Concussion protocol and racing
The focus on concussions and their treatment within professional sport has magnified in recent months. But is cycling doing enough to protect the health of its riders? Paul Knott surveys the current landscape
For cyclists it is almost a duty to the sport and a point of pride to be seen as tough on two wheels. Quite often you will hear phrases like “don’t show them you are in pain” or “get straight back on the bike” as part of the lexicon of group rides, race commentary or in the wider media after a crash. These attitudes are often applauded by onlookers as a badge of honour for pushing through the pain barrier all in the name of competition.
Most of the time following that sentiment will only have minor knock-on effects but when it comes to concussions and head injuries the implications can be far more serious.
Tom Skujinš’s crash at the 2017 Tour of California while riding for Cannondale-drapac showed just how the hardman mantra can affect riders’ attitudes towards injuries, so much so that Skujinš didn’t realise until 20 minutes after he crashed and suffered a concussion that he had also broken his collarbone.
“It’s definitely one crash that stands out,” Skujinš recalls. “There were a lot of circumstances that definitely didn’t help for a quick resolution. The race had been split up, there were no team cars anywhere and the only footage that was out there was on the TV. At the same time, that area is pretty bad with cell service, so it’s not like you could really let anyone know.”
There has been a growing awareness of concussion in other sports (see box) and last week in the UK the Parliamentary committee on Culture, Media and Sport launched an inquiry into the handling of concussions at both pro and grass-roots level. It all begs the question, is cycling doing enough to protect its riders?
One of the biggest challenges cycling faces when concussions occur is that race or team doctors usually reach the rider many minutes after the initial incident. As Skujinš points out, in last year’s Tour de France Romain Bardet finished a stage concussed but didn’t line up the following day once he had been properly assessed.
Once a team or race doctor reaches a rider, ensuring a reliable concussion test is carried out can also be pretty hard to achieve, explains Team DSM’S physician Anko Boelens.
“There are race doctors in the race, and they play an important role because team doctors are quite often not in the race cars. What makes it hard, is that an examination takes time and the race continues. So that rider automatically will lose time, or lose contact with the race entirely, if he or she is being evaluated.”
Dr Matt Gray – race doctor for the Tour of Britain and Women’s Tour – points out that time constraints are just one of the issues that he faces when arriving at crashes in the middle of a hectic race.
“Our primary objective is the safety of all the riders but the rider’s priority is to continue the race. When a full concussion assessment takes a minimum of 20 minutes, it is not practical to carry this out without withdrawing the rider from the race.”
Even with the help of team-mates and the race convoy, no rider is going to bridge a 20-minute gap to the peloton mid-race, therefore Gray has to rely on a mix of clinical skill, experience and rapid roadside tests to assess and decide on a rider’s ability to continue. But Gray claims there are no clinically validated tests for this specific to cycling.
“It means that we have to be extremely conservative with our decisions. We use a modification of Maddock’s questions. These consist of generic whereabouts questions from the Sport Concussion Assessment Tool (SCAT-5) like, where are we riding to today? Who won yesterday’s stage? etc... to determine the rider’s orientation and awareness.”
Other red flags such as double vision, neck pain or tenderness and headaches are just a few signs Gray will look for and if there is any doubt the rider will be withdrawn from the race.
Magic adrenaline
In Skujinš’ case jumping back onto the bike – despite his obvious concussed state to those watching on TV – was at the forefront of his mind; the Latvian rider has since worked out he has about 20 minutes from around the crash missing from his memory.
“People afterwards blamed the motorbike driver for giving me the bike and letting me continue. But it was not really his job to stop a cyclist, even if he feels like they should not continue,” he says. “I don’t blame him. I don’t blame anyone for that. Not even myself, because I was not really in my body at that time.”
Skujinš eventually was stopped by his team car when they finally
caught up with him on a tricky but rapid descent. R iding on with head injuries comes with the risk of further immediate or long-term harm. Boelens and Skujinš don’t believe that riders are ever forced to ride on in these cases, but Skujinš is aware cycling faces unique challenges in these situations.
“It is obvious cycling is not a sport where concussion protocols are easy to implement. There is no start and stop play. So it’s always hard to take a timeout and reassess if there should be a rider pulled out of the race or not.”
Gray recalls an extreme incident in the Women’s Tour where multiple crashes in the neutral zone led to inrace medical personnel being on the scene in seconds and being able to treat the multiple casualties but the race was paused to ensure that riders caught up in the crash and further up the road received the correct medical attention required. But even in that incident with exemplary caution and treatment, riders can still slip through the net, as Gray came across.
“I was travelling with a police escort
“If an assessment takes 20 minutes, it’s not practical to continue”
for approximately five minutes, when we came across a rider on the side of the road leaning up against a car vomiting. She had not been assessed at the initial scene, having already stood up and remounted her bike. She had signs of concussion, and was withdrawn from the race following assessment.”
TV doctor
Gray is frequently asked why they are not able to use live TV footage for immediate assessment and identification of injured riders. There are many reasons why this is impractical. For starters the TV feed is 20-30 seconds behind live action, which often means he arrives at the scene before it appears on TV. “One cannot sit reviewing TV footage to assess the specific nature of injuries, when riders may need immediate medical attention. The incident may not have been caught on camera either. That’s due to the nature of the sport, our field of play is constantly moving, and therefore we do not have the luxury of multiple static cameras to capture and review the incident. However, the footage can often be used after the incident to help identify the mechanism of injury which may help with ongoing care.”
In 2019 a scientific review around Sports-related Concussions (SRC) published in the British
Medical Journal concluded that road cycling poses unique challenges for SRC assessments. This backs up Boelens’s claims that the then UCI recommendation of the SCAT-5 concussion test is impractical and requires modification for road cycling.
The UCI has set a new protocol for 2021, with recommendations that are tailored to cycling specifically. Concussions currently account for between 1.3 per cent and 9.1 per cent of all injuries within cycling, depending on which of the eight disciplines (road, track, mountain bike, BMX Racing, BMX Freestyle, cyclo-cross, time trials and indoor) you’re looking at.
The new protocol places greater responsibility on non-health personnel, such as sports directors, mechanics and other riders, to recognise the signs of concussion. It’s far from ideal putting decisions that affect the long-term health of the injured rider in the hands of those whose primary function is sporting success, but it’s a practical response to the constraints of the sport.
Riders will be monitored by medical personnel as soon as is practical, but the UCI seems keen on initial assessments being carried out immediately by non-health personnel to get a swift decision on the injury.
It adds that cyclists who suffer a concussion should have a period of complete rest of between 24 and 48 hours, and not return to competition for at least a week after their symptoms have cleared up (two weeks in the case of juniors). However, the long-term effects can be just as serious, or even more so, than easily recognised injuries. As shown in other sports such as American football, rugby and football, with CTE and
“Riders must know about it, know the symptoms and what do to ”
dementia plaguing athletes in later life. After all, concussion is not just a head injury, it’s a brain injury.
Luke Griggs, deputy chief executive at Headway, a brain injury charity that provides support and information services to those injured from concussions says: “You can have all the buy-in you want but you need to have complete buy-in from riders who understand the risks. It’s difficult for medics, let alone the general public to actually identify concussion. So we need that buy-in from the athletes, the individuals doing the sport to put their hand up say, ‘This isn’t right, I need to step back,’ and that can be difficult.”
Griggs emphasises that concussion myths can easily lead to misdiagnosis or a lack of it altogether. One of these is thinking you have to lose consciousness to have suffered a concussion, but this isn’t true, with only 10 per cent of concussion cases resulting in the person losing consciousness. “A brain injury is not like a muscular injury or an impact injury like a dead leg that you can say you can run off. The reality is that your brain has been disturbed. Any further blow to it is going to risk exacerbating that damage. It is not something that you can afford to just ignore,” he explains.
Concussion clarity
Skujinš does believe that cyclists are becoming smarter when it comes to concussions and the potential long-term effects they can bring. But where cycling goes from here to home in on its unique demands for in-race concussion analysis is unclear. Skujinš echoes Griggs when he says education is the first step.
“The best way we can take care of each other is the riders knowing about it, knowing the symptoms, what to do and the consequences it can have. If you can notice that a rider is a little bit off balance or reaction time is suddenly worse, then let’s talk to the rider themselves while we are still racing because no one wants to stop.”
Another way of combating the initial dangers with immediate team feedback could also be through technological advancements. “Putting accelerometers on the helmets would indicate that the impact has been high enough to possibly trigger a concussion,” Skujinš says. “That would be a great way to actually let teams and medical staff know that a rider might be in trouble. Even if he says that everything is fine, you can pay extra attention and take extra care of this rider. Maybe rider unions can help this and we can implement some extra precautions when it comes to concussions.”
It’s clear that though cycling is getting to grips with the potential dark side of its hardman obsession, there is still some distance to go before we can be fully confident that those suffering crashes today won’t still be paying the price in years to come.