If you want a snapshot of the way head injuries were treated in professional cycling until very recently, start with the viral images of Chris Horner at the 2011 Tour de France. After the American cyclist crashed toward the end of Stage 7 and was knocked out cold, he climbed back onto his bicycle, despite displaying clear signs of the disorientation caused by a severe concussion. At the finish line 15 miles later, television cameras captured Horner’s bewilderment. “I don’t understand,” he stammered as he rolled in. “Where am I? When did I crash? I don’t remember.” Horner, who was forced to drop out of the race, suffered from dizziness and confusion for months. To this day, he has no memory of the 24 hours surrounding the crash.
How have things changed? In 2014, the UnitedHealthcare pro cycling team developed a new cognitive analysis that utilizes baseline testing done on its athletes throughout the season. The team’s post-crash practice changed after team doctors pulled UHC star sprinter Kiel Reijnen from a race following a crash. The ad hoc nature of the assessment left Reijnen angry and the doctors searching for a less subjective procedure.
The new protocol replaces the laborious SCAT3 sideline exam used in other sports, which largely results in a judgment call by an on-site health professional. The theory is that the new test eliminates most of the guesswork of whether a rider should be removed from competition. Had Horner been put through the UHC protocol, he’d likely never have ridden the final 15 miles.
“In professional cycling, if you can’t make a decision in under five minutes, your day is over. These tests help us make the decision less subjective.”
“Nobody wants to take out your star quarterback,” says Michael Roshon, UHC team physician. “But given everything we’re starting to learn about traumatic brain injuries, this has to be a medical decision, not a business one.”
In the past few years, a national spotlight has been turned on traumatic brain injuries, focused largely on a lawsuit brought by retired football players against the NFL for concealing the sport’s dangers. Less known are the incidence rates of serious head injuries in adventure sports, including those that took the life of freeskier Sarah Burke in 2012 and nearly killed snowboarder Kevin Pearce. Dangerous crashes are also a routine part of road cycling and mountain biking. UHC’s program is just one example of a growing desire within many of these sports to take serious steps to mitigate the damage.
“Everyone is looking at ways to diagnose injuries quicker and more accurately,” says Rob Wesson, senior director of research and design at Giro, which has built helmets for cyclists and skiers for 30 years. This year, Giro, along with more than a dozen other helmet brands, invested in a technology called MIPS (multidirectional impact protection system) that is designed to reduce rotational forces on the brain, thereby minimizing the risk of concussion. Still, helmets will likely never prevent concussions entirely, which makes the decision over how to handle injured athletes critical.
Currently, the U.S. Ski and Snowboard Association, along with the NFL, NHL, and MLB, use a computerized neuropsychological test called ImPACT, which was developed by Dr. Mark Lovell, former director of the Sports Medicine Concussion Program at the University of Pittsburgh Medical Center. ImPACT gauges memory and reaction time and is considered the gold standard in the industry, but it takes 30 minutes and must be administered in a quiet room. “It measures fine gradations of cognitive functioning,” says Lovell, who has been studying concussions since his work with the Pittsburgh Steelers in the mid-eighties. “It’s not appropriate for return-to-play decisions.” That means a sideline diagnosis is typically made with the slightly less time-consuming, pencil-and-paper SCAT3 test. “It’s the best we have,” says Dr. Julian Bailes, chairman and neurosurgeon at Chicago’s North Shore Neurological Institute, who has consulted with the NFL Players Association.
“In professional cycling, if you can’t make a decision in under five minutes, your day is over,” says Roshon. That’s why UHC made its protocol quick and simple enough to administer in the press of a race. “It always comes down to a judgment,” he says, “but these tests, and especially the comparisons to an individual’s normal results, help us make the decision less subjective.”
Of course, no one considers the new program foolproof. “It’s a good start. But remember that these tests aren’t official,” says Dr. Anna Abramson, an internal-medicine physician at the University of California at San Francisco and cochair of Medicine of Cycling, which is pushing for higher care standards in road racing. “There is some evidence behind them, but there isn’t a lot of data. Many questions remain about how the brain reacts when it is injured.”
Lovell underscores the point: “It’s a very tricky injury to diagnose. Chemical changes in the brain from an impact can take up to 12 hours to manifest. Our advice is always: When in doubt, sit them out.”
Roshon is undeterred. He hopes that someday UHC’s diagnostic test, or something like it, could become a standard procedure everywhere from the Tour de France to the NFL sidelines. But for now, he’s just happy to have a tool that he trusts to protect his riders. “The priority,” says Roshon, “must always be the athlete’s health.”
How UnitedHealthcare's TBI Protocol Works
Before racing season begins: A team physician conducts this series of tests three times to establish a baseline.
Step 1: Balance
- The athlete stands with both feet on the ground, with eyes closed, for 20 seconds. Each balance correction is noted.
- The test is repeated on a single, dominant foot.
- A final, one-legged test is run on a soft surface like grass, carpet, or a foam pad.
Step 2: Cognition
- The physician tells the athlete a list of five words: banana, golf ball, pillow, coffee, feather. After the next two tests, the athlete attempts to recall the list. Accuracy is measured.
- The athlete is given a series of five or six numbers. The physician then records how long it takes to repeat the series backward.
- An iPad app like MindMetrics ($3) or BestTime! (free) is used to calculate reaction speed.
When an injury is suspected: The physician asks a series of orienting questions—name, birth date, home address. If the athlete doesn’t know the answers, or recalling them is difficult, the test is over; he or she has failed. Next, the doctor asks if the athlete feels tired, dizzy, agitated, or sensitive to bright light. Finally, the balance and cognition tests are run and the results compared with the baseline. A decrease in performance in one or more of the tests could indicate a brain injury, resulting in the athlete’s removal from the competition.