Following the EWS Injury Study, we have reached out to experts in the field to learn about injury research in mountain biking and what can be done to make the sport safer. A few weeks ago, we published reflections from Debbie Palmer, who led the EWS study at the Edinburgh Napier University. Now, we have Chris Leatt to explain how companies and organizations -- from protection manufacturers to race organizers -- can use the data from such studies to minimize the frequency and severity of injuries.
Can you just start by telling me who you are and what your background is?
My name is Chris Leatt, founder and chairman of the board of Leatt Corporation. I started this company after experiencing a traumatic event where somebody I knew broke his neck and died in an off-road motorcycle event. My four-year-old son was with me at the time, and we tried to resuscitate the rider, but unfortunately he passed away from a neck injury. This incident was the catalyst for my research into neck injuries, as well as spinal and head injuries. At that stage in my life, I was a neurosurgery resident at a local teaching hospital and halfway through my studies I left medicine for a year to develop the neck brace, though my plan was to hand the project off to somebody else, so I could go back to my studies. That was 15 to 16 years ago, and I haven't gone back to medicine since. I come from a background of road racing, so I've been racing motorcycles since I was 16. These days, I don't really ride motorcycles much anymore, but I do ride my bicycle a lot. I live in a beautiful area in South Africa, namely Stellenbosch, where there is a lot of cycling in the area, so I pretty much ride five days a week.
What do you think about the bike world's relationship with injuries?
Injuries are an inherent danger in extreme sports. In some instances, they are a barrier to entry for those who don't want to get injured. On the other hand, some people enjoy risky sports as it gives them an adrenaline rush and a sense of being vividly alive. At the end of the day, extreme sports are still very dangerous. One can mitigate the risk of injuries – all we can do is try and reduce both the number and severity of injuries by using various strategies. However, other factors come into play, like track design or the safety equipment you choose to wear, as well as how it performs on and off the bike. Many different things influence injuries. At the end of the day, I think if you can limit the numbers and severity of injuries, it's good for extreme sports and for maintaining the number of riders.
Yeah, it seems like injury studies right now are a good step in that direction. What are your takeaways from that research?
Well, I have a few opinions on the EMS Action Sports study
in particular. My first opinion is naturally that it's great they did it. In fact, it's long overdue. Injury statistics are extremely difficult to get in the right numbers, and I think the design of the study is what makes it so good. Most of the published studies we see are journal articles and academic articles that are often more road-based. These studies focus more on motor vehicle accidents, pedestrian accidents etc. or looking at where bicycles fit in with other road users, like cars. Other factors involved are whether or not a helmet was used, as well as hospitalization rates, which are often the defining factor in the study. This study looks at a much broader spectrum of injuries in a very particular discipline, over a very long period – 10 years in fact. Riders were interviewed as the second part of the EMS study, to gather data on injury rates and the riders’ personal experiences. I think they are two quite distinctive sub-studies, so to speak. The first type is conducted objectively, in terms of looking at everybody who sought medical attention, what the diagnosis was, what the treatment was and what the follow-up was. So, that's the typical design of a study. That said, I do think the numbers are significant enough to draw some conclusions from them.
The other type of study looks at personal experience, and the really big difference between the two types are as follows: in the first study, they look at every injury that occurs during an event, whereas in the second study, they used a “significant injury” approach, and these didn’t all happen at events specifically. So, what is a significant injury? In the EMS study, a significant injury is one that takes at least a month to recover from. Moreover, participants were asked to recall significant injuries they had previously sustained. So, for example, if you had a concussion and it took you four days to recover, that injury wasn’t included in the study. If you broke your collarbone, got it plated, and were back on your bike within two to three weeks, you weren't included, as you had to be off your bike for at least a month to qualify as a study participant.
So, this particular study focused only on a pre-defined group (significant injuries) as opposed to including “minor injuries.” In the EMS study, there were a lot more minor injuries than significant ones. However, there are some parallels that can be drawn between the two groups, as they show a similar injury pattern, although head and spinal injuries were higher in the second group. Generally speaking, the upper body - shoulders, clavicles, upper arms, hands and extremities showed similar injury patterns. As a company, this allows us to look at body regions that need protection most, as well as drawing other conclusions, like the need for a concussion protocol at events and always carrying a mobile device when riding out in case of an emergency.
So, for those of us going out and riding on the weekends, what should we be paying attention to in that study?
For me, the biggest takeaway I got from the second part of the study is that if you are going to ride out, preferably ride with a buddy, and have a form of communication with you. So, if you do get injured, somebody can arrange to get you either to a hospital or back home. Here in South Africa, I can ride for 100km from my house without a tar road in sight. So, if I were to fall off a downhill section somewhere, I'd be lucky if somebody cycled past me… We know that your outcome is very much dependent on how quickly you can get medical attention, so that would be my biggest takeaway. Additionally, due to the high risk of concussion should you fall, be sure to choose a good helmet.
So, what’s a really good helmet?
Well, particularly one that reduces rotational, as well as linear acceleration. MIPS popularized the theme of rotational acceleration, which is important. In the medical profession, we used to primarily focus on linear deceleration – in other words, if you fall directly in a straight line onto your head – as we believed this to be the main cause of serious head injuries. However, now we know that you need about a quarter of that velocity, if your head strikes something and rotates, to cause the same, if not worse damage. Rotational acceleration on the brain can be absolutely devastating, as it shears tracts within the brain, leading to severe brain injuries. With this understanding, new, much safer helmets were developed to reduce rotational acceleration – a giant leap for safety technology.
Going back to your question, you want to choose a helmet that’s not too old and hasn't sustained any big impacts before, as once a helmet has been severely impacted, it significantly changes the EPS liner, rendering it far less effective. Accordingly, choose a new, good quality helmet, one that passes the safety standards and preferably one that reduces rotational acceleration, which not all helmets do. At Leatt, our helmets are designed to mitigate rotational acceleration, even at low speeds.
In the U.S., looking at what happens in football, where players endure repeated head impacts over a prolonged period of time, some companies developed CET – post-traumatic encephalopathy. What they found is that the impact velocity wasn't as high as they initially thought. It was less than five meters per second, which is on the low side compared to what you would test a standard helmet at. Helmets are typically tested at 3.5, 5.5 and 7.5 meters per second. Currently, motorcycle helmets are tested at impact speeds of up to eight-and-a-half meters per second. So, we’ve also designed and tested our helmets for repetitive, relatively low-velocity impacts, which are linked to concussion.
It seems like those studies could be a nice guide for figuring out where our weak points are with protection.
Yes, choosing the right limb and body protection is important. You could make a shopping list by going through the EMS study and looking at where injuries commonly occur. So, if the upper limbs, elbows, and knees suffer many lacerations, abrasions, and contusions, then having elbow guards and knee guards is an easy and relatively inexpensive way to stop most of these injuries as this is where they occur most often. Previous studies mirror these findings, so upper body and limb extremity injuries are the most common.
In the first group of EMS study participants, fewer concussions occurred and the recovery rates were quicker, so they were all relatively mild concussions – but, in the second group of 1934 participants, there were close to 80 significant concussions. This showed us that riding on the trails involves a much higher risk of concussion. The second group also included fewer professional riders who were often on the trails where medical assistance wasn’t readily available. Other factors involved may be that at an event, the rider is more focused or during trail riding, a rider is more likely to try new tricks or must navigate highly technical obstacles that may cause a fall. In which case, choosing a good helmet is one approach. The other approach, particularly when it comes to DH riding is to use a neck brace. We believe a neck brace can alter injury patterns in a number of different ways, as it not only limits neck injuries, but the EMS action sports study showed a 45% reduction in collarbone injuries when wearing a neck brace, which is a very interesting finding.
I'm currently doing a Ph.D. on brain injuries, and we believe that the neck brace reduces brain injuries as well because it catches the head earlier, so deceleration is more controlled. When you hit the ground initially, you rapidly decelerate, which causes your head to move relative to your body and decelerate again. If you see high-speed videos, head excursion is dramatic. With neck brace use, the head is caught earlier in the second deceleration. In terms of neuroscience, the damage to your brain occurs because of the cumulative effect of all the above insults. So, if the brain has a primary impact, then a secondary impact, then let’s say a temporary lack of oxygen, together with physiological changes, the result is a cumulative insult to the brain.
What protocols have you seen from race organizers, and how could they be improved?
If you look at the Great Lakes Action Sports EMS study, it beautifully sums up where you can access more information on safety gear. The last way riders tend to access this information is from their sponsor, and the second last is from governing bodies. Riders are more likely to rely on their friends, family and people they know to tell them what is safest, what's unsafe, as well as what they should and shouldn't do in terms of safety in riding. I think to be able to move the governing bodies up to number one would be ideal.
In other words, I believe sport governing bodies should actually use research, data and outcomes to determine the minimum equipment required, the standard of the latter, and how often it should be replaced. If you had a big impact, should you have your safety gear replaced? In moto racing, you can't start a race until all your safety equipment has been thoroughly checked. I think it would make a big difference in terms of mountain biking safety. Then obviously there are the protocols. If you sustain an injury, the red flag system is a fantastic idea. Moreover, having first responders adequately trained in the event of a crash is critical. First responders should be medically well-trained to do a proper concussion assessment. So, if a rider has the basic symptoms of a concussion, the first responder should be qualified enough to determine whether or not it’s a “Red Flag” and should be able to decide whether or not the rider is unfit to continue riding.
You see, if you have a primary impact, that should be addressed immediately ideally. The reason being, if you have a primary impact, carry on riding, and then sustain another, it’s a lot more devastating to your brain. Your brain can get over one concussion fairly well, but if a second, third or fourth were to occur in a row, the damage would be significantly worse.
Many years ago, I did the injury assessments for Motorsport in South Africa. What we did was look at injury patterns and what we could do to change them in off-road motorcycling. We found that in junior motocross, if we changed it from a jump to a straight, rather than a straight into a jump before a turn, all of a sudden, the injury rates dropped off dramatically. So, they were previously jumping, then accelerating, rather than accelerating and doing a big jump after, as well as a turn. You still have the same average speed, the same size jumps, but if you just change the track design slightly, you immediately see a different injury pattern altogether. We know from the research, for example, downhill, i.e. rocky sections where people get hurt, if riders fall off in practice in exactly the same place, we need to change the route ever so slightly, or add something safer to fall onto. If there's a tree – you've all seen those horrific pictures of a downhill rider hitting a tree – we discovered that by moving the airbag or barrier slightly, lead to less injuries.
How does emergency vehicle access play into course design, especially with what the study told us about where injuries will likely happen?
I think emergency vehicle access is very important because from the time the injury occurs to the time when the rider actually receives medical attention is of utmost importance. First responders call it the critical hour. It may literally be critical minutes if someone is severely injured. On a downhill course, it may not always be practical to get EMS vehicles to a site where there are high injury rates. In such cases, you can CASEVAC the person out of that area on a stretcher or on the back of a quad bike. But, as you say, it’s definitely a good idea to have an extraction point that is close to the gnarly points.
What should riders know about injuries that they don't typically know?
I think it's more about having the awareness not to go off on your own, where you could get hurt and not have access to medical assistance. Additionally, awareness of the fact that should you sustain a concussion or be showing symptoms of one, you should immediately seek medical treatment because everybody bangs their heads, and sometimes you see stars and you might have a headache afterward, but it may be a significant concussion. In which case, you really shouldn't get back on the bike again. The concussion policy I think is important. The rest is logical. Now, looking at the EMS study, if people are having lots of abrasions and contusions to elbows, well, put an elbow guard on. It doesn't hinder you from riding and then having a form of communication is critical. My advice would be to ride with a buddy and always have a form of communication with you.
An interesting thing that is not often touched on is that, if you look at the riding population now, we've seen a lot of people starting to ride e-mountain bikes, causing injury rates to increase. E-mountain bikes have power, speed and are sometimes used by riders getting back into the sport at a later stage in their lives. If you don't have access to a bike lift, and you're not pedaling uphill and doing the run twice, you can now do it 10 times because you've got a motor and you've got some pedal power. There are the young, fit guys who just want to do lots of downhill. But, in my experience, most people are older, less fit, and previously may have ridden hard and want to get back into it, but they don't feel like they're fit anymore, and that’s a dangerous sign. They want to go fast, but their core strength is not as good, they haven't been on a bike for a long time, and with an e-bike, which is slightly heavier, you carry more momentum downhill, as a result lots of accidents occur. So, I think more awareness is needed among the e-mountain biking groups, particularly the older age groups that accidents are more likely to happen due to the reasons mentioned above.
Also, if you are older, even on an e-mountain bike, you're still getting your heart rate up, so just take one aspirin with you. If you have chest pain, take half an aspirin. That’s probably the most beneficial thing that you can do until you can get medical help. If you can take half an aspirin if you're feeling chest pain while cycling, it can affect your outcome in the long-term. When I ride with elderly people, which I sometimes do, I ask "Are you carrying your aspirin with you?" Because I've seen it happen before.
Where would you like to see injury research go in the future?
There are a few things that are important in terms of being able to do studies. Studies don't kill sports, as some people may falsely believe. Studies are good for sports because if you see an injury trend, you can do something about it. I know from the moto racing industry, and particularly off-road motorcycling, there is a lot of reticence to publish data, and they keep that important information to themselves. Take the Dakar, for example. It would be really interesting to see the injury data on that. I've had people who've alluded to what is in the data, but I haven't seen it myself, and their decision-making can be directly linked to the data. We've been involved in the Dakar for 15 years, and we eliminated neck injuries, where previously there were one to two deaths a year occurring from neck injuries. Now, they've made rule changes, and I don't think they've considered the data properly. Data collection by authorities that govern a certain event and curating that data in a scientific way is really important.
Then, of course publishing it would be very helpful because protective apparel manufacturers like us can actually look at the data and design products that are relevant to any one particular sport. If we find an injury trend in say, for example, e-mountain biking, the products may potentially need to be altered. If a normal bicycle falls on you, it’s no big deal, whereas, if a 22kg e-mountain bike lands on top of you, it can be far more injurious. If we see a different type of injury pattern, which can only come from gathering and publishing data, we can be better prepared to produce better products. I'd really like to see more authorities producing protocols and doing prospective studies, where they start a season, put together a protocol, capture all injuries, and then publish the data like EMS did. I would like to see a lot more racing federations doing the same moving forwards.
Do you know of any research that's in the works or people who are trying to move in that direction?
I think there's ongoing research within EMS, but I'm not aware of any other bicycle-related research. There is motorcycle and pedal-powered two-wheel research that's ongoing, but whether we're going to see that data or not is the unfortunate part. We have something called an injury library at Leatt. When any significant injury is reported to us, with or without a neck brace, or a significant accident, with or without an injury, we collate it in a library. We often will talk to the doctor, get the MRI and CT scans, and compile a report. If we see something interesting or out of the norm, we will design a test rig to try and damage the safety apparel in the same way as it was damaged in the accident to understand how much force was applied and the force vector. Then we can look at it, in terms of our safety offerings, and whether we can make changes to our products to ensure this kind of damage is avoided. That type of research would just make our sport a whole lot safer in the future, which hopefully will support the numbers, the bike manufacturers and safety apparel manufacturers, as well as the abundance of riders themselves.
Due to COVID, a lot of people aren't going to gyms as much anymore to work out. They're avoiding going inside and small gatherings, and instead going outdoors to exercise. We have noticed a massive uptick in people out riding. I live in an area where there are a lot of mountain bikers and runners – the numbers are astronomical, and people are just out there getting their daily dose of exercise. No doubt, COVID has changed our lives a great deal. More and more people are turning to mountain bikes now that perhaps, if it weren’t for the pandemic, may not have done so.