Injury Prevention and Treatment
Horner was disoriented as he crossed the line...

USA Cycling, physicians develop head injury protocol

Concussions in bike racing are common, but diagnosis and treatment often fall short. Medicine of Cycling and USAC aim to change that

With increased scrutiny on BMX crashes and head injuries on the road, as well as brain injuries in sport, USA Cycling has engaged a number of physicians to develop protocols to help riders and their doctors better manage post-head injury recovery.

When Chris Horner crashed during the seventh stage of the 2011 Tour de France, he got back on his bike and finished the 135-mile route to Châteauroux. At the finish — clearly disoriented, with abrasions oozing on his face — Horner asked his soigneur, “I don’t understand… when did I crash? Has it been a long time?” Told that he had been riding for some time to get to the finish, Horner incredulously queried, “We’ve been chasing for 25K?”

Even after going to the hospital and getting word from doctors that the blow to his head was so severe that he could not continue racing, Horner later recalled that, “I wanted to race the next day and start the stage at the Tour!” After all, he thought, “We crash so much; it’s just part of the job. Eventually you are going to hit your head; that’s why we wear a helmet.”

Horner’s response to his injury is typical of serious cyclists: after a crash, if nothing’s broken, the impulse is to keep on riding.

Kristin Wingfield, the physician for the Exergy-Twenty12 professional women’s team, explained that cycling is particularly unique when it comes to concussion management in that, unlike other sports, “there is no time out; there are no player substitutions.” Yet putting a rider who has suffered a concussion back into a race can be both harmful to the rider, who may be suffering loss of balance and cognitive function, and the riders around who are depending on her to hold a line, stay upright and exercise sound judgment when diving into corners and sprinting for the finish.

Developing the protocol

Now a group of doctors who focus on cycling medicine are working with USA Cycling to develop brain injury protocols aimed at caring for bike racers. According to concussion management guidelines written by the Medicine of Cycling group co-founder and University of California-San Francisco physician Dr. Anna Abramson, signs of concussion can include loss of consciousness, headache, poor balance, memory loss, nausea and confusion. Watching Horner being interviewed after crossing the line at the Tour, he was clearly suffering from a few of these.

USA Cycling Vice President of Athletics Jim Miller said his organization first became interested in working with the Medicine of Cycling doctors to put together more formal concussion management policies because of BMX racing.

The dirt-track racing “is a high-risk, high-impact sport when they crash,” Miller explained. And because BMX courses are tight and competition for first position into the banked turns is furious, the riders crash a lot. Not being doctors, the BMX coaches and USA Cycling officials did not feel comfortable making judgment calls “when these kids crash and get up and say they are fine and they want to race the next round.”

Miller said USA Cycling worked with Richard Quincy, the Associate Director of the U.S. Olympic Committee, as well as Abramson and other doctors with the Medicine of Cycling organization, to adopt cognitive function tests like those used with athletes in the United States’ National Football and National Hockey leagues.

Using a software program that tracks motor and mental function, riders take a test to establish a baseline level of cognitive function prior to an injury. When cyclists crash and suffer a head injury, they can take the test again to assess when recovery has returned them to their normative cognitive state — that is, where they are safe to ride their bikes again on the road with traffic and in racing and training with other riders.

Miller said of the testing data, “Today we have a lot in our database. So now when they crash, we just ask them to do the cognitive function test again, and it tells you if they passed or failed.”

He clarified that during an event, a race doctor is going to make an on-the-spot assessment as to whether or not the rider can race again that day, but later, the test data is an additional tool to measure his fitness to return to racing and training.

“Before they can return to the field of play they have to pass this cognitive function test,” said Miller.

USA Cycling is now rolling out the same protocol into all the cycling disciplines it manages. “Our goal is that with every discipline you capture as much baseline data as you can.”

Eric Freitag is a clinical neuropsychologist who has worked with Wingfield and the Exergy-Twenty12 team. In his experience, in the aftermath of cycling accidents, the trauma management often focuses on skeletal and muscular injuries, not concussions. Beyond that, “there is a vast variability in knowledge about how these injuries should be managed.”

For instance, he has treated head injury patients whose doctors told them to take a couple of days off and others whose doctors told them to stay off the bike for a year.

The reason for the variability, Freitag explained, is that the field is progressing rapidly — partly because of the amount of data coming from two decades worth of soldiers returning with brain injuries from wars in Iraq and Afghanistan, and also as a result of better brain imaging technology.

“And not everyone is up to date on the research,” he said.

To put this progress in perspective, Freitag noted that “the amount of peer-reviewed literature within the last 10-to-15 years on mild-to-traumatic brain injuries or concussions has eclipsed the last 50 years, combined.”

Mechanics of a brain injury

When someone falls off his bike and hits his head, even when wearing a helmet, a number of things happen. While the helmet absorbs some of the impact and protects the skull itself, a major blow still traumatizes the brain by slamming it around inside the skull. As Horner said of his accident in France, even with the helmet, his was “like a car accident. You didn’t hit your head, but you stopped so fast that the brain literally hits the skull.”

“At that moment of impact, all cells in the brain fire,” Freitag explained. “Through the stretching and the twisting of the axons (nerve fibers), and the actual damage that’s afflicted against the cells, it causes a major brain event: electrical activity. Our brain functions on chemical transmissions and electrical impulses; just like we used to hit the old CRT televisions on the side to get the reception back, the same kind of thing happens in the brain.”

When all the brain cells fire at once due to smacking a stationary object like the ground, a metabolic dysfunction occurs. “Chemicals that should be inside a cell go out, and chemicals that should be outside the cells go in,” Freitag added.

The net result off all this is “a traumatized organ system.” To return to its previous state of chemical and electrical equilibrium, the brain requires energy delivered by the blood.

Resting the body and mind

However, in the case of a crash like Horner’s, at the very moment the brain most needs energy to begin repairing itself, traumas elsewhere are compromising that energy-delivering blood flow. During and immediately after a head-injury-causing bike wreck, “our physiological capabilities have significantly decreased,” Freitag explained.

In turn, the brain enters a state of metabolic crisis, the symptoms of which the disoriented Horner displayed after crossing the finish line. “That’s what is happening in your brain when you are having the symptoms of headache, fatigue, fogginess, dizziness, balance problems, lethargy, upset stomach and vertigo. All those symptoms are due to that metabolic mismatch,” said Freitag.

And while dedicated cyclists’ impulses might be to get back on the bike and start training, especially if all their bones are intact, Freitag explained that for the brain to recover its equilibrium, it needs to rest. And this is perhaps the most surprising discovery for cyclists. By rest, research shows “that’s not only physical rest, but often times it’s also mental rest, cognitive rest,” he said.

Because the brain demands energy when concentrating on something, hopping on the bike and heading out into the input-rich, attention-demanding world of a traffic-filled training ride, or a criterium that demands utter focus and incessant, split-second judgment calls (can you squeeze through that gap?), riders can actually further delay recovery from a head injury, or even make it worse.

“They could potentially be having balance problems; they could potentially be processing information much more slowly. They could be having visual-spacial judgment problems. They could be having problems with concentration,” Freitag added about why a cyclist should see a doctor who has concussion management expertise after striking their head in a crash. If a rider’s primary care physician does not have that expertise, [the doctor] should tell him, and refer him to someone who does.

Questions to ask include how up to date the doctor is with concussion management literature, and how comfortable he is overseeing recovery for an athlete — which requires a different approach than that taken for a typical, sedentary American.

Freitag said there comes a point in recovery from a concussion “where we will actually want athletes to start exerting themselves.” While they might not be cognitively ready to ride on the road, getting on a stationary trainer can actually help with recovery.

“There’s a point during the recovery process when symptoms are at a more manageable level, where we want to start slowly introducing physical activity because that activity can actually be helpful in supporting recovery,” said Freitag.

Horner explained that his gradual recovery was forced by the fact that the blood clot he suffered put him on blood thinners for six months after his crash. Even a minor crash while on blood thinners could be life-ending, so he stayed off the road for the duration. That said, it was really up to his doctors to give him to go ahead when he was cognitively ready to get back on the bike.

And he definitely felt the effect of the accident. “Oh yeah!” Horner laughed, thinking back to the second half of 2011. “You are just not grasping things for a couple of weeks.” He said he has hit his head before, but never like this. “I just don’t remember the whole day. That day has never come back, and I don’t expect it to, either.”

The Medicine of Cycling concussion management guidelines USA Cycling is using (available here in PDF and Word format) are written in plain English. For coaches, doctors and riders, they are worth reading for advice on what to look for should a fellow rider crash and hit his head. They include a series physical traits to look for in a crashed rider, as well as a series of questions such as “What city is this?” and “How far are you from the finish?” that can help assess the rider’s cognitive state.

For more information, visit the Medicine of Cycling website.