Sports-related concussion in cycling

Sports-related concussion (SRC) is a recognised sport-related injury and a growing global public health concern,1 accounting for between 1.3% and 9.1% of all injuries reported during cycling events.2 Road cycling, however, does not have a sport-specific SRC assessment protocol,3 particularly lacking a roadside screening (‘go/no go’) assessment protocol. We would therefore like to propose the creation of a cycling specific RoadsIde heaD injury assEssment (RIDE) protocol

The solution: RIDE protocol

In order to account for the often transient, evolving or delayed onset of SRC symptoms, serial clinical evaluations should be embedded within a three-stage process to optimise the diagnosis of SRC.4 This RIDE protocol will evolve as epidemiological evidence on SRC in road cycling develops4 5 and feedback is received from interested parties.

The three-stage diagnostic process involves (see figure 1):

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Figure 1

Cycling RoadsIde heaD Injury assEssment (RIDE) protocol (adapted from World Rugby HIA protocol).7

1. Initial road-side assessment immediately following head impact event (RIDE 1).

2. Reassessment immediately following completion of the stage on the same day of the injury (RIDE 2).

3. Reassessment the day following the initial injury (RIDE 3).

Riders can be evaluated more regularly if they display any suspected concussion symptoms which would warrant further evaluation.

RIDE 1

In the first stage, riders who sustain head impact events with the potential to result in SRC are identified by key team staff, team doctors or independent race doctors (figure 2). This can be by direct observation of the event or video review. The three components of RIDE 1 are: (1) an assessment for the presence or absence of 12 immediate and permanent removal features that, if present, warrant immediate and permanent withdrawal from competition; (2) in the absence of any of the 12 immediate and permanent removal features, a standardised road side screening assessment including symptom checklist, medical evaluation, balance assessment and cognitive tests performed by the race doctor and/or team doctor; (3) clinical evaluation by the race doctor and/or team doctor.

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Figure 2

Concussion protocol 1. RIDE, RoadsIde heaD Injury assEssment.

Riders displaying any of the 12 immediate and permanent removal features will be immediately and permanently withdrawn from competition. Other riders who have the potential for SRC but without clear evidence of observable signs or symptoms undergo a standardised assessment at the side of the road using the RIDE 1 protocol (figure 2).

RIDE 2

Riders who have a normal RIDE one assessment and then complete the race without further symptoms/signs suggestive of SRC will then undergo an immediate post-stage clinical evaluation (RIDE 2) (figure 3). This assessment is performed using the formatted SCAT5, completion of neuro-cognitive tools and a full neurological exam. These tests are informed and guided by player baseline data, which should be obtained at pre-season screening.

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Figure 3

Concussion protocol 2. RIDE, RoadsIde heaD Injury assEssment.

RIDE 3

In the third stage, riders receive a further clinical assessment and cognitive battery test after one nights rest to identify a late diagnosis of SRC, similar in content to RIDE 2 (figure 3).

Practical considerations for implementing the RIDE

The Union Cycliste Internationale (UCI) will need to address the practical considerations of implementing the RIDE into routine use in road cycling. A key issue to consider is who should perform the in-race RIDE 1 assessments? Another issue is the time needed for the RIDE 1 assessment and we suggest a fixed time of 10 min. A key practical consideration is whether it is feasible to return a rider to their previous position in the race once they have completed the RIDE 1 or whether an estimated finishing time will need to be attributed to the rider. The UCI will also need to ensure consistent application of the RIDE across the road cycling discipline and to do this, we therefore encourage the development of an appropriate education programme for riders, management, race and team medical staff in addition to wider briefing of the media and the viewing public. A final issue to consider is how the UCI will monitor the application of the RIDE to avoid any potential misuse of the system, with the possibility of disciplinary referrals if the assessment process is shown to have been abused.

Summary

We hope that discussion of the RIDE model can start to bridge the divide between SRC assessment in road cycling and sports with more developed SRC assessment processes. We recognise that this is very much a ‘first step’ in this process and indeed we anticipate discussion and debate with the sporting community involved in road cycling and beyond. We believe that the UCI can bridge the divide from where SRC assessment and management is currently,6 and where we should be, through the creation of an evidence-based road cycling-specific RIDE, which will be refined and updated with analysis of use and as new evidence emerges.