Could we all benefit from pro-level concussion protocols?

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Crashing, injury, and even hitting your head have long been considered accepted risks in the sport of mountain biking. But as the evidence mounts on the long term risks of even minor head injuries, Hannah wonders whether we ought to be thinking again about risk and responsibility when it comes to protecting our heads, and whether pro-level concussion protocols could help all of us.

Knowing the risks.

If you’re an American mountain biker reading this, perhaps you’re already clued up on the long term risks of head injury and concussion, since in the world of American Football this is big news. The NFL is now taking concussion risks so seriously that it’s taken to labelling helmets to grade them on the basis of how effective they are at reducing injury, so that teams and players can make better informed choices about their equipment.

As far back as 1994, the NFL created the ‘Mild Traumatic Brain Injury Committee’. In 2007 a hotline for players being forced to play contrary to medical advice was created, although it took until 2016 for the NFL to admit a link between football and Chronic Traumatic Encephalopathy (CTE). There’s now a whole Play Smart Pay Safe’ initiative aimed at reducing injuries – not just ones to the head – and making the game safer. Data is collected, trends are examined, and rules are changed. Of course, there are some numbers driving all this: in schools, participation levels in American Football are reported to be falling as concerns about concussion mount, and there have been some costly legal settlements.

There’s been a human cost too: football fans have seen CTE posthumously confirmed in a number of cases of suicide by former players. It’s a pretty sobering story: elite athletes crippled by personality changes, dementia and depression as a result of head injuries sustained during activities we considered good for health.

Cycling Playing Catch-up

Mountain biking, and professional cycling more generally, seem to be lagging behind. There’s still a great deal of emotional debate around helmet compulsion, despite all the evidence showing that forcing people to wear helmets is bad for general population cycling – it reduces participation, making this statistically safe form of transport a less popular choice. In competitive sport and mountain biking however, where the nature of the activity (increased speed, bunch riding, technical trails) increases the risk of falling off beyond that which your average pootle to the shops presents, the wearing of helmets isn’t really a point of debate. Which helmet might protect you best is under increasing scrutiny, and you should read Barney Marsh’s article on MIPS from Singletrack Issue 121 if you’re interested in that debate.

You should have a read of Barney’s article.

Even if you’re wearing a helmet when you hit your head, you’re not in the clear, and it’s perhaps less well understood what happens and what you should do about it. Chris Hall wrote about the topic having interviewed Katy Curd, asking whether we’re taking crashing seriously enough, and offering some advice as to what to do if you do crash on your head (or your neck – you don’t have to hit your head to be at risk, it’s your brain bashing around inside your head that’s the problem).

However, hearing pro-riders at Bike Park Wales recently in a Q&A session, it was clear that there’s more that could be done. Certainly, individual riders need to have the information they need about the risks of head injury, so that they can make informed choices about their own health. There can surely always be more awareness raising taking place. And hey, you’re reading this, which is a start.

Riders at work.

But what about the professional riders, who are, effectively, at work. We all expect our employers to look after us and not expose us to undue risks, so shouldn’t pro-riders have similar expectations of being supported and protected? And what about younger riders, who might be hoping to make a career of riding? It’s easy to see how a racer could make poor decisions in an effort to please sponsors (or even parents), who may well have shelled out considerable expense to get a rider to a race.

concussion protocols
These pros agreed, there’s nothing cool about riding when concussed.

One professional who knows all too much about the potential effects of a concussion, or repeated concussion, is Katy Curd. She’s only just returning to racing after two years of rehabilitation, and the effects of her head injury are still with her. She is grateful that all her sponsors supported her during her time out from racing as she sought to recover:

“I really am SO grateful for all my sponsors who stuck by me through the two years I wasn’t competing, I guess they could see I wasn’t just sitting on the side line not doing anything, hopefully they knew the commitment I was putting in each day to try and get back to racing again but I really wouldnt of been able to keep pushing or have the same motivation behind me if I didn’t have the backing from all my individual sponsors who helped through everything. Everyone always asks me if I ever feel pressure from any of my sponsors and I can honestly say no, I have never felt any pressure from any sponsors of mine and it means the world to me that they have stuck with me through everything.

However, that support came after Katy made the decision to race while already concussed – after the damage had been done, and became apparent. What about in the adrenaline high of race day?

Tahnee Seagrave said: “You’ve got like 16 year old kids who turn up and race their first World Cups, smash their heads in, they’ve been knocked out for a good 30 seconds and then you see them racing the next day. You talk to them and you’re like ‘why are you here?’ and they’re like ‘oh well I’ve got to race’. It’s like ‘no, you don’t’. It’s not the end of the world missing one race. Get better or you’re just going to get worse.

Vero Sandler added: “A lot of kids think it’s cool, like ‘I was concussed yesterday when I was racing’. It’s so not cool.

In hindsight, Katy says “I guess there’s just not enough advice out there, like people do hit their heads and don’t know [the risk] – I certainly never knew it – I wish someone had told me ‘don’t bloody race your bike’“.

Levels of protection.

Depending on what event you’re doing, you might find yourself being given this level of protection – or you might not. The EWS and Crankworx have introduced new protocols in the last couple of years, while the UCI says its protocol is under review. Athletes displaying signs of concussion in EWS or Crankworx races are banned from further participation until cleared by a doctor, and the rules on this are covered in specific protocols for dealing with concussion. Both organisations seem to recognise that athletes may not be best positioned to make choices about whether or not to compete.

Darren Kinnaird, Crankworx General Manager, says:

Developing policies and procedures around concussions, and head injuries in general, has been a big focus of ours over the past few years. We take it incredibly seriously. Our main goal in developing a specific protocol that we applied across the Crankworx World Tour was to protect our athletes, both in the short and long term. There are still so many questions around head injuries – sometimes an injured rider can seem healthy and still feel good, but that’s just the surface. There are many layers to these types of injuries that need to be looked at and monitored closely. A lot of the information that’s come out about brain injuries is so new – there’s a lot of learning still to be done. But in order to protect our athletes as best we can, we wanted to be at the forefront of this movement. We worked on developing what’s become our concussion and head injury protocol through the 2017 season and put it into practice at the start of 2018. So far the response from athletes, fans and the industry has been incredibly positive.

Chris Ball, EWS Managing Director said:

One of the main reasons we initiated the concussion protocols is to remove the decision making process from the rider and their team. In order to please sponsors etc, it might be tempting for a rider to want to push on with a race when it’s really not in their best interest to do so, this way we can make that decision for them based on solid medical advice. Once a rider is removed from the race, they can’t then return to competition until they show us a doctor’s letter proving it is safe for them to do so.

concussion protocols
Time for a time out?

It’s also encouraging to hear that the EWS is collecting data about injuries, and that that this will be released for use in studies. Chris Ball says:

We’ve been conducting a medical survey for the last two years to not only better record and understand the injuries at our races, but to learn how to prevent them. We’re looking for correlations between things like trail design and weather conditions and how they contribute to injury rates and the types of injuries sustained. Once the survey results are all collated we’ll be publishing it publicly and it will be a free resource for anyone who wants to learn more about injuries and concussion in enduro racing.

Back to the NFL

Looking again to the NFL, it’s possible to see why this kind of data might be useful: it recently conducted a targeted intervention with seven teams that had higher concussion rates than was normal, with a reduction in concussion rates subsequently taking place in six of those teams. It’s currently hard to imagine such a coordinated and data reliant intervention taking place in the professional cycling arena, especially with such a fragmented set of event organisers and ruling bodies, and as yet the UCI does not have such a robust set of rules as the EWS or Crankworx – meaning that Downhill World Cup riders may not be being given the same level of protection. Certainly, Katy was left to make her own decisions about whether to ride:

“If I could go back I obviously would now sit out of the race but I just wish it had never been my decision to race”

When I took both my falls, I went directly to the medics and both times I was told I had concussion, or mainly Jake [Ireland, her partner] was told as I wasn’t quite all there, I had concussion but both times I was never told I couldn’t race. I was however asked on race day by the UCI if I felt ok and if I felt good enough to race, so they knew I had concussion but left me with the decision as to whether I felt ok enough to race. So ultimately it was my decision. Of course being a racer and getting wrapped up in the world and pressures of racing I went ahead and raced. Not knowing back then what I know now about head injures so of course went ahead and raced literally putting my life on the line. If I could go back I obviously would now sit out of the race but I just wish it had never been my decision to race, I just wish with the doctors/medics/UCI team knowing that I had concussion less than 24hours previous to race day, that they were the ones who could of made the decision and told me I wasn’t allowed to race.

The UCI told us that their rules are currently under review (though we’ve had no word on what form this is taking or the proposed timescale) but with just a single line in the current rules covering the matter (13.3.064 Any rider with a suspected concussion should be immediately removed from the competition or training and urgently assessed medically) there would appear at present to be a less comprehensive approach to the management of head injuries than in the EWS and Crankworx. As additional clarification, the UCI Press Office told us:

Under the UCI Medical Regulations, the organisers of UCI registered events have the responsibility to provide medical staff and equipment to ensure the health and safety of riders and all involved in the event. The UCI official doctor’s remit is to carry out checks of compliance with the UCI Regulations on the medical services provided by the organisers. This stands as the overarching framework to deal with signs or symptoms of a concussion on riders.

The difference in approach seems to be borne out in race experience. Katy says:

I know for the EWS and Crankworx events they have doctors on site and as far as I know if you fall and hit your head the doctors run a full concussion test with you and if you are showing signs of concussion they are the ones to say you can not race, which I think is the right way to go. I would love to see this in the downhill as well. I won’t go into detail but yet again I experienced similar treatment from the doctors/medics on site this year, still after a big fall the decision is still left in the hands of the rider as to whether they feel fit and well enough to ride. I know at the end of the day, riders are being paid a lot to race down a hill on a bike but knowing the consequences its not worth potentially a career ending injury. It took two years of my life from one stupid decision and I would hate to see that happen to anyone else.

Your head in whose hands?

Taking responsibility for your own safety is sensible – and you do it every time you get on a bike. But that’s not to say that our governing bodies can’t do more. Would a NFL style helmet grading influence your buying choices? Would knowing that you don’t need to be knocked out to be concussed help you assess your own fitness to ride? Would knowing that there are long term implications for both physical and mental health resulting from repeated minor head traumas nudge you into a prudent approach to self care? Quite possibly.

Our pro athletes perform for our entertainment and adulation. Their performance requirements push forward the technologies that we get to experience on our own bikes. Perhaps we all – fans, sponsors, brands, media, event organisers, governing bodies – owe it to them to ensure that they get the benefit of some of the workplace protection that the rest of us take for granted? And in turn, perhaps we all might benefit from the research and development that could follow? After all, what’s more important – a few grams shaved off your components, or the well-being of the grey matter in your head?

It’s great to see that the EWS and Crankworx are taking the issue seriously – let’s hope that the UCI review catches up soon.

Further reading.

If you want to know more about what to do if your friends crash, the risks associated with head injury, or the experience of living with the after effects, check out the following links:

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Comments (12)

    Don’t forget that the NFL spent years actively denying that concussion and head injuries had any lasting effect on players. This included paying doctors to go on record defending the NFL’s position and blocking/discrediting studies and evidence linking concussions to long term problems.
    More than 5,000 ex-NFL players successfully sued the NFL and are entitled to $5 million each.

    Scottish Rugby have been looking at impact head injuries and taking it seriously in recent years, also looking to the American football research. More research seems vitally important. The information in Singletrack 121 MIPS helmets feature about the findings of research into multiple small head injuries was pretty sobering (as someone who’s had a few non-bike related bashes including concussion around 20 years ago). And as several people in Hannah’s feature have said, getting more knowledge, information and advice out there to as many people as possible is hugely important.

    Interesting to compare to rugby (union as i watch these days, but expect League will be similar if not further ahead)…
    In amateur club rugby a KO in a game results in being stood down for 2 or 3 weeks min I believe (certainly used to be a decade or more ago).

    At a professional level, there are assessments during games after head collisions, and other ‘return to play’ protocols if confirmed as a concussion.

    Rugby has a LOT still to learn and improve upon, and there are still (luckily fewer these days due to public outcry) cases of players continuing after clearly being KOd or dazed (Georg North a prime example at at least one Northampton Stains game i recall, and for Wales too – not a swipe specifically at that club/country but a noted example).

    But what on earth are the UCI faffing about with to even come up with ANYTHING meaningful ( answer… nowt). Too busy avoiding sorting out doping. Oh and trying to stop innovative Scotsmen winning of course, history tells upls.

    One other point / Q. How much do american football helmets actually protect against concusssion ? From what i think Ive seen from BoD’s uncle (former advisor to IRB before he resigned due to not enough activity on exactly this topic) I had the impression that concussion was due to the ‘secondary’ bashing of the brain, not the initial impact (one reason it’s not necessary to be KO’d to get concussion).

    Great to see STW covering this extremely important subject, and featuring outside the paywall – it should stay!. This resonates with me, big road bike accident in 2016 – TBI, maxillofacial surgery, T7 etc. Head injuries are particularly hard on those around you. I was a a difficult patient and now realise that I’ve changed. I’m not the same person that I used to be, my emotions are different. The Kevin Pearce documentary was motivational and we need to heed the message ‘Love your Brain’. I’m certain that my helmet saved me from more serious damage, and further research across sports and consideration of the link to dementia is key.

    My understanding is that concussion is more a collection of symptoms indicative of mild brain injury than the injury itself (which can of course take many forms) – the precise definition varies, but loosely I think it boils down to ‘a head injury that leads to disruption of normal functioning’. There is apparently increasing consensus that (as mentioned in that MIPS article) torsional forces may play more of a part in concussion than direct impacts, which the brain/CSF system is slightly better (though far from perfect) at dissipating.

    Certainly it’s possible to get American Football helmets with MIPS, and I’m sure other systems, which attempt to increase protection from torsional forces.

    OK, I was trying to do something clever there and it clearly backfired. But my comment was directed at @robertajobb :0)

    Healthcare places a huge emphasis on ‘capacity’, which is the state of ability to correctly process available information and make decisions in their own best interests. As concussion has the potential to interfere with only certain parts of cognitive ability, leaving the impression of general lucidity with only a few specific symptoms, it seems clear that capacity may well be compromised and possibly not obviously so.

    It’s frankly unethical to allow concussed riders to decide for themselves – and that’s before you include emotive factors of competition or even fears of losing out on sponsorship!

    A really informative article on an important topic – not seen anything like this on the other mtb sites so good to see Singletrackworld taking a lead on this.

    With that in mind, is there a case for leaving this article outside the paywall permanently?

    The ironic issue you have hit upon is that since it’s so important it should be behind the paywall. It’s a very expensive feature. Hannah is a salaried staffer here and she spent a great deal of time on this. That’s cost us quite a bit, because, well, good content is expensive. Advertising doesn’t cover anywhere near the cost of production of an article like this anymore. Behind a paywall we can cover the costs and more and therfore invest in commissioning more content like this. It’s a pickle for sure innit?

    However, as an Online Feature it’s not paywalled off at a price. Registration is all that is required and that’s free. If the article is that good I’m sure a 1 minute registration to view it is worthwhile.

    And if there’s a consensus that content like this is popular, important and we should do more of it, then subscribing is the best way to help us make that happen. We absolutely love making content like this. Content that is important, useful and worthwhile. But it’s really bloody expensive and we need the support of you guys to make it happen. This is what we can do if we get your support.

    Thanks for the reply, Barney.

    I remember in days of yore, canoeing helmets often had a cradle inside the helmet that sort of ‘suspended’ the shell off your head. Some where the original fairly naff ‘Ace’ ones from the 70s. But others were some of the leading kit at the time (eg from Romer for those of a cetain age and paddled). Interesting the cradle arrangement seemed to fall out of favour in kayaking. Maybe they were onto something without knowing it ?

    I’d like to see some of the MIPS research / testing done with more lifelike test heads. Ie with something that simulates flesh/skin and hair on the head, rather than the bald hard aluminium heads. I realise thw Alu heads will make the results more repeatable. But nonetheless I’d like to see how MIPS performs with the more realistic layer that exists on most people’s heads (even Kojak has a scalp that can move around a good few mm in an impact and possibly reduce the loads on the brain).

    Anyway. Great article, and well worth my subscription ! Keep stuff lile this coming please, its this kind of quality article that does differentiate ST from Surrey-centric publications.

    I can’t speak for MIPS, clearly, but I’ve heard quite a few people put forward the argument that skin and hair would do that job.

    I think that alloy heads packed with gear are the state of the art as far as physical testing is concerned; the computer modelling they do (although it’s never going to replace real-world testing) does contain information about skin, bone, CSF and Pia and dura mater as well as a surprising number of brain substructures (eg cortex, cerebellum, hippocampus, corpus callosum and brainstem), all of which have varying densities and as such will react differently when subjected to the same shear forces. As I understand it, the primary issue is tearing around the meninges on the surface of the brain – subdural haematoma. Essentially if you experience enough force to start tearing the substructures about you’re pretty well screwed regardless if what you’re wearing on your head.

    But to go back to the skin thing – the CSF also plays a role in preventing rotational brain movement like this… but the idea of MIPS and their competitors – POC, Kali etc (but I’ve not spoken to them yet) is to give the helmet as much float as possible, regardless of skin or hair. MIPS aim for at least 10-15mm of ‘float’ when subjected to shear forces, but of course, more is better. If your skin also gives you a few mm of stretch/flex/whatever (remembering that skin anchoring and elasticity varies from location to location and from head to head) then that’s all to the good, right? Certainly, this new way of testing stuff is a massive step in the right direction compared to just designing lids around the previous tests…

    The EWS and UCI should use the Sports Concussion Assessment Tool (SCAT) and make it compulsory for all athletes to submit their baseline rests at the beginning of the season so that in the event of an accident they can retest and compare to the original. That way the pressure is removed from the athlete, his sponsors and the team.

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