Are we taking brain injury in cycling seriously enough? Heather Batey, managing director and founder of brain injury rehabilitation specialist Reach, looks at attitudes, the role of cycling helmets, and the need for greater awareness of ‘invisible injury’
The cogs just keep on turning
As Gonzalo Serano took to the podium as the de facto winner at the end of stage five of last year’s Tour of Britain after its early termination in respect of the passing of Queen Elizabeth II, I recalled an incident at the start of the tour when one of the Bardiani CSF Faizanè riders, Marcellusi I think, had his bike disappear from underneath him in rather wet conditions as he came into a corner at speed. The position of the camera and the quality of the footage made it difficult to see in any detail, but it looked like his helmet impacted the tarmac with what must have been some force… he must have been travelling in excess of 20mph as he started to lean into the corner and his tyres lost traction with the road.
Marcellusi continued to the conclusion of the tour without further incident and I’m sure he was fine, he was handed a replacement bike and sent on his way to finish the stage only 41 seconds behind the leader. But one is given to wonder how thorough any assessment could be that would allow a rider to re-join the race without incurring sufficient time penalty to render any challenge for the general classification (GC) ill-fated? And for any readers unfamiliar with the world of professional cycling, the GC is top prize in any cycling tour and is won by the rider with the quickest aggregated time of all stages of the tour.
Unlike field sports, where the referee can stop play, add-on injury time, and the team managers have the option to supply substitute players to limit the effects of injury on competitive outcomes, the peloton rarely stops. All directors of sport (DS) and team riders know that every second counts in a grand tour of cycling, or any road race for that matter. When you combine this with the competitive drive, endurance and indomitable attitude of sporting cyclists, it presents some serious obstructions. And anyone thinking that this an issue limited to those with the Y chromosome would be mistaken, as women at various levels of cycling are equally prone to dismissing serious injury to continue a race, it is an issue that transcends the sexes.
Fighting attitudes and conditioning
Cycling is a sport that conditions participants to push themselves beyond the normal limits of endurance, to ignore the pain from screaming lungs and leg muscles, and its athletes are not psychologically conditioned to abandon a race. There are countless examples of professional cyclists treating serious injury in the same way as Monty Python’s Black Knight treats a missing limb “Tis but a scratch!”, when these are injuries that would see the likes of us lesser mortals screaming in pain for medical assistance. For instance, take a look at the injuries that Lauren Dolan crossed the finish line with in the 2017 UCI Road World Championships!
More pertinent to the crux of this article is the crash involving Romain Bardet in stage thirteen of the 2020 Tour de France, when Bardet brushed himself off, and then got back on his bike to complete the remaining 90km of the race in the mountain passes of the Massif Central. Despite admitting to feeling a little groggy, Bardet pushed himself to finish the stage in 27th place, no doubt fuelled by his desire to limit his time losses in his contention for the GC title, where he was then sat in fourth place. According to statements released by his team, he was found to have been concussed in the crash and subsequent neuroimaging revealed that he had in fact sustained a “small haemorrhage” as a result of his impact. They went on to say that he would “rest for an indefinite period”, ending his tour.
The incident with Bardet is far from an isolated one, with similar scenarios played out throughout the history of competitive cycling. The previous incident that comes to mind involved Toms Skujins, who came a cropper at speed, his front wheel slipping out from beneath him as he entered a turn on one of the descents in Stage 2 of the 2017 Tour of California. After sharing clear signs of vestibular issues with the viewers and spectators at the roadside, he was helped onto his bike by one of the neutral support outriders. He was eventually pulled from the race by his team and hospitalised with a broken collarbone and concussion. It’s a little disappointing that one of the support mechanics, who are often the first on the scene of an incident, aren’t a little better trained to spot some of the more obvious signs of concussion… like disorientation and poor balance!
Given that the idolatry of sporting heroes is not a phenomenon that has escaped cycling, it is not difficult to imagine that this spirit of indomitability has pervaded the amateur cycling scene and that a dismissive attitude towards injury is often seen at club level. Keen amateurs compete in local level races at significant speeds and with limited access to medical support, especially with good knowledge of concussive injuries, so it is important to promote awareness at all levels of the sport to increase the opportunity for the identification and early management of head trauma.
Recent years have seen progress at the professional level and a number of sports have made significant improvements to their safeguarding procedures in relation to concussion and traumatic brain injury, the RFU’s Head Injury Assessment protocol a fine example. Awareness of the potential long-term consequences of undiagnosed head trauma is growing within sporting communities, but it is important that we continue to encourage the adoption of best practices, even when they may conflict with aims of competitive sport.
The obligatory discussion about helmets
Given the old idiom that prevention is better than cure, no article about brain injury and cycling would be complete without a discussion about helmets, which remains a hotly debated and very contentious issue in some circles, though I suspect that this is not one of them. Whilst the UCI (the international body for cycling) made the wearing of helmets compulsory almost twenty years ago and affiliated national bodies followed suit, the use of cycling helmets is still optional for non-competitive, everyday cycling activities. There are robust arguments on both sides of the mandatory helmet debate, but like smoking, the focus should really be about educating people to make the right choices, especially amongst younger riders who may have image concerns that need to be overcome.
However, there is a problem, in that the messaging is very mixed even within the broader medical community, which makes education a divisive issue in some circles. The majority of medics that see the consequences of head injury acquired while cycling would regard the use of a helmet as a no-brainer. On the other hand, some public health professionals believe that the statistics do not merit a legislative approach to mandate their use in law. They say that protection is only afforded in minimal circumstances and that an enforcement approach will dissuade a significant number of potential cyclists from ever adopting the activity. Then we have cycling personalities implying that helmets would not be as necessary with better traffic legislation and street design to improve cyclist safety, which may well be true to some extent, but helmet use should really be encouraged and such messages are bit of a distraction.
The Press are just as divided, with The Grauniad reporting studies suggesting that helmets may not improve safety, as drivers and riders take more risks when the rider is wearing a helmet and that this compromises safety and that people should not have “to dress for urban warfare”. The previous year, the very same publication reported a study that helmets reduce risk of serious injury by almost 70 per cent, so their readership is left to form their own opinions based on these conflicting reports.
One of the issues here is that the lobby against the mandatory helmet use for cyclists has the unintended consequence of creating negative sentiment surrounding helmet use. Many lobbyists are not specifically anti-helmet and may even wear one for the majority of the time that they ride, but to counter the lobby for a mandate, they have to find evidence that says that helmet use is not sufficiently effective to make it a legal requirement. The rise of the e-bike has seen an increase in both the older generation and novice cyclists hitting the road, which is great, but if they have had their world view informed by some flake arguing that helmets aren’t that effective, then you have a number of ingredients in a recipe for disaster. Sprinkle with a momentary loss of control and an ice-cold kerb stone and we have everything needed for a cone.
A more recent study, Evaluating the impact of cycle helmet use on severe traumatic brain injury and death in a national cohort of over 11000 pedal cyclists: a retrospective study from the NHS England Trauma Audit and Research Network dataset (Dodds N, Johnson R, Walton B, et al, 2019), should strengthen the argument in support of helmet use, as it finds a significant post-accident increase in crude 30 day mortality rates (almost four per cent) in un-helmeted riders, whilst those wearing helmets saw huge reductions (almost 30 per cent) in severe traumatic brain injuries (sTBI) and ICU admission rates (almost 10 per cent).
And if retrospective cohort studies fail to impress the bare headed cyclist, maybe the potential for financial injury will offer a more convincing argument. Whilst judgements are complex, there have been a number of cases through the British law courts that have successfully argued that the failure on the part of the cyclist to wear a helmet amounted to contributory negligence, and that injuries sustained would have been less severe if a helmet had been worn. Such judgements have had a significant impact on the final settlement of these cases. Holiday insurance is a variation on this theme, as cycling holidays are ever more popular it is worth mention that many insurers will invalidate a claim if it is found that an injured cyclist was not wearing a helmet.
The need for rehabilitation
With early intervention being one of the most important factors in a good recovery, we are always enthusiastic to see improved protocols and procedures that can enable this. However, with milder head trauma there is often no visit to A&E, resulting in the absence of proper medical evaluation. This absence of a medical diagnosis means that it is only the symptoms that can be addressed, but as we know that intervention goes hand in glove with assessment, the opportunity for the best outcome is afforded to those who seek triage early on, ideally at the point of injury.
High velocity impacts, such as those that befall cyclists, will often result in cerebral contusions from the impact of the brain against the skull, the common side effect of sudden deceleration. The potential for these types of injury is quite high in these scenarios, irrespective of the choice to wear a helmet. The longer-term effects of a mild head trauma can be ongoing cognitive and executive issues, for which the early identification (such as via triage assessment) and treatment offers the best possible outcome.
Reach have identified this as an area where there is a paucity of services to treat those in need and have developed Headlight to afford those with the benefit of funding access to a high-quality head trauma triage service. Through Headlight, we are able to identify the need for intervention and supply individually tailored therapies, while signposting to other specialties to ensure holistic treatment.
Because the mechanism for reporting is not standard, there remains a high risk that those with concussive injuries will slip through the gaps. However, in instances where there is a case manager involved, we would be confident that the need for identification and treatment would be picked up and referred appropriately.
The case of the invisible injury
As we know, some of the injuries that may be sustained falling from a bicycle can be pretty… well, not pretty at all. If the fall was a direct result of an impact with a motor vehicle, or dare I say, an HGV, then the results can be horrendous and will often involve significant forces. A patient with pelvic injuries and a normal GCS will not meet inclusion criteria for a neuro-assessment and, once they have been treated for their injuries, they often fall onto the desk of a case manager with a referral for physio following pelvic injury sustained in an RTC.
Case management is a sometimes-tricky task requiring years of experience, and whilst case managers will usually pick up on clinical issues that may not have been disclosed on a referral form, or discovered in an INA, sometimes the nature of the injury being treated will mask subtle neurological symptoms sufficiently to allow them to be overlooked. This is not a common occurrence, but for cases where there are no case managers involved, it merits a quick review.
Look out for invisible injuries
Mild head trauma may not be picked up and it is important to look beyond the obvious injuries. It is something that we are all aware of, but it is useful to be reminded from time to time.
Mild symptoms are an early warning sign
It is important to follow-up on mild symptoms that may appear to be of no real concern. The effects of mild head trauma can spiral over time and it is important to assess symptoms as early as possible, to limit their impact on the clients’ independence and wellbeing.
Always be on the look-out for the red flags
Despite the injury being treated, if there were impact forces involved in the accident then there is the potential for head trauma. These will be obvious to most clinicians, but it is important to keep them in mind when treating someone with an orthopaedic injury sustained in an impact.
- Reduced tolerance, or increased irritability.
- Difficulty maintaining emotional control.
- Lethargy, or excessive fatigue.
- Mild altered cognition, such as reduced attention and memory.
Refer to appropriate services for the best outcomes
Early intervention is the gold standard for positive outcomes. Refer as early as possible to an appropriate neuro-rehabilitation provider if you have identified any of the red flags for mild head trauma.
The increasing recognition of the long-term impact of mild head trauma has resulted in the inception of Headlight, which is the head trauma triage service created by Reach to provide case managers, insurance claims handlers and solicitors an early intervention pathway to address the effects of mild head traumas.
Reach provide specialist, tailored neuro-rehabilitation programmes to clients with acquired brain injury as a result of trauma, and to those with functional disorders requiring neuro-OT intervention. To make a referral to our service, click here or call a member of our team on 01423 326000.
References
- Paul Farrell, Bicycle helmets reduce risk of serious head injury by nearly 70%, study finds, The Guardian [Online] https://www.theguardian.com/lifeandstyle/2016/sep/22/bicycle-helmets-reduce-risk-of-serious-head-injury-by-nearly-70-study-finds (Accessed: 1st November 2022)
- Peter Walker, The big bike helmet debate: ‘You don’t make it safe by forcing cyclists to dress for urban warfare’, The Guardian [Online] https://www.theguardian.com/lifeandstyle/2017/mar/21/bike-helmet-cyclists-safe-urban-warfare-wheels (Accessed: 1st November 2022)
- Dodds N, Johnson R, Walton B, et al, Evaluating the impact of cycle helmet use on severe traumatic brain injury and death in a national cohort of over 11000 pedal cyclists: a retrospective study from the NHS England Trauma Audit and Research Network dataset, BMJ Open 2019;9:e027845. doi: 10.1136/bmjopen-2018-027845
- Nigel Wynn, Lauren Dolan finishes World Championships race despite horrendous crash injuries, Cycling Weeky [Online] https://www.cyclingweekly.com/news/latest-news/lauren-dolan-finishes-junior-womens-time-trial-despite-crash-injuries-351650 (Accessed: 3rd November 2022)
- Alexis Gagné, Toms Skujiņš Amgen Tour ofCcalifornia 2017 crash, YouTube [Online] https://www.youtube.com/watch?v=12OUjb6N7Ro (Accessed: 3rd November 2022)
