The suicides of two former NFL stars prompted more than 4,500 former players to sue the NFL after it emerged that the players had suffered from the concussion-related injury Chronic Traumatic Encephalopathy (CTE).

While the lawsuit was rejected by a judge in January, studies of NFL players with long-term health effects showed their propensity to suffer from neurodegenerative diseases such as Alzheimers or Parkinsons at three times the rate of the average person. Could the same be occurring in cycling without anyone realising?

“Put me back on my bike”

On stage 5 of the 2011 Tour de France, Janez Brajkovic crashed and reportedly lost consciousness before being taken to hospital. Tom Boonen crashed on that stage too, but it was not until the morning before Stage 7 that he abandoned, telling Cycling News, “I think I have a concussion. I have a terrible headache. I was a danger to the other riders in the race”.

Another crash occurred on Stage 5, around 40km from the finish. While the cameras focused on Brad Wiggins’ broken collarbone, Chris Horner lay in a ditch nearby. As if channelling Tom Simpson, Horner said “Put me back on my bike”.

Image: everymantri.com

Image: everymantri.com

The Radioshack team did not stop Horner. Neither did Tour doctor Pascal Rivat, who told L’Equipe, “I said what I thought (that he should stop). I let him continue, but I never left his side.” Crossing the line, Chris Horner asked his Soigneur repeatedly, “Where am I…? Did I finish…?”

Horner was quickly transported to hospital in nearby Charteauroux and the Radioshack medical team stayed overnight with him. Horner did not race again for seven months. As Bruce Barcott noted in Bicycling Magazine, “more than a year after (the incident) Horner says he retained no memory of the incident”.

Horner showed little sympathy a year later talking about the NFL concussions. “I find it insulting what some of the players have done, bringing lawsuits. There’s not a single athlete, including cyclists, who isn’t willing to take risks. You could walk up to just about any athlete and say, ‘You can play your sport for two more years and have a head injury or quit now without one’, and just about all of them would say ‘I’ll play two more years.’”

In March 2013, Garmin Sharp’s Jack Bauer crashed badly at Dwars door Vlaanderen. Lying unconscious in the mud, he was a forlorn figure. Team Doctor Kevin Sprouse confirmed to Cycling News afterwards:

“We actually don’t distinguish between mild, moderate and severe concussions any more – it’s either you have one or not and the symptoms can develop 24 hours later so it’s kind of an observational period at this point. As per international medical guidelines, he will be progressed through the team’s protocol with regard to his return to competition”.

Bauer raced 11 days later at Ronde Van Vlaanderen, and managed 19 more race days in the next two months before the Tour de France. After crashing there on stage 9, Bauer had another crash on the descent of the Col du Glandon on stage 19, suffering bad concussion and facial injuries.

Jack Bauer lies motionless after his Dwaars door Vlaanderen crash.

Jack Bauer lies motionless after his Dwaars door Vlaanderen crash.

Doctor Kevin Sprouse said, “He has been examined by the team medical staff and has been determined to have sustained a concussion as a consequence of his head injury and loss of consciousness”. Bauer raced again 15 days later.

Garmin teammate Lachlan Norton also crashed in 2013, telling journalist Reece Homfray: “I’d never had a head injury before and you wouldn’t think it would set you back that far but it took me a month to get going again”.

At the Tour de France that year, Tony Martin crashed in a massive pile up on stage 1, finished in 190th place, and collapsed inside his team bus. Strapped to a stretcher and loaded into an ambulance, he was reported to have lost consciousness while travelling to hospital. Martin returned to the team hotel that afternoon, and next morning was cleared to start the day’s stage. Martin raced on all the way to Paris.

Concussion protocols

In January 2011, the UCI seemed ahead of the game when it ratified the Zurich Consensus Statement 2008, relating to concussion protocols, and provided WorldTour teams with its ‘Recommendations of the UCI on Concussion’.

This document recommends removal from the race for concussed riders, and suggests use of the Sport Concussion Assessment Tool (SCAT2), along with steps in ‘returning to play’. Specifically it advised that “the cornerstone of concussion management is physical and cognitive rest until symptoms resolve”.

All this isn’t to say that the riders or doctors mentioned above breached the UCI protocols or any other reasonable medical duty of care. We do not know all the details, and these examples merely point out the potential dangers. But, with a former president and board members of USA Cycling on its board, the Medicine of Cycling is qualified to state, “in cycling, post-crash management is generally conflicted and flawed”.

Tony Martin's crash on stage 1 of the 2013 Tour de France.

Tony Martin’s crash on stage 1 of the 2013 Tour de France which saw him lose consciousness while on his way to hospital.

Long-term effects

Some in professional cycling have already had concussion damage their careers. Kiwi Brett Tivers raced in Canada for the Louis-Garneau Test Team and won the iconic Tour of the Battenkill in 2011. He suffered a serious crash in a race in 2012 and told CyclingTips:

“I’m still suffering from post-concussive symptoms ten months down the track and can’t do much. Specialists are saying I have two years until full recovery. I think cyclists and the community in general know very little about [concussion], and the implications [of just how bad] a small head concussion can be, let alone the implications of having numerous head knocks, or like me just one massive head knock”.

Understanding concussion

Concussion is usually considered a physiological injury rather than a structural one, defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.

While many think of it as a blow to the head, concussion can also be caused by impact to the neck, or an impulsive or shearing force such as whiplash. Tests have shown that impacts from radial inertia can be as damaging to the brain as a direct blow. A US report also suggests that less than 10% of concussions result in loss of consciousness.

Cerebrospinal fluid surrounds the brain, protecting it and helping absorb impact. Traumatic Brain Injury (TBI) occurs when the brain moves inside the skull to impact the brain parenchyma (the functional parts of the organ), causing bleeding and swelling. While helmets do an outstanding job of keeping our skulls intact in a major crash, they do almost nothing to prevent concussion.

Research suggests that around 80%-90% of concussions resolve without issue within five to seven days, although recovery time may be longer for children and adolescents. For those that don’t recover so quickly, and for whom concussion is a repeat occurrence, there is a risk of Chronic Traumatic Encephalopathy (CTE), a progressive degenerative brain disease.

With CTE, changes in the brain can begin long after the last concussion and can include memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia. Most CTE sufferers die in their middle age, as the symptoms advance rapidly. Often, an outcome of CTE is depression.

Tour of the Battenkill: "America's Queen of the Classics".

Tour of the Battenkill: “America’s Queen of the Classics”. Brett Tivers is seen at the back here with the pink shoulders.

Concussion in cycling

Dr. Anna Abrahamson of the University of California noted “concussed cyclists are more likely to have impaired function that leads to a repeat crash, potentially hurting themselves and others”. Working with USA Cycling, Abrahamson’s concussion statement provides a strong benchmark for cycling team managers and coaches to recognise symptoms and better manage concussed cyclists.

Unfortunately, there is little information available for cyclists and cycling clubs in Australia regarding concussion. For instance, there is no specific reference to concussion on the Cycling Australia website. Football codes set out their ‘Return To Play’ protocols; Cycling Australia is yet to release a ‘Return To Riding’ one.

CyclingTips contacted Cycling Australia (CA) on this issue and learned that CA has not advised clubs or the various cycling bodies in Australia about specific concussion protocols or specific education programmes. We also learned there is no concussion policy at CA, and were advised that “we are concerned about the emerging issue, and it’s something we are working on with our sports science and medical teams.”

The President of Australia’s largest cycling club acknowledged the seriousness of the issue, but expressed frustration at the limitations in being able to deal with it. President of the St. Kilda Cycling Club, Andrew Gooding said:

“If there is a crash, St. John’s [i.e. a first aid volunteer] goes to the site and does the assessment, but a rider may refuse attention, or alternatively just rides off. We make an effort to contact the rider in the days that follow to make sure they are OK and to fill in an accident report. Sometimes, despite our best efforts, we don’t know who the rider is, or we don’t have their contact details”.

A concussed Luke Durbridge moments after his Tour of Flanders crash.

A concussed Luke Durbridge moments after his Tour of Flanders crash.

Dealing with concussion when it occurs

So what should cyclists, parents and clubs do about concussion? The simple rule is this: get checked immediately. This means stopping the activity, getting medical assessment and resting until symptom-free.

The most common assessment for concussion in sport is the Sport Concussion Assessment Tool – Edition 3, which calculates a standardised assessment of concussion score from a range of 22 symptoms, plus a cognitive and physical evaluation. Available in app form, there are several other concussion assessment forms and information available on the web.

Physical signs of concussion are nausea, constant or recurring headaches, inability to properly control motor skills or balance, a change in ability to see/smell/taste, dizziness or hyper-sensitivity to light or sound, a shortened attention span or distraction, difficulty focusing or understanding directions, and speech difficulty such as “finding the right word”.

If concussed, you should not drink alcohol, or take sleeping tablets or anti-anxiety medication. Your medical practitioner will most likely advise no physical and cognitive exertion. This means no computer or videogames, or reading, or TV. Sometimes concussion requires recuperation in a dark room.

If symptoms recur when returning to cycling, you should stop immediately and get re-assessed. Children, adolescents and even pros are often concerned about losing their spot on the team, so coaches need to support athletes with concussion rather than banning them.

Experience from other sports shows that athletes hide symptoms of concussion to remain on the team. Parents and coaches therefore need to understand concussion, and promote rest and rehabilitation.

Concussion may mean you need to take sick leave. Always heed the advice of medical professionals, not those who would advise “harden up princess!” as an appropriate response.

Tips for dealing with concussion

If you are concussed while riding (or if you have hit your head and might have sustained a concussion) you should consider the following steps:

1. Drop out of the race / stop riding
2. Recognise the symptoms of concussion
3. See a doctor
4. Understand when it’s safe to ride again
5. Know that concussion may not always resolve quickly.

Remember, these comments are “tips” and do not replace proper medical advice, which should be obtained immediately after a concussion occurs.

All level of amateur and professional cyclists face the risk of concussion, and cycling’s love of “suffering”, while a noble trait in our sport, may also be its most dangerous aspect.

Remember, getting off the bike won’t kill you, but if you’re concussed, staying on it might.

Have you had any experience of being concussed as a cyclist? How did it unfold?