HAVING AN IMPACT
“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 ”
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