giugno 08, 2018

Concussion Repercussions

“A range of four models developed according to following concepts: aerodynamics, ventilation, lightness and emotion.”

This is the opening gambit in a press release from one helmet manufacturer on its latest designs. It continues in greater detail to explain the levels of comfort, the “nice shape and attractive lines”, and both the wind tunnel and real-life testing undertaken to ensure the best possible aerodynamics.

Nowhere is there any mention of safety: whether these helmets might actually perform their primary function – saving lives and reducing head injuries in crash situations.

And when those frequent professional bike racing collisions and crashes occur and the helmet makes contact with the ground at high speed, what happens next? That may depend, we discovered, on which team the unfortunate victim is riding for.

*******************************

“I realised I had lost some memory and I needed to call it a day”

Stage two of the Amgen Tour of California, 2017. Toms Skujins, now of Trek-Segafredo, then with Cannondale-Drapac, is eying a repeat of his stage wins in the two previous editions of this race. In a group of five contenders on a fast descent, his front wheel slips out and he goes down hard, tearing jersey and shorts to shreds, losing skin down most of his left side.

What is unclear from the YouTube clip that has now been viewed almost a quarter of a million times is that Skujins has also banged his head on the unyielding Californian tarmac. It becomes apparent as the determined Latvian staggers to his feet, attempts to remount – assisted by a neutral support mechanic – and tumbles into the middle of the road. In an horrific example of how to unwittingly become an internet video sensation, Skujins then staggers around trying to retrieve his detached Garmin, escaping further calamitous injury by inches as the peloton weaves either side of the clearly confused rider.

Incredibly, he remounts and tries to continue. The team’s car is not behind Skujins and so directeur sportif Tom Southam is unaware of the unfolding drama further down the mountain.

“Because the cell [phone] reception is pretty bad there, it was hard to make contact and make them aware of what was going on,” says Skujins. “Obviously, people watching TV saw it. I don’t remember the 15 minutes after the crash, but apparently I talked to the race doctor and he didn’t see the crash. All the questions I asked were normal, cyclists talk: how far is the group ahead? How far behind? He said I could ride.”

Team boss Jonathan Vaughters’ phone started ringing off the hook. He thankfully made contact with Southam and any further calamity was avoided.

“That was the same time that I started coming to my senses,” Skujins continues. “Everything was not as it should be. My skin has gone and I’ve got a broken collarbone. It was not really a question of ‘if’ but ‘please’ – just let me get in the car. I realised I had lost some memory and I needed to call it a day.”

Illustration: Hayley Warnham

Cannondale-Drapac’s concussion protocol kicked in during the crucial following days. As Vaughters told reporters later that day: “When I raced, in my generation, a concussion was just: ‘Oh, you’ll be dizzy for a little bit and then get back on your bike.’” Attitudes are changing, with American teams at the forefront.

Holed up in a Californian hotel room with the blinds down, Skujins was advised not to use his phone, laptop, any screens, books – anything that requires brainpower. “I pretty much spent four days in darkness in the hotel, waiting for surgery. I went out once for a coffee and once for dinner. My girlfriend was helping me out texting, because obviously there were a lot of messages. Other than that, I didn’t read or even listen to any podcasts. The first days are the crucial part, the same as with any injuries. If you judge those correctly, you will come back quicker.”

Skujins made a full recovery and returned to racing at the Latvian National Championships the following month. Not every rider has been so fortunate.

*******************************

“It can be extremely debilitating and frightening, a wholly overwhelming phenomenon.”

As the peloton swept round a left-hand bend in the centre of Retford en route to Newark-on-Trent in the 2017 Tour of Britain, a flag-waving marshall could not prevent all of the riders from colliding with a poorly-placed parked car on exit. Most of the BMC team went down, with Brent Bookwalter coming off worst – his head smashed the rear window of the car.

The 34-year-old American, one of those who had just managed to avoid colliding with Skujins in California earlier in the season, got a sickening introduction to the world of concussion. Bookwalter was driven to Belgium to see Dr Stijn Quanten, an expert in the field.

“We had a few guys on the team last year who had head injuries – myself, Ben Hermans, Rohan Dennis,” he tells me. “The team networked and found a concussion specialist in Belgium. I was the continuation of that. I think all three of us helped in developing our protocol.

“Unfortunately for me, we didn’t have the advantage of having the baseline tests from when I was healthy, but there are enough standard baselines of brain activity and function and responses to give us a good idea. And for me, it did show some major deficiencies in my brain. Most of the exercises are done via computer, which is sort of problematic in itself, because right away I was sensitive to screens and had a splitting headache.

“Another method that is common throughout the psychology and brain testing world is QEEG brain mapping. They put this sort of hat on your head with all these electrodes or sensors that monitor the pulses passing through different areas of the brain. And while you are doing that, you are reading a newspaper article, or solving a problem, or doing reaction-time tests. That data was then analysed by a neurologist. That, combined with team medical staff’s assessment, formed the beginning phase of where I was at. It was pretty clear there were some major deficiencies.”

As Bookwalter points out, individual responses to head trauma can vary enormously. “Some people who are knocked out cold for five minutes can be back to normal the next week. I, on the other hand – conscious and coherent the whole time and pretty much ready to get back on my bike and race – had these foggy, grey symptoms for weeks and months, and even with these tests and doctors, they couldn’t tell me when it was going to stop, or when it was going to get better.

“You hear about riders having head injuries, taking time off, and making the ‘smart call’ to sit out and not compete, and I always envisioned it as they are maybe a bit foggy, can’t risk hitting their head again, take some time at home. Once I had experienced it myself and dug deeper, I found out that was not the case at all. It can be extremely debilitating and frightening, a wholly overwhelming phenomenon.”

Despite the best medical advice and treatment – like Skujins, sat in a darkened room with minimal brain stimulation for the best part of a week before gradually reintroducing gentle walks and exercise – it took two months before Bookwalter felt he was anywhere near his pre-crash state of mind, and even then, he was still suffering lingering headaches.

“It is terrifying,” he admits. “I was getting nauseous and motion sickness riding down twisty roads. There is a still a bit of an unknown [as to] how I am going to process those race situations. I haven’t had anything coming at me that fast in a while now. There is definitely some delay in getting that back.”

Concussion protocol testing at teams such as BMC and what was formerly Cannondale-Drapac takes the form of an online baseline memory test, taking 30 to 40 minutes, completed ahead of the season. Any accident involving a head injury and the rider can redo the test and see how the results stack up. But it is at the team’s own discretion to provide this resource.

“That’s what the sport needs to be looking at, maybe even making it mandatory,” Bookwalter advises. “Every year or two we have to do these heart stress tests, blood tests – there is no reason why a baseline test shouldn’t be mandatory too.”

As for his roadside treatment at the Tour of Britain, Bookwalter praises the race’s emergency staff who were on the scene, preventing a potentially catastrophic scenario like Skujins’ in California. “If I had gotten back on my bike that day, it would have been a total disaster. Fortunately, we had some good medics respond to me right away. They had me on the stretcher and in the ambulance, and not trying to get me back on the bike.”

Dr Quanten flew to the team’s winter training camp in Spain to access the rider’s condition, bringing the same laptop and QEEG head unit used following Bookwalter’s crash in September. It showed good improvement. At the time of writing, Bookwalter is back to racing hard with BMC, helping them to win team time trials, as is their wont.

*******************************

“If you damage your brain, don’t use it. It is quite simple, but if no one tells you…”

Matt Brammeier knows more than most about our chosen subject and it is one he is passionate about. Indeed, it was talking to the Aqua Blue Sport rider that sparked the idea for this feature. His gut-wrenchingly sickening crash on a descent in the 2015 Tour of Utah when racing for MTN-Qhubeka, headfirst into a Porsche race support vehicle, is one I heartily recommend you do not seek out on YouTube.

Despite the horrific nature of Brammeier’s car collision, he emerged relatively unscathed, to the extent that there were no immediate signs of concussion.

“I didn’t know I had it until two months later, when I started recognising my symptoms,” he tells me. “It is not always about being dizzy, falling over, or throwing up. There is so much more to it than that.

“With me, I was getting headaches further down the line, and I still do now. If I sit at my computer and I’m working on something for six hours, even two hours, I feel properly tired. And if I go out and train, I’ll be tired. I can manage one or the other, but if I do both together, I am useless, physically and mentally. That was something I never suffered from before. I can’t recover properly, and I am super-grumpy.”

Brammeier’s wife, cyclo-cross star Nikki, picked up on personality changes and mood swings affecting her husband long after the initial incident. “She says that since that crash I have not really been the same – nothing drastic but little things.”

Nikki has her own experience to call on when it comes to concussion. A high-speed collision between GB team-mates Brammeier and Helen Wyman at the start of the 2016 European Cyclo-Cross Championships left them both with nasty facial injuries and Wyman sustained a broken collarbone. When I spoke to Wyman at the end of 2017, she reported still struggling to process ‘cross courses when they were complicated: fast, twisty races like the one we were at in Spain remained potentially problematical for her.

Nikki, by contrast, recovered fully, possibly due to Matt’s prior experience. “If it was left to her, she probably would have just got on with it, and it might have taken her six months to recover, if she ever recovered fully. Because I was there, when it’s someone you care about, you want the best treatment for them.”

He was directed to Dr Willie Stewart, a leading clinical neuroscientist at Glasgow’s Queen Elizabeth University hospital who appeared on Alan Shearer’s excellent BBC documentary on dementia in footballers.

“The problem is there is no real objective test for concussion,” Stewart explains. “It’s not like a heart attack, where you can do blood tests or heart tracings, or a stroke, where you can do a brain scan. Essentially, it’s down to the athlete reporting what they feel, and you hoping you can pick up the signs and put them all together. When people get in touch with me, I listen to what their problem is, then try and direct them to somebody who can best advise them.”

Stewart in turn pointed the Brammeiers towards Professor Tony Belli in Birmingham, an advisor on sport concussion to the Rugby Football Union, Football Association, GB Rowing and British Basketball. They travelled to the Midlands for treatment. “Alarm bells started ringing when he told us what could happen,” Matt says, but with Belli’s advice and treatment, Nikki recovered. Matt was not so lucky.

“Tony assessed me and said you have got lingering symptoms that you may never get rid of, because you never dealt with them properly in the first place. That is what I am trying to make people aware of. If you are lazy and you don’t do it properly, just jump back on your bike like an idiot, then you are probably going to be stuck with some of these things for the rest of your life.

“Tony said to me it is all about the recovery process. If you break your leg, you don’t go and try walking the next day. If you damage your brain, don’t use it. It is quite simple, but if no one tells you… A lot of what I learnt about myself was after Nikki crashed and got advice. It took until after that for me to recognise the symptoms.”

If the US teams are leading the way in this area, as it appears, where does that stem from? “It comes from American football and that has filtered across to other sports,” Brammeier thinks. “It’s an awareness thing. It is the American teams that are driving it at the moment and most of them have their protocols in place. I was chatting with [EF Education sprinter] Dan McLay, and he said he had forgotten to do his concussion test, so he has to log on to a website and do a cognitive test as part of his medical examination. They seem to be doing more than the traditional European teams.

“We do some testing with our team doctor [at Aqua Blue Sport] and do base tests at the start of the year. But if someone crashes and bangs their head in a race, there is no protocol in place for the directors or soigneurs to carry out their own assessments. A couple of times last year, it came down to the riders to go to the doctors themselves. And this can’t come from the riders, because all they want to do is jump back on the bike, keep training and keep racing. We have to be protected from ourselves. It sounds stupid but it’s true. We can’t be trusted to make that decision ourselves.”

*******************************

Per Hamid Ghatan has worked in brain injury rehabilitation for 30 years, also campaigning for prevention of head injuries, leading to compulsory helmet wearing for cyclists up to the age of 15 in Sweden. He also works in conjunction with the POC Lab, a think-tank of experts for the Swedish helmet manufacturer.

“When I meet a patient in the rehab setting, mental fatigue is the major problem for many of them,” Ghatan explains, echoing Brammeier’s personal experience. “The work with my team is very much around adaptive rehabilitation. We help them to be active as they can, but not stray outside the limit of their capacity. Then we increase gradually from there.”

Ice hockey is leading the way in Sweden, he says, with a gradual monitored return to playing. “If the symptoms increase when they go up a level, then they go back to the previous level.”

Ghatan describes his own treatment methods as being like interval training – starting with 20 minutes of activity and building from there. “I see patients who return to work or school, they are in a stressful situation and they keep pushing themselves too hard, then they have this setback and end up seeing me. And it is too late, I would say, because I have to restart everything from scratch.”

For professional cyclists such as Skujins, Bookwalter and the Brammeiers, it is the last thing they want to hear. When your career hinges on performances season to season and contracts are increasingly hard-won, prolonged time off the bike could spell the end of the road. They need to focus for five hours, not 20 minutes…

“Most people think that you have a blow to the head and that’s it,” Ghatan warns. “But it can trigger an avalanche in your brain and in your body, this kind of domino effect, that can continue for weeks and even months.”

He and his team in Sweden continue research into inflammation, which may cause headaches, dizziness, light sensitivity and fatigue, “which has been ignored for decades when it comes to brain injury in general. But I think within a couple of years now, we are going to have much more information for treating these kind of injuries.”

Until then, POC continue to lead the way in helmet safety, advised by the likes of Ghatan and Magdalena Lindman from Volvo – bringing with her a wealth of knowledge on cycling accidents involving cars that helped inform the design of their Octal helmet, introduced to the pro peloton with Garmin-Sharp in 2014 to the derision of many for its unusual appearance. Three years later, they fitted SPIN pads to their entire range, based on input from Ghatan and his fellow think tank members, claimed to reduce injuries by allowing the helmet to move relative to the head on impact.

As Skujins told me – and it is unusual for a pro rider who has changed teams and therefore now uses equipment from another manufacturer to comment – “POC make really good helmets, I have got to admit, and they probably saved a lot of recovery time for me. I had no time to react, so hit my head full on. The padding in those helmets worked well for me, and I think that is one of the key reasons I escaped so lightly. There is a lot more to the backside than other helmets. And if you go straight down without warning, there is a good chance that is what will hit the ground.”

Regarding professional teams and concussion protocol, it should indeed be mandatory, as Bookwalter suggests. If the popular misconception is, as he thought, that concussion sufferers sit out for a few days feeling foggy, then return to normal, then the entire sport needs educating. It can be life-changing. And career-ending.