With two incidents in quick succession at the Giro d’Italia involving head injuries, concussion once again came to the fore and protocol around in-race assessment and roadside evaluation came under scrutiny.
Firstly, it was Joe Dombrowski in a sickening high-speed collision towards the end stage 5, where his head made contact with the ground. He eventually limped across the finish line but was withdrawn from the race following concussion testing at the team hotel. It followed the biggest win of Dombrowski’s career the previous day and, to top it off, the crash happened on his birthday, of all days.
Next came Matej Mohorič, whose spectacular somersault on a rapid stage 9 descent resulted in a snapped-in-two bike and a dazed-looking rider sat on the roadside barrier until the team car and race doctor arrived on the scene. After the mechanic had initially prepared a replacement bike, it was the Slovenian himself who felt unable to continue as he slumped back down onto the tarmac. A diagnosis of mild concussion later followed. It appears he escaped very lightly from an horrific-looking crash.
Watching on with interest will have been Professor Xavier Bigard, UCI Medical Director overseeing the governing body’s concussion protocol introduced at the start of the 2021 season. Work began in 2019 with a group of doctors, scientists and neurologists producing a study and recommendations for sports-related concussion [SRC] across all disciplines of bike racing under the UCI auspices. It has not been a rapid response, but such is the world of medicine. Getting it right is more important than getting it out there. And thorough research takes time.
The difficulty lies, of course, with rapid assessment in a fast-moving sport like road racing, where the difference between being in or out of the race can be a matter of minutes. We have witnessed numerous incidents in recent years where racers are desperate to continue. It is understandable, but they clearly need protecting from themselves in these situations.
“That is what the riders want, to continue,” Bigard confirms. “That is a big problem. To evaluate cognitive function, we need good contact with the patient. If the aim of the rider is to get back on the bike and continue, that is a problem for the team doctors, clearly.
“We have validated tools to use in the field, developed by such sports as ice hockey, rugby and football, but for us the challenge was to translate these protocols to road cycling where we don’t have enough time to do a good diagnosis. We need a minimum of ten minutes to use this tool, which is impossible at the roadside.”
The key, Bigard believes, is in educating every single team member on the signs of concussion, not just team doctors, mechanics and directeur sportifs – often first responders – but raising awareness throughout the sport. “That is why we are developing short papers to report the main clinical signs of risk and detect signs on the road, and producing videos as well,” Bigard says.
“As you know, the first person to come in contact with an injured rider is the mechanic. These people can play a key role to suggest concussion diagnosis – not to do the diagnosis, of course, but to say that there is a risk of concussion and to call the doctor on the race. It is important to educate all of these people.”
Photo credit: Tim de Waele/Getty Images
When I first wrote on this subject back in early 2018, concussion seemed barely discussed in cycling, yet it was career-ending for several of the unfortunate riders we interviewed who had experienced the debilitating symptoms that, if incorrectly treated, could be lifelong – and life-changing. Has the new protocol been well received and are the teams listening to the message?
“The first positive point for us is that we have focussed attention on this medical issue of traumatic accident and awareness has risen,” Bigard says. “This is a good point – to remind that you have to focus your attention on this injury. That is very important for us.
“Now we need feedback from our colleagues, who are working at the roadside and at the races. We need this feedback to improve this tool and to make it more effective. Clearly it is not perfect, absolutely, but in six months, one year, we expect this feedback to improve this tool.”
An interviewee for my initial magazine feature, Brent Bookwalter, who had entered a car head-first via the rear window at the 2017 Tour of Britain, called for baseline testing before the start of each season, as his then-team BMC had done. Does Bigard feel this could be a useful tool?
“Baseline testing is suggested in some papers. When we look at these papers, the consensus is it might be useful but it is not necessary, but we recommend it before the beginning of the season for road riders. It measures only cognitive function. That said, a consequence of this baseline testing is to focus the minds of everyone on the team on concussion. I think it could be interesting.”
One very welcome mandatory ruling for teams is reporting concussion injuries suffered by their athletes to the UCI. The “three strikes and you’re out” rule identified way back in 1945 by an American, Dr. Quiqley, concluded that any athlete suffering three concussions during the space of one season should be withdrawn from competition for the remainder of the year. It took decades before the cumulative effects of repeated injuries became properly understood, mainly from studies done with American football players – the highest profile sufferers of this condition in the world.
“Now it is clearly defined as the repetition of concussion, not the severity of concussion,” Bigard explains. “This is one item that is mandatory for the teams, to declare concussion cases from the riders. I don’t say that we will stop the career of a rider because of reported repetition, it is not my purpose, but it is important to collect all of this story to verify the recovery of neurological brain function.”
There is definite progress from the UCI on this subject. There is still a way to go, but the incidents involving Dombrowski and Mohorič, and how their respective teams reacted to them, indicate an improved understanding from all involved – both athletes and staff.
Concussion is an extremely serious matter. Finally, cycling is waking up to the fact.