al­low them to pass and re­turn to play­ing even when show­ing signs of con­cus­sion. Some­times, when it comes to health, ath­letes can be their own worst en­emy.

Cru­cially, the test of­fers no so­lu­tion to the im­me­di­ate urge to put riders back on their bikes, yet Riepen­hof be­lieves he has an an­swer. Dur­ing his work with Brighton & Hove Al­bion FC, draw­ing on re­search from Stan­ford Uni­ver­sity and work­ing with a com­pany in Ger­many, he cre­ated a set of vir­tual re­al­ity glasses that track eye move­ment. The wearer

has to com­plete VR tasks with their eyes – fol­low a ball or find an ob­ject – and the glasses track how the eyes re­spond.

“What we see with pa­tients with head trauma is that ev­ery­thing is im­pacted by it. The num­ber of sac­cades [fast eye move­ments, when your eyes jump be­tween points] first of all in­creases a lot and then to­tally de­creases. There

are dif­fer­ent re­ac­tions to light, so how wide and how closed your lenses go, is to­tally changed.”

Riepen­hof be­lieves this could of­fer an ob­jec­tive test for con­cus­sion that can be car­ried out much more quickly in the mid­dle of a race. He also pro­poses a so­lu­tion where a rider in­volved in a crash could get in a ve­hi­cle fol­low­ing the pelo­ton and un­dergo as­sess­ment, a mo­bile ver­sion of the ‘con­cus­sion bin’ touch­line as­sess­ment pro­to­col cur­rently be­ing pro­posed by the Premier League in cases of head in­jury on the foot­ball pitch.

“The doc­tor de­cides if he can con­tinue or not. If he’s not sure of the de­ci­sion right away, there must be some­thing that can say, ‘Okay, he’s out for to­day, prob­a­bly has noth­ing to do with the GC any more, but we need 24 hours to make a de­ci­sion.’ It’s so easy in cy­cling, but we have to be more open or flex­i­ble with our rules. With ev­ery rule there is a chance to abuse it in a way, or use it in a way that is not right for the sport, but in a sit­u­a­tion like this, the health of the riders is the pri­or­ity.”

Riders are no longer the ob­sta­cles when it comes to re­form­ing cy­cling; with greater aware­ness has come a greater will in the pelo­ton to make their sport safer. In­stead, the struc­ture and the cul­ture of the sport is in the way. “What is the cul­ture of cy­cling after a crash? Get him back on his bike and see how he is,” Cavendish says. “Tir­reno – I crashed on my face, be­cause my bike broke. Roger Ham­mond stopped in the team car and wouldn’t let me get up un­til I could feel ev­ery­thing. I stood up, he checked me to make sure I was al­right. I ride to the fin­ish and get time elim­i­nated. There’s a fun­da­men­tal prob­lem,” he adds.

It will take a lot to bat­tle the tough-guy cul­ture. How­ever Riepen­hof – who will take on a role as doc­tor with Di­men­sion Data next sea­son - is op­ti­mistic. “Years ago I would have laughed and said it’s im­pos­si­ble. These days I think it is re­al­is­tic. Slowly they are be­gin­ning to un­der­stand.”

Chris Horner was left with con­cus­sion and forced out of the Tour on stage 7 in 2011De­spite crash­ing heav­ily at the Tour of Cal­i­for­nia, Toms Sku­jin car­ried on rid­ing his bike

Cavendish hit a bol­lard, som­er­saulted into the air and landed hard at Mi­lanSan Remo last year

Cavendish crashed hard three times in a month last spring, this time at Tir­reno

The NFL is ex­plor­ing whether VR glasses could help de­tect if a player has con­cus­sion

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