Concussion in Road Cycling

The authors of an April 2019 paper that systematically reviewed all literature on concussion and concussion management in road cycling call for a cycling-specific concussion protocol. They call upon the Union Cycliste Internationale (UCI) to hold a consensus meeting with road cycling medical teams to develop this cycling-specific concussion protocol.

The Need for a Cycling-Specific Concussion Protocol

Cycling reportedly accounts for almost 20% of concussion cases in the U.S — the highest percentage of any sport

Cycling reportedly accounts for almost 20% of concussion cases in the U.S — the highest percentage of any sport (1). In an analysis of Tour de France races between 2010-2017, concussions accounted for just over 2% of the injuries suffered by professional cyclists (2). More generally, concussions account for 1.3-9.1% of all injuries in cycling events and this rate is increasing (3-6). Concussions in cycling not only place the injured athlete at risk of short and long term harms, but an undetected injured athlete may also cause an accident (for example, due to a lack of balance which is a common side-effect of concussion), thereby potentially harming other cyclists (7).

Current Cycling Guidelines

Unfortunately, there is no internationally agreed-upon protocol for concussion in cycling.

Given the prevalence and consequences of concussion in cycling, it would thus be expected that there are cycling-specific concussion diagnosis and management protocols, yet this is not the case. Unfortunately, there is no internationally agreed-upon protocol for concussion in cycling (8). The UCI and the American Cycling Association (ACA) recommend using the SCAT5 and SCAT2 respectively to diagnose concussion in road cycling. These recommendations are problematic (9). The SCAT2 is out-of-date (having been created in 2008) and the ACA guidelines are largely meant for education and providing a means in which a team can put in place SRC diagnosis and management processes that are “a bottom line of best practice on which team medical staff can build on.” While the SCAT5 is the latest concussion tool published by the Concussion in Sport Group in 2016, this UCI recommendation remains problematic because the SCAT5 requires modifications in order to be relevant and effective in cycling.

Further Cause for a Cycling-Specific Protocol

There are specific challenges that come with assessing concussion in cycling more generally, such as: the fast pace of the sport and the “remote nature of medical monitoring for cyclists” given that sometimes cyclists are in one country and the medical team is in another (10,11). Ultimately, simply using generic concussion tools is not adequate because they do not address the unique qualities of road cycling.

How to Move Forward

Very few studies have examined this issue and the two studies that were reviewed for this paper’s systematic review make broad statements that are not helpful in further developing a cycling-specific protocol (9,12,13).  Some specific recommended developments/changes that the authors of this paper have suggested are to:

• Use real-time and replayed television images to create a concussion spotting system;
• “Motor-pace” a cyclist back into position after they are assessed for concussion to reduce the negative impact a concussion assessment may have on the individual/team’s performance and position;
• Change the Maddocks questions to include cycling-specific questions such as: what is the name of the race, how many kilometers are left in the race, who is the road captain, what was your last race, and what is your coach’s name; and
• Create a central injury database to understand patterns of injuries which will, therefore, help develop methods to reduce concussion incidences in cycling.

Other changes that could be made are:

• Adopt the saying ‘if in doubt, sit them out’ as per many other sports worldwide;
• Provide the cycling concussion guidelines in multiple languages to reflect the internationality of the cycling community; and
• Potentially consider an independent evaluation to ensure adherence to the concussion protocol (14).

Considerations also need to be made for both medical and non-medical roles — such as neutral mechanics who may be the first responder at the scene of a concussion-inducing incident.

Any adaptations also need to be evidence-based which means more research must be done specifically on concussion in cycling and what changes will make: 1) the sport safer and 2) concussion diagnosis and management effective in the cycling environment.

The paper can be found here: https://bmjopensem.bmj.com/content/5/1/e000525.

Works Cited

• Nonfatal traumatic brain injuries from sports and Recreation Activities—United states, 2001-2005. JAMA 2007;298.
• Haeberle HS, Navarro SM, Power EJ, et al. Prevalence and epidemiology of injuries among elite cyclists in the tour de France. Orthop J Sports Med 2018;6.
• Roi GS, Tinti R. Requests for medical assistance during an amateur road cycling race. Accid Anal Prev 2014;73:170–3.
• Emond SD, Tayoun P, Bedolla JP, et al. Injuries in a 1-day recreational cycling tour: bike New York. Ann Emerg Med 1999;33:56–61.
• Decock M, De Wilde L, Vanden Bossche L, et al. Incidence and aetiology of acute injuries during competitive road cycling. Br J Sports Med 2016;50:669–72.
• Yanturali S, Canacik O, Karsli E, et al. Injury and illness among athletes during a multi-day elite cycling road race. Phys Sports med 2015;43:348–54.
• McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5 th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;12.
• Echemendia RJ, Meeuwisse W, McCrory P, et al. The sport concussion assessment tool 5th edition (SCAT5): background and rationale. Br J Sport Med 2017;51:848–50.
• McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport – the Third International Conference on Concussion in Sport held in Zurich, November 2008. Phys Sports med 2009;37:141–59.
• Hutchinson J. California bleeding. shocking moment 50mph cyclist crashes out of tour of California.then is nearly mowed down by rivals. The Sun
• Sport concussion assessment tool – 5th edition. Br J Sports Med 2017;51:851–8.
• Gordon K, Do MT, Thompson W, et al. A ‘knock on the noggin’. Paediatr Child Health 2013;18.
• MR, G. An epidemic of traumatic brain injury in professional cycling: a call to action, 2012.
• Rules and Regulations. [online] UCI, 2018.