Road racing is one of the most dangerous endeavors in cycling, perhaps in all professional sport. It takes place in an uncontrolled environment, in all weather conditions, as nearly 200 riders frequently traveling at high speed compete for place (and space) with hundreds of accompanying cars and motorbikes. Injuries are common, endemic to the sport. By stage 9 of the 2011 Tour de France, there were 14 broken bones, 16 riders retired for medical reasons, and 1 was being treated in an intensive care unit.1
Professional cycling experienced a devastating year of traumatic brain injuries in 2011. On May 9, 2011, Wouter Weylandt died as a result of traumatic brain injury on a descent during the Giro D'Italia. Colombian cyclist Juan Mauricio Soler experienced devastating neurological injury in June from a crash at the Tour de Suisse. In the 2011 Tour de France, Jani Brajkovic, Tom Boonen, and Chris Horner withdrew from the event after concussions. Many other riders at the top level of the sport have experienced concussions in competition or training.
Among the challenges faced by medical staff covering cycling events are the absence of sidelines, no timeouts, and no substitutions. When evaluating head injuries, including concussions, physicians cannot apply the standards of care common in most other sports. Clinical guidelines such as the Zurich Consensus Statement on Concussion outline a range of symptoms that should trigger careful evaluation and indicate specifically that “it was unanimously agreed that sufficient time for assessment and adequate facilities should be provided ….”2 Such is not possible in professional cycling. On the side of the road, with the peloton racing away at 50 km/hour, medical personnel are required to make decisions in 1 to 2 minutes … if a cyclist is going to be able to return to the race.
The general practice is to perform a very brief assessment of the rider and, as long as they are able and willing to get on their bike, to allow them to do so. To catch up with the peloton, the rider then must race at top speed, among other speeding vehicles on winding roads. Medical staff concerned with an athlete's well-being will often accompany the rider, keeping them under close observation until the finish where a more detailed examination can be performed.
This is far from the pattern and standard of practice in other sports. Fundamental concerns remain as to the safety of a potentially brain-injured athlete being allowed back on their bike. With compromised cognitive functioning, delayed reaction times, and impaired coordination and balance, there is significant chance of reinjury with potentially devastating consequences to the rider … and to other competitors.3–5
With insufficient time and resources to perform proper testing, decisions may need to be made based solely on immediately recognizable high-risk features of traumatic brain injury. Although loss of consciousness is far from a gold standard for the evaluation of concussion,6 it is an indicator of many forms of brain injury, and although not a key part of the current concussion in sport consensus, it has been used in the past as a grading measure for some concussion classification systems.7,8 Amnesia, another important symptom of concussion, is a more sensitive element of brain injury evaluation but generally requires interviewing the rider.6 We would argue that these 2 features of brain injury—loss of consciousness or amnesia—should be grounds for the removal of a cyclist from competition. This does not mean that cyclists without these symptoms are necessarily safe to compete, but rather that they are at particularly high risk for traumatic brain injury, and an immediate comprehensive medical evaluation is indicated.
The recommendation that riders experiencing a loss of consciousness be immediately withdrawn from competition was drafted by the Concussion Task Force of Cycling Medicine and has been presented both to USA Cycling and the Union Cycliste Internationale, the governing body of international cycling.
Much work remains in the development of evidence-based criteria for the return to sport of brain-injured cyclists. But, in a year marred by many neurologic injuries, there is a need for thoughtful action. We strongly recommend that cyclists at all levels of the sport be removed from competition and undergo a systematic evaluation after sustaining a head injury, resulting in a witnessed loss of consciousness or demonstrating amnesia, at a minimum.
The authors acknowledge the Medicine of Cycling Concussion Task Force. This group has been active in developing guidelines for the management of head injuries in cycling, including the recommendations outlined in this editorial.
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