October 7, 2020
In Part I of his commentary, we examined a recent crash in this year’s Tour de France where Romain Bardet was allowed to remount his bicycle, rejoin the peloton, and finish Stage 14 of the Tour de France after a crash resulting in a concussion. Agence France-Presse’s VeloNews entry explained that Bardet did not present clinical symptoms of a concussion at first, but that he became symptomatic after the finish and even asked his driver to pull over to vomit on the way to the hospital. “Paul-Henri Jost, a neurologist who examined Bardet during the stage, said the Frenchman passed the concussion tests. ‘He spoke clearly. He asked for painkillers and gave their names correctly. These are reassuring elements in a neurological examination’.” Televised viewers may have had a different opinion after seeing Bardet stumble.
Jost’s assessment of Bardet cleared him because cognitive symptoms were seemingly nil. Medical research, however, makes it clear that concussive symptoms may not be obvious immediately and may be delayed. Knowing what we now know about Bardet’s symptoms at the time of the crash, he should not have been allowed back in the race to finish the stage, both for his own safety, and the safety of other riders in the peloton. Regulations and protocols should be clear as to whether a cyclist should be allowed to continue to race or not, and not open to subjectivity.
Part 1 outlined why we believe that helmets alone are not enough – that they do not prevent or properly diagnose head injury. Additionally, we showed that the limited concussion protocol provided by the Union Cycliste Internationale (“UCI”) are not being adhered to by race directors, officials, or team management. We recommend a collaborative approach between riders, race organizers, team management, and regulatory groups that the UCI can take to improve its concussion protocol, including the implementation of new helmet technology and cognitive assessment exams.
Media coverage will almost always be unreliable on visualizing a concussive event. Instead, non-subjective data should be used to determine whether an impact has occurred. Products like “ANGI” (integrated in Specialized helmets) use a patented technology useful for diagnosing head injuries. The ANGI technology “analyzes and reports a collision….to a communication device controlled by user-designated persons.” Additionally, an accelerometer that signals when an impact surpasses a threshold eliminates the questionable occurrence of a concussion because of its binary nature – the rider is either safe to compete or not. Requiring athletes to use this technology could be the first step to improving the accuracy of diagnosis and providing proper treatment.
Victims of a head injury are often asked to take a cognitive abilities exam. SCAT is a common physical exam, while the ImPact exam is a detailed computer-only exam. The two are most effective when used together. But, without a baseline for comparison on a patient, the results of these exams are difficult to use for a proper diagnosis. Baseline cognitive assessments should be taken annually and held by team doctors for use in the case that a rider may have a severe or mild head injury.
A Collaborative Approach to Improve Concussion Protocols
Could Bardet’s crash have been prevented? A separate discussion, maybe, but Bardet’s treatment should have been different. Athletes that incur even mild head injuries are at far greater risk for another accident if reintroduced to competition too quickly, putting other riders at risk. Even mild concussions can cause brain damage. Further, a second head injury without proper recovery increases the risk of long term cognitive ramifications, coma and even fatality. In order to properly care for the well-being of professional cyclists, we must combine the suite of tools available to prevent injury whenever possible and properly diagnose a patient with a head injury when needed – as mild as it may appear.
Below are a list of seven actions the UCI can take to go beyond the standard protections that helmets offer:
- Annually mandate baseline SCAT & ImPACT exams for athletes
- Increase accountability of event organizers and the UCI for course safety
- Require that SenseTech LLC technology in helmets to be worn by all athletes
- Require live accident communication with team directors, UCI and race directors
- Provide comprehensive on-the-road medical assessment
- Provide a grace-period assessment for an athlete to rejoin competition
- Following a specific protocol, either safely re-integrate or side-line the athlete
A number of possible reasons exist as to why cycling has some of the most incomplete protocols and standards when it comes to sport related concussions in competition. Because implementation of concussion standards costs time, money, and complexity, both the UCI and race promoters appear disinterested at best, or at worst, reluctant because of the costs to implement extensive changes. The cyclist union, which is funded by both promoters and the UCI, also doesn’t have a strong enough voice to force change. There is the risk that riders involved will be black-listed for being troublemakers, finding themselves without a team, or left at home for the next race. The goal of the Pro Cyclist Foundation is to be an independent advocate for the professionals, one that is separately funded and not related to either the governing regulatory organization of the sport, race promoters, or team management.
Pro Cyclist Foundation
Denver, Colorado USA