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The Time to Rethink the Cycling Concussion Protocol Is Now

By William Fotheringham | Images by Chris Auld

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It wasn’t the way anyone would have wanted Romain Bardet’s Tour de France to end. A crash 90 kilometers from the finish of stage 13, a struggle to get back in the race, time lost at the finish, and then a visit to hospital where concussion was diagnosed, resulting in his immediate removal from the race. Saturday afternoon, Bardet issued a statement saying he had suffered a small brain hemorrhage, he was still suffering from headaches and nausea, and it was uncertain when he would return to racing.

By William Fotheringham | Images by Chris Auld

For the French star it was a bitter end to his final Tour de France with the AG2R team that has been his home since he turned professional, the more so because he had been moving inconspicuously yet effectively around the upper reaches of the overall and looked set to push for a top six placing overall – perhaps even a slot on the podium or a major stage win – when the race reached the Alps. 

But the incident had wider ramifications due to the fact that Bardet had raced the final 90 kilometers of the stage while suffering the after-effects of his crash, and by his own admission “feeling groggy.” The UCI’s concussion protocol on its website is relatively brief, but states the following: “Any rider with a suspected concussion should be immediately removed from competition or training and urgently assessed medically.”

Romain Bardet (front rider) finished stage 13 despite suffering a head injury in a crash and “feeling groggy.” Image: Chris Auld

Clearly in Bardet’s case that did not happen. It is not the purpose of this article to point the finger at one individual case, but the episode should prompt a rapid re-examination of cycling’s procedures around concussion. That’s all the more urgent given the recent wider discussion around rider safety in general. Concussion has rightly become a live issue in contact sports such as rugby with the introduction of strict protocols and cycling needs to become far more aware of the issue and work harder to mitigate it.

There are some very obvious issues in dealing effectively with concussion in a bike race. The principal one is this: there is extremely limited time to carry out any form of protocol in a way that allows the rider to be evaluated properly while keeping him or her within the race. Simply put, it’s not practical to spend 10 minutes checking out a rider at the road side and then expect them to get back into the bunch, short of bunging them in a car and driving them to the rear of the convoy.

There’s more. In contrast to a soccer or rugby match, crashes in a bike race can involve multiple casualties, up to 15 or more at a time. Moreover, if there is one crash, there is perfectly likely to be a second or a third given that road conditions and rider nerves will play a key part. The obvious example here is the Tour’s opening stage in Nice, where there was one crash after another due to “summer black-ice.”

Medical personnel will be stretched covering one incident let alone multiple ones within a short time frame. Add in the fact that a major bike race can be spread over a large area – half an hour or maybe 20 kilometers of road – and the difficulties are obvious. Then there is the fact that many races – not just at WorldTour level – involve multiple nationalities presenting language difficulties for race doctors.

There are various ways in which the current protocols could be improved. One would be to formalize a two-stage protocol, with, first up, a basic and rapid roadside assessment carried out at the crash site before the rider gets back in the saddle. This would involve four or five basic questions and a rudimentary balance test – the rider stands up with his or her feet together, closes the eyes and tilts the head back. If the rider passes, they could then be put back on the road and helped to regain the bunch. More detailed and more complex tests could be carried out on the move from the race doctor’s car at the back of the peloton.

The question of who carries out the roadside tests is critical. As one doctor involved in cycling for three decades told me, typically at a serious crash, if the race doctor is on site, he or she will – understandably – be focused on the rider (or riders) who are immobile, probably with broken bones. A head injury victim may not be that obvious, and quite possibly will be among the “walking wounded”: those who can stand up and get back on their bikes.

The immediate solution, at WorldTour races, is to make it compulsory for teams to have a doctor in one of their race convoy vehicles, something which some if not all teams do already. That immediately increases the number of available medics and makes it more likely that a doctor will be on site along with the race medical staff to deal with “walking wounded”.

The presence of a team doctor would take pressure off the DS when it comes to pulling out a rider with possible concussion, and it is also more likely that a rider will trust his team doctor than a race doctor when it comes to making the call. Additionally, a team doctor should know his rider and would more likely be able to tell if something is not right.

The protocol should also make it compulsory for a team doctor – or anyone else – who has carried out an immediate first-phase assessment to take the rider’s race number, and advise the race doctor who can investigate further as soon as possible. This is particularly important as concussion can be delayed – an initial head injury might not seem suspect but could be aggravated later in the race.

Teams should also mandate one person who has been trained to carry out the basic initial test to travel in their other team car, because there will be occasions when the team doctor is not available. Typically at a crash site, the person who will get out of the team car and go to assist riders is the mechanic, so most logically it would be him or her who is trained up. It would also make sense for national federations to train up those who run non WorldTour teams, particularly those who drive regularly within race convoys.

There are other steps that can be taken to ensure riders cooperate. One is to make them aware of the protocols through education and communication via team doctors, so that the rider knows that if he or she crashes and hits his or her head, this is what will happen. Some doctors probably do this before the start in any case, as it is sensible medical practice. That will reduce the possibility that a rider crashes, has a head injury, but continues regardless because of a fear that the delay for assessment will affect their race.

A further one would be for teams to be mandated to supply race medical personnel with head injury history for their riders, to ensure that “baseline neurological function” is readily available for in-race assessment.

You can only wish Romain Bardet the best recovery possible and a rapid return to racing. For the future, expanding that protocol should be a priority, but the most important aspect is to take account of what happens in bike races in real life. None of this is simple in the dynamic environment of a bike race, but only then can it be truly said that this issue is being taken seriously.

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