Concussion Repercussions: The real consequences of head traumas in cycling

“I am still living it. People think I look fine, but I am not. My head is broken. It really is awful.”

Carmen Small, twice US national time-trial champion, crashed during the 2017 Ronde van Drenthe, landing on her head and losing consciousness. Six months later, the then-37-year-old announced her retirement from racing, as planned. Less expected was that now, two years after that seemingly relatively innocuous accident, Small was still suffering the consequences of her head coming into contact with the tarmac. It is a daily battle of blinding headaches, pain and frustration.

“It wasn’t like I had an extreme crash and was in intensive care for days. It was like a silly, normal crash – nothing special. I landed on my head pretty hard and was knocked out. But I had so many concussions prior to this last one that it really tipped me over the edge.

“I have headaches every day still. No one can help me. If I post something [on social media] then people want to tell me what to do. And they don’t know how many things I have tried. It’s not that I’m just sitting around feeling sorry for myself. I have gone to a lot of doctors, I have tried both Western medicine and homeopathic, and it’s really frustrating.”

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As we saw in the first part of this story in issue 18.3, complete recovery is not a given where concussion is concerned. And neither is treatment uniform across the sport. 

Toms Skujins, despite suffering a televised horror crash at the 2017 Tour of California, was right as rain within days. Brent Bookwalter, whose head smashed the rear window of a parked car in the same year’s Tour of Britain, took months to overcome the symptoms of headaches, nausea and motion sickness, describing the experience as “extremely debilitating and frightening, a wholly overwhelming phenomenon”. His team at the time, BMC, are thankfully one of the more advanced when it comes to concussion protocol testing. 

Matt Brammeier, however, was not so lucky after his 2015 crash at the Tour of Utah. The former pro, now a GB Academy coach, still suffers the after effects today, in the form of mood swings, headaches and inability to concentrate for lengthy periods. When his wife Nikki crashed at the start of the 2016 European Cyclo-Cross Championships, Matt’s unfortunate prior experience in the concussion field proved invaluable. She saw an expert back in the UK and was soon back to racing. Whether her team would have been in a situation to assist, in the cash-strapped and old school world of women’s cyclo-cross, is highly debatable. 

“That’s what I’m really frustrated about,” Small says, with feeling. “That I didn’t have immediate help after. Holland has good hospitals, but they checked me, said I was fine and released me. I have never been so sick in my life. I should have probably gone to a neurologist straight away and got help. But it was a good three weeks later, when I was still suffering from vertigo, and someone from USA Cycling said this is not normal and I probably needed to go see someone. Luckily, I was still part of the Olympic training centre, so I was able to get some help through them.

“But you feel really helpless. You don’t know what to do.”

Small is now a directeur sportif with Ceratizit-WNT and is, unsurprisingly, hyper-aware when it comes to head injuries – both amongst her own riders and those of other teams. 

“Maybe I’m just more sensitive to it now that it’s happened to me, but last year when I was directing at races, how many times did I see girls get concussions at races and get back on their bikes? I had a girl not even know where she was and was getting back up to ride. Why isn’t her director saying ‘no, no, you’re getting in the car.’ How is this okay?

“I saw one girl who was knocked out for two or three minutes. I ended up saying my piece to her. ‘You need to not be racing, not be training, you need to go home and shut it down, because you’re not okay.’

“If the girls on my team hit their heads, I am straight after them – I’m really aggressive about it. It doesn’t matter whether they broke their helmets or not.”

If, as Small contends, it was this final knock on the head of several during her career that tipped her over the edge, hers is a familiar story to followers of NFL and rugby union. Both sports have their own issues with concussion, with the cumulative effect of regular collisions between increasingly huge men having long-lasting – and occasionally fatal – consequences. A recent article in The Economist cited record numbers of concussions reported in both sports during the 2017-18 season, plus “a study in 2017 of 111 deceased NFL players found that 110 had chronic traumatic encephalopathy (CTE), a generative disease that may cause erratic behaviour, memory loss and depression”. 

In the relatively cash-poor world of professional cycling, no such studies have been undertaken. But anecdotal evidence suggests concussion is a big problem in this sport, one that we are becoming increasingly aware of. If some teams are taking their responsibilities towards their athletes seriously in this area, others are burying their heads in the sand.

Mandatory baseline concussion testing, as suggested by Brent Bookwalter in our previous feature on this subject, measures baseline brain activity, function and responses, so that any racer involved in a potential concussion situation can be easily assessed later in the day. But it is currently at the team's own discretion.

To the UCI's credit, in-race assessment was introduced for the 2021 season across all cycling disciplines. Road cycling's disadvantage in its peculiar setting – the old school adage of patch them up, get them back in the race, assess the problems later – makes it a difficult one to deal with satisfactorily, and the jury is still out on how teams are dealing with incidents.

Perhaps it requires a tragedy, such as Andrey Kivilev’s death in the 2003 Paris-Nice that sparked compulsory helmet-wearing, to trigger a similar response, awful as that sounds.

In the meantime, there is at least one company doing serious research into reducing the likelihood of head injuries in crashes. And they are in Sweden.

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Stockholm in November is cold and grey. No surprises there. A smattering of snow on the ground means we tread carefully before entering the premises of MIPS – a fascinating building that formerly housed iconic lighting designers Louis Poulsen. One of Poul Henningsen’s famous and beautiful shades hangs above a stairwell inside, left behind by the previous occupants. So far, so Scandinavian.

Should the Rouleur crew have slipped and fell on the icy surface outside, hitting our heads, at least we’d have been in good hands. Hans von Holst is a brain surgeon and co-founder of MIPS who turned his attention to improving helmet designs in 1995. His research brought him together with Peter Halldin, a student at KTH [Royal Institute of Technology] in Stockholm. The brain surgeon persuaded the engineer to undertake a PhD in biomechanics focussing on injuries to the head and neck. They’ve been working together ever since.

Their first effort – a safety belt for the head to be used in cars – proved to be unsuccessful, but they next turned their attention to helmets. “I didn’t know anything about helmets to be honest,” says Halldin. “I was riding a motorcycle at the time, so I found it interesting. 

“We came up with the MIPS idea, to have a sliding layer inside of a helmet. We then started reading how helmets are tested: dropped straight to the ground. And we looked into accident reports that stated most accidents occur at an angle. We started to put the pieces together and thought that the test methods should be changed, and also that there is a possibility to make helmets much better. This was 1996.”

Think about it. How many people do you know who have landed directly on the top of their helmet in a crash; literally head-on, 90 degrees to the hard surface they have the misfortune to hit? Yet this is the standard test rig set-up across the industry – helmets dropped from a height onto a metal plate. Halldin and Hans von Holst sought to take a – literally – different angle to solving the problem.

“An English guy called Phillips had a patent in 1994,” Halldin informs me, “a helmet design that mimicked the scalp, with a gel structure on the outside of the helmet. We did it on the inside. But except for Phillips, not many people were talking about rotational forces.” 

MIPS [Multi Directional Impact System] was the fruit of their research, addressing what Halldin describes above as “rotational forces”, alongside the “linear impact” that helmet designs traditionally offer protection from. The company first released its own product, an equestrian helmet, in 2007, attracting sufficient venture capital to continue further research and development. Over 22,000 experimental tests have been carried out in the lab, Halldin tells me, before we enter the room packed with a variety of what appear to be modern equivalents of Spanish Inquisition torture machines. These people take their research seriously. 

Back in the meeting room with coffee and cake, Von Holst’s presentation shows a brain poking through an open flap in the top of the skull, opened by a surgeon to successfully relieve pressure on an injured brain post-trauma. I decide against the cake for now…

It may not be rocket science, but it sure as hell is brain surgery, so I’m struggling to keep pace with the flow of information from the massively intelligent gent in front of me. Suffice to say, having worked as a surgeon at Karolinka University Hospital for 40 years, this man knows his onions, despite the initial doubts of his fellow doctors regarding working alongside engineers like Halldin at KTH.

“My colleagues said engineers cannot help in surgery, but they can. Nowadays, they are convinced that engineers are very good for such a hi-tech speciality as neurosurgery.

“We can treat these conditions to some degree, but we need collaboration between engineers also. I had problems accepting all these brain injuries, but I could not come up with MIPS by myself. And Peter is the same. But together, we had discussions for some months, and our discussions led to MIPS.”

Fellow forward-thinking Swedes POC were the first cycle helmet manufacturers to feature the MIPS inserts. Lazer and Scott soon followed suit, and now most serious companies in the field offer a MIPS version of their helmets at around €20 extra to the non-MIPS equivalent – a small price to pay. 

The company has gone from a team of five to 25 in just a few years. They now supply MIPS inserts to a wide array of cycling helmet manufacturers, alongside equestrian, moto and snow sports. There is also ongoing research in conjunction with Volvo, another famously safety-conscious Swedish brand.

“The helmet industry is maybe 30 years behind the automobile industry when it comes to injury prevention,” Halldin says. “Now the helmet industry is catching up. For example, the concussion situation in NFL and American football. They are putting a lot of money into understanding helmets and protection.”

 *    *    *    *

Trek-Segafredo directeur sportif Steven de Jongh was out riding in the hills near his Catalunya home last October. He was alone. When he did not return later that day, his wife Renee posted an alarm on Twitter and the oft-maligned social media platform kicked into action. 

De Jongh’s Strava file indicated his ride ended abruptly on a descent nearby. An extensive search by the Catalan emergency services resulted in a helicopter locating the unconscious man lying in a ravine. He was lucky to survive. 

“Everybody was happy that they found me alive. It showed that the cycling community is small but will help each other. That was really good to see. It was a good move from my wife to put it on Twitter. She works with ambulance crews and knows how crucial it is to be found early. It was not nice weather and a pretty cold day and when they found me, I was already hypothermic. It was a question of hours.”

The team’s Twitter account posted the following the same day: “Steven did not sustain more serious injuries other than a concussion in the crash”. 

Three months later and De Jongh was finally beginning to feel like his old self. A broken bone or two would have been preferable to concussion. For a man who’d have suffered his fair share of crashes during a 14-year professional career, this was a scarily new phenomenon. 

“I never felt so low on energy after a crash as this one. I suffered most with concentration and energy when I was back home for the first few weeks. I was just sleeping, walking round the house a bit, then sleeping again. And then I suffered a lot from noisy situations – everything was coming in much louder. It was really hard to focus on a conversation when there were background noises. Going to public places with a lot of people, I could not focus. 

“At nine weeks after, if I was in a room with a lot of people, I was lost after ten minutes. It was really draining. After 45 minutes, I would go to bed.”

For a man who runs or rides on a daily basis, it was a strange feeling, this lack of enthusiasm for exercise that had informed his routine for a lifetime. The Trek-Segafredo team doctor recommended gradual return to the public situations De Jongh was finding so difficult, reasoning that avoiding brain stimulation would possibly hinder recovery. By the team training camp in Sicily last December, normality was returning, but there was still work to be done. 

And has he ridden solo since the accident? “That took a long while. My first ride on my own again was 11th January. That was a big mental step to take, but I was happy I did it.”

Specialized launched their ANGi system, a helmet-mounted tracking device that also detects crash impacts and will send alerts to the rider’s emergency contacts. It seems like a step in the right direction, to at least put our nearest and dearests’ minds at rest. Renee must be having kittens each time her husband goes out the door…

“I have a similar thing activated on my Garmin,” says De Jongh. “If you crash it will send the location of the Garmin. And now, when I’m riding on my own, I send my live location on WhatsApp. That is also good.”

 *    *    *    *

If the effects of concussion are a relatively new concern on the cycling horizon, then other sports provide a worrying blueprint for a future scenario. As The Economist reported: “Some 5,000 former players sued the NFL, winning payouts that are expected to come to around $1bn … Another lawsuit is being brought against the governing body of Australian rules football.”

And as Hans von Holst told me: “Traumatic brain injury has a substantial risk of Alzheimer dementia, either following moderate to severe head injury, or following multiple mild head injuries.”

About to turn in my copy and put this story to bed, a tragic story that cannot be ignored unfolded before my eyes. Kelly Catlin, a supremely talented track rider, Olympic medallist, violinist and student, committed suicide, aged 23. She had suffered a concussion injury in December last year. 

Her father Mark told The Washington Post: “Everything was open to her, but somehow her thinking was changed and she couldn’t see beyond, I guess, her depression. After her concussion, she started embracing nihilism. Life was meaningless. There was no purpose. This was a person with depression. For her, she could no longer concentrate on her studies or train as hard. She couldn’t fulfill what she felt were her obligations to herself, she couldn’t live up to her own standards. She couldn’t realize that what she needed to do was get away and rest, heal. We were all searching for the magic words, that life was worth living.”

Mental health has become a hot topic in this sport in recent times, due to athletes speaking out and being happy to talk about their issues. And concussion is part and parcel of the subject, one that cannot be ignored. Cycling needs to address this debilitating – and potentially fatal – condition immediately. One Kelly Catlin is one too many. 

Updated feature from Rouleur issue 19.3