The chronic effects of concussion.
Anybody who pursues a career in mountain biking is inherently aware of the risks. It’s unusual to find a top racer who hasn’t broken a bone – it comes with the territory – and when you pitch competitive people on bikes against mountains, accidents will happen. Largely, we accept these risks and for the most part, serious injuries are rare, though finding data and quantifying serious and non-serious injury is a moot subject. Nevertheless, we know what we’re getting into when we swing a leg over our bikes.
In the same way that strains, sprains and fractures constitute a scale of injuries that affect bones and joints, brain injuries similarly occur across a range of severity, from concussions, through contusions, to lacerations.
John Waddell was in his prime. Riding for the Intense Tyre/Santa Cruz team, John was a rising star of World Cup DH. Like many of his Aussie peers, John was focused on racing World Cup DH, and succeeding at his chosen sport. At the 2003 Mont Sainte Anne World Cup, John’s life would veer in a direction that no one saw coming.
Coming into the infamous 65-foot double jump with too much speed, John got bucked mid-flight. Going over the bars, his head took the brunt of the impact.
Since Waddell’s crash in 2003 the sport of downhill mountain biking has progressed massively. The market for mountain biking is bigger, the tracks are faster for TV marketability and the equipment and training knowledge we have has transformed the performance level that athletes are able to consistently achieve. Helmets are better, body armour has been revolutionised, and overall the sport is in a great place. Yet there are areas of this discipline, and mountain biking as a whole, that haven’t kept up.
We aren’t the first sport to witness first-hand transitionary periods where elements of the sport progress faster in some areas than others. In the 1960’s, Formula 1 was at its most exciting and arguably most dangerous. Jackie Stewart, three-time World Champion, knew the dangers of Formula 1 first hand, having seen many fellow drivers die in tragic accidents. Stewart, along with the late, great Formula 1 Medical Officer Sid Watkins, lobbied hard for improvements to be made and in time, Formula 1 evolved from a sport where young men went to die, into a sport where death has mercifully become the exception rather than the accepted.
What is interesting though, is that prior to these changes becoming enforced, Stewart hired his own private doctor to travel with him to all races. Chastised at the time for being ‘unpure’, Stewart was far from the ‘weak’ character many claimed him to be; conversely, he was incredibly tough for proving you could both win and be safety conscious. Through his actions, Stewart directly shaped the future of Formula 1 and we’ll never know how many lives he indirectly saved.
Of course, the two sports are very different and crashing at 165mph is a whole different world compared to crashing at 40mph. Yet, head injuries don’t need an excuse or a certain speed to occur.
John Waddell spent 26 days in a coma, but has gone on to make a tremendous recovery, even racing the 2007 24hr World Championships . Credit: Russell Barker
Eventually John returned to MTB, racing marathon events, including the epic 2007 24hr World Championships. His story is one of the most positive outcomes we’ll see in sport and furthermore, John’s life now has a sense of normality and his future looks bright.
However John’s crash, some 13 years ago, should have served as a warning sign. While his injury was indeed at the more severe end of the Traumatic Brain Injury spectrum, as a community we have largely ignored the seemingly lesser injuries of concussion, which, we are now discovering can lead to devastating consequences, as bad if not worse than the more obvious TBI’s, if not managed properly.
Recovering from a brain injury is not as simple as mending a broken bone, and as mountain bikers racing at Elite level in DH, Enduro and Freeride (and further) are starting to discover, concussion is very much the elephant in the room.
Concussion, from the Latin concutere (“to shake violently”) or concussus (“action of striking together”), is the most common type of Traumatic Brain Injury.
One of the biggest problems of putting this article together was the alarming lack of data available on concussions among Elite World Cup DH riders, or any other discipline for that matter.
The issue is further muddled by the fact we are dealing with racers who will choose to race even with the odds firmly stacked against them and the fact that diagnosing a concussion is the job of a qualified healthcare professional.
We spoke to many riders and nearly all said they’ve raced a World Cup race with a concussion or symptoms aligned with concussion. Furthermore, we aren’t just talking about single concussions either. Successive blows to the head can cause equally as much damage even if they are less severe, with the effects being cumulative.
This way of thinking is alarming, but not unexpected. It’s time we were aware of the damage that this can do to our long term health.
A simple way of thinking regarding ‘cumulative’ – rather than simply repeated – blows to the head is that 2+2=22, not 4. Two mid-grade concussions, not too far apart in time, may result in an extremely severe concussion, with potentially life-changing outcomes.
A good analogy is the Richter Scale used for earthquakes, which is a base-10 log scale, with each successive step being not 2x but 10x the severity of the former.
In short, we know riders are racing and competing with concussions and after bangs to the head, we have no idea what is going on inside their brains when they do this rarely and even less so when they do this repeatedly. We don’t know how many times they have suffered a concussion, we have no return-to-race program, no formal medical director on site and at the moment, no power to stop them breaking the beam when they are not fit to race.
We aren’t the first people to notice this state of affairs and in 10-15 years time, we could have a serious problem on our hands with today’s riders having to deal with the most devastating consequences.
After watching countless World Cup DH racers on the Red Bull TV live feed, emergency doctor Colum O’Hare contacted Wyn Masters (a vocal advocate of rider safety on social media), to discover more regarding the safety protocols in place.
There is a legacy of ” toughness ” that surrounds sport, and as they say; courage is the finest of all traits, as all others are derived from it. Yet we are talking about peoples lives here and riding with a concussion is not a case of riding through the pain barrier, being made of steely stuff or however you want to describe it.
So far, 87 deceased NFL players have been discovered with CTE on examination. So just what is CTE and why should we be aware of it?
CTE, or Chronic Traumatic Encephalopathy, is a result of repeated concussions or blows to the head. It is formally described as a form of tauopathy, a progressive degenerative disease found in people who have had a severe blow or repeated blows to the head.
For those that dismiss the notion of severe blows occurring when wearing a full face helmet, Dave Mirra was diagnosed with CTE upon his autopsy following his tragic suicide. CTE can technically only be diagnosed via autopsy, although the tell tale signs can be spotted through the use of fMRI (functional MRI), PET (positron emission tomography), and various specialist MRI scans, as well as some more specialised scanning techniques.
However, awareness is key and in the past, many have mistaken the symptoms of CTE, leaving the sufferer ostracized, alone and confused about why they feel like they do.
“After a certain number of blows to your head, nobody knows exactly what number, your brain resets itself and begins to initiate abnormal biochemical cascades that result in the buildup of abnormal proteins like tau. So by the time tau is accumulating, the injury is already done” – Dr Bennett Omalu
We all know that blows to the head are not uncommon in DH, enduro, and even general non-race riding (let alone events like Rampage). And serious head injuries aren’t just the preserve of professional big, butch male riders taking savage blows.
Lorraine Truong is slight of build, determined by nature and was riding for the BMC global team when, after a series of prior blows to the head, she had a hard impact at the Samoëns round of the EWS in July 2015. Lorraine’s story is one of personal struggle at an age where she should be in her mental and physical prime.
“It was in the first stage of the 2nd day, and I think I went over the bars when my front wheel hit a hole or something. I don’t remember it really, but think I remember going forwards and thinking “it’s gonna be ok”. -Lorraine Truong
Lorraine completed the race, and even grabbed an 8th place finish
“ I have a memory of being in the last stage, stopped, with tape all around and thinking: “Where I am? What I am doing?” Weeks later I saw that I gave an interview after my crash, but I have no recollection of it. So in short, I finished the race, having no idea how I did it.” -Lorraine Truong
Since that moment, which was a small crash in a line of prior crashes, Lorraine’s life has been transformed into something no-one could have predicted.
“ Soon I had to face it wasn’t fine at all. The headache was crazy, I needed to vomit all the time, light and noises were driving me mad, I was struggling to speak, my body wouldn’t respond, each tiny task was a huge effort, my mind was so cloudy.. something was wrong.” -Lorraine Truong
Tracy Moseley, one of the most decorated ever to race a mountain bike adds some insight into the psyche of athletes, and this applies to athletes across the board, not just professionals.
“ Having studied Biology at Uni I have always had an interest in the human body and especially the anatomy and physiology and what makes us work. I always had an understanding that hitting your head a second time in close proximity to a first hit, was not good….but that was as far as my understanding really went when it came to concussion !
I think like most athletes, you often don’t think that any of the problems you hear about or potential dangers of our sport will affect you, when things are going well you feel invincible and the drive to succeed and be the best can often overshadow and push away any concerns you have with your health or injuries.” -Tracy Mosely
A year on from Lorraine’s initial crash, life has not improved. With a history of bangs to the head during the three years leading up to that Samoëns crash – bearing in mind the cumulative effect ( crashes often occured outside of races as well) – Lorraine is acutely aware of what she faces and is focused on staying positive, yet that doesn’t make it any easier for her.
“ Since the crash, I haven’t had a day without headache. Going from being a junior engineer, who used to be able to do her mathematical analysis homework while following a class of quantum mechanics, to a person who struggles to write this text, having to look at it with a massive font size to be able to read it and have to take breaks every 10 minutes or so, is a massive change in my life and also in my self esteem. I was a young rider appreciated for her riding style and with a bright career ahead; now I am a woman who walks with a stick. It’s hard to hold on. Most of the time I feel very ashamed of myself. Despite all I’ve learnt and am still learning about brain injury, I still have that inside voice that tells me it’s nothing. That if I was stronger I could de more rehab and get better faster. I’ve only hit my head a bit! But how to fight what your own central computer can’t achieve? I often feel crazy and so desperate that the only way I see to make all those symptoms stop is not a way where I am alive. Luckily, my sport doc has always backed me up, is kind and compassionate and allows me to take my time and to rest as much as I can. I also sometimes read or meet someone who’s been through the same kind of journey or a doctor who actually understands, reminding me that I am not alone and that all this is not my fault, but that I am wounded.”
At the top of global cycling and hence mountain biking, sits the UCI. They are indeed aware of the issues that concussion can present. I spoke to Ton Zasada, the UCI medical officer. Ton is not on site at World Cup races but has prepared some documentation for the Local Organising Committees (LOC), which reads like a plan that makes sense.
“ For appropriate clinical evaluation for suspected concussion, for concussion management and return to training and competition, doctors should refer to the Sport Concussion Assessment Tool 3 (SCAT 3). However, the SCAT 3 should not be used solely to make, or exclude the diagnosis of concussion in the absence of clinical judgement. A rider may have a concussion even if their SCAT 3 is “normal”. I want to emphasise that when there is any doubt, then the rider should stop training or competition immediately” -Ton Zasada
Ton is a decorated GP and has been around the scene for a long time.
“ Every experienced race doctor will have had at least once a discussion with teams and will remember the pressure they tried to put on us to let the rider compete. Never there should be an emotional or commercial argument that affects the medical decision. ” -Ton Zasada
It is clear there are many strands to the web here, not least the commercial interests of teams and sponsors, as Ton continues.
” I think it would be a great step forwards, if the people who are living next to the rider would be paying more attention to the signals of a concussion and undertake action when there is a suspicion. And, like I mentioned in my document, the drive to achieve sport results should not make people blind to this. So an appeal to all the people who are living close to the rider and all the stakeholders may be helpful”-Ton Zasada
So why aren’t these procedures being implemented by the LOC or medical staff at World Cup DH races and why on the UCI Sport Mentoring program are there no DH riders listed? And are team managers and riders themselves doing enough ? The medical regulations of the UCI medical regulations state:
The medical regulations of the UCI medical regulations state:
“At cycling events, it is the responsibility of the team or race doctor, if any, to determine whether an injured rider may continue in or return to the competition. This decision may not be delegated to other professionals or personnel. At all times, the priority must be to safeguard the health and safety of rider. The potential outcome of the competition must never influence such decisions.
If the team doctor and the race doctor have a different opinion on whether the rider may continue or return to the competition the rider shall not continue or return to the competition. “
Of course, we have focused heavily on racing in this article, but sole responsibility does not just lie with the UCI, EMBA or other organisers. There should be a collective drive towards rider protection and that includes riders themselves being educated about the consequences. A head injury can occur at any point, and as shown in Lorraine’s case, her EWS crash was the tipping point on top of other concussions sustained both in and out of racing.
“I am all for a good show and crashes are a part of the sport for sure, but there needs to be some way to make sure the rider safety is taken care properly, the rider is the last person who should be deciding if he can ride following a concussion, especially as there is also financial and outside pressure on them already to be competing, and when you hit your head your brain doesn’t work as it should normally so how can you make a good decision? I hope that some systems can be brought in to manage rider safety more effectively and in the near future” – Wyn Masters – Wyn Masters
“ It was only this year that I realised how much of a serious injury concussions actually are and with how much respect they should be treated, I had a crash in Lourdes and it caused on going issues for a month or more, during which time I have done plenty of research and almost feel bad for not knowing how serious these injuries really are, even just one can be enough to cause serious and potentially life changing effect especially if it isn’t treated right. The general attitude from what I have seen from my years racing is that following a concussion you just to get on with it and it will be alright. I have seen so many crashes and people with serious concussion’s within the World Cup racing over the years and even this season and generally the riders are racing the same or the following day. That is just wrong, and for sure the riders need to be more informed of how much risk that poses to their future health and wellbeing, no race is worth long term health issues, full stop” Wyn Masters – Wyn Masters
Armed with a better grasp of the problems we face, how can we, as a sporting community, develop a pathway to tackle a problem that might not arise for another 5-10 years, if at all?
While for many riders concussion is a subject they don’t want to spend much time thinking about, for obvious reasons, some are looking at the future and life beyond the bike.
Chris Kilmurray – coach to a raft of top EWS and World Cup DH riders – understands the mechanisms of head impacts better than most, and takes steps to protect his riders wherever he can. On-site at a lot of races, and a driven, good rider himself, Chris has a clear idea when it comes to this topic.
The SCAT ( Sport Concussion Assessment Tool ) procedures have helped considerably but as world famed neurologist Paul McCrory states, these are constantly being redeveloped to match with new research and knowledge.
“ We should treat any bang to the head as the worst possible scenario – and there is absolutely no return to play on the day – amateur , elite, child. The reason we treat any symptoms at all as a concussion is that we have became less certain about our sideline assessment”.– Assoc Prof Paul McCroy, Neurologist
The Return-to-Play pathway is something we can use as a model to build upon. Chris Ball, EWS director is well aware of the risks and has a track record of implementing positive change in mountain biking
“I began work back in January on a database that I intend to grow into an injury monitoring database for our riders. We’ve invested heavily in this and we plan to educate managers and riders to keep this up to date outside of EWS races as well. The issue is hugely complex and isn’t as simple as saying “lets have a doctor on site”. I want to build the data first so we know what we are dealing with, and how we can best protect the riders health. In my experience over the years, the biggest problem has been team managers, I have stopped one woman racing a World Cup once (ED: Chris was UCI Technical Delegate), way above my pay grade, but she had been taken out of the medical room by her manager after a massive head injury.” – Chris Ball, Enduro World Series
Recently, AMA Supercross became the first motorised sport in the world to implement a concrete pathway and protocol when concussions are concerned. To compete in the AMA series, every racer must undergo a baseline test before the start of the season. In a recent RacerX article, Asterix health care professional, Eddie Cassilis, gave some insight into what they are doing and why.
“ We have a baseline test that every rider has to take. In the event that we find the rider did have a concussion at the race, then we require them to take the ImPACT test and pass that before they can return to the races. If we’re trying to determine if the rider had a concussion at the event in the first place, we use what is called the SCAT 2 test. They are taken into our rig—by themselves, parents are not allowed to come with them—and we test memory, short and long term, balance, coordination. We have a minimum score they have to reach in order for us to have confidence that they can race or not” – Eddie Cassilis – Asterix health care
AMA Supercross is currently the leading light in managing these situations, and with the introduction of SCAT 3, there are people constantly seeking to improve procedures. However, AMA SX is financially light years ahead of mountain biking and we need to be pragmatic.
“ I have to mention that a ton of head injuries, including a lot of Lorraine’s, happened out of competition. So to focus as much on EWS and WC racing is to miss a vast amount of rider injuries. That’s why I feel focus needs to be on education, a centralised database of info that the manager and rider have to understand that they need to keep up-to-date. Otherwise, for example, you could have a rider turning up at an event, concussed, with no record or knowledge anywhere of that injury. I have also witnessed one of the sports most known team managers allow his rider, who was concussed during training, having not seen medical, race in the afternoon. I was shocked, but again that would have flown under the radar of any doctor.”– Chris Ball, Enduro World Series
There are of course influences that need to be considered as the sports of EWS and DH get commercially bigger. We need to make sure that procedures are followed as best we can, and ad-hoc decisions aren’t made.
Riders and teams have sponsor obligations that need to be respected and we can’t just witness a crash and rule someone out of competing because it looked ‘a bit rough’.
An on-site medical director has many potential benefits, not just medically, and also helps to portray our sport as outwardly more serious, with a correspondng big marketing potential. Bear in mind that in Formula 1, Professor Sid Watkins became a marketable asset in his own right for companies brave enough to embrace a personality that, by default, they couldn’t have control over, although in mountain biking there are currently financial obstructions to making this happen, which will require an industry-wide push to overcome.
Racing is a career for the top riders and at every opportunity we should be giving them the chance to go out to do their job, but at the same time, we need to be acutely aware of the devastating effects that concussion and CTE can have on individuals, families and friends. Furthermore, we can affect change from the top down.
“If changing culture is core to a longer-term improvement in concussion ‘issues’ in the sport, then the top down approach may very well educate the grassroots faster than we think…just like you choose your tyres based on what your favourite rider runs, if the top dogs don’t ride when ‘zoned’, your weekend warriors will be less likely to as well.” Chris Kilmurray, Point One Athletic
The testing procedure at races needs to be entirely independent and carry ultimate authority – it should be free from sponsor, parent, relative or other influences.
Of course, how we find a team of health care professionals or doctors for the year is an issue that needs to be broached. A rounded, collaborative financial funding model would surely be attractive, and this is a discussion for the main players: manufacturers, major sponsors and other key stakeholders.
As far as a route forward is concerned, I believe a five point program going forward should include:
– Build awareness in the wider mountain bike community of the potentially devastating effect of multiple head injuries, and establish a working group made up of all parties to develop a framework for education.
– Implementation of baseline testing (fMRI or similar hospital-based test, together with a cognitive SCAT3 ) for UCI World Cup DH riders and EWS riders. This will be voluntary to begin with but all UCI Elite teams and EMBA teams should be actively encouraged to participate. This is repeated every 12 months with spot tests throughout the year in case of crashes outwith races. People are already exploring creative ways of making this financially feasible.
-Provide any on site medical officers with ability to make an absolute, final decision on whether a rider is allowed to race or not based on a SCAT 3 or similar assesment. A team of healthcare professionals on site to make initial, fast reaction, trackside assessments. We must frame this for what it is – A long term health benefit to the rider.
– Open a dialogue with all key stakeholders to create a finance initiative to create a feasible solution and ensure that the rider rep is involved in this process that also covers new developments in tech or procedures.
– Build a support structure for riders who may need to take a long term rest from competition due to risk or long term damage.
The medical science in proven, the desire for improvement in management is clear and as Professor John Pickard states:
As you know, there is now worldwide concern about sport related concussion – it does not seem sensible for every sport to develop its own guidelines, but it is essential to document the extent of the problem in each sport and the evidence for what components cause the concussion.” – Prof. John Pickard, professor emeritus of neurosurgery, Department of Clinical Neurosciences, University of Cambridge
This is not a case of what we can afford, it’s a case of what we can’t afford to ignore. The time for action is now.
Join the debate about head injury awareness on social media by using the hashtag #InForTheCount
For external referencing or to learn more about concussion you can use this link Trip Database and you can also get involved at Love your brain and at Headway – a brain injury association is a charity set up to give information to people about the signs and symptoms of concussion and support to those affected by brain injury.