October 30, 2023
By Dr. Rebecca Breslow
When Jim, an avid mountain biker in his 60s, suffered a cycling-related traumatic brain injury (TBI) that left him paralyzed on one side of his body, no one would have blamed him if he had never wanted to venture onto a bicycle again. Instead, he couldn’t wait to get back out there. When My Body Odyssey caught up with him on September 10th at the Maine Lighthouse Ride, a fundraiser for the Eastern Trail multi-use recreational trail system in Kittery, Maine, he had just participated on a specially fitted 3-wheel adaptive bike.
“I love being on a bike,” he says, “and I was so happy not to lose that.”
He attributes much of his success in coping with his injuries and negotiating the long road to recovery to cycling. He continues, “…it definitely helped me because I had a goal and a focus then to get back out on the road and to go farther and farther.”
Jim is one of many who have suffered a TBI related to cycling. According to the National Electronic Injury Surveillance System, cycling is the most common sports- or recreation-related cause of TBI in females and is the second-most common cause in males.
However, unlike other sports such as football, which also carry a high risk of concussion/TBI, return-to-sport guidelines for cyclists are neither standardized nor widely implemented. Because many cycling-related injuries cause impairments that affect coordination, balance, and the ability to handle a bicycle safely – placing operators at greater risk of re-injury – this is an area of concern and active research.
Dr. Dana Kotler, the Director of the Cycling Medicine Program at Spaulding Rehabilitation Hospital in Massachusetts, is attempting to formalize cycling injury prevention and return-to-sport protocols. A dedicated cyclist herself, during her medical training she became interested in how to promote general health and injury prevention through cycling. Ultimately, she partnered with physical therapist and bike fitter Greg Robidux, and the two founded the Cycling Medicine Program at Spaulding in 2015.
“Oftentimes when you’re an athlete and you go in for a medical evaluation, you might see a doctor who asks you a bunch of questions, takes a history, does a physical exam,” Kotler says. “They might send you over to a physical therapist who takes a similar history, does an assessment, comes at it from a slightly different perspective. They might send you to a bike fitter who talks to you about those issues and has a certain set of tools that they use… We thought, how great would it be if we could combine it into one assessment.”
Kotler has built her program not only to help cyclists interested in maximizing their performance, but also those who are battling chronic health issues. Karen Zunti, another physical therapist who works with Kotler, discusses how a wide variety of athletes can remain active through cycling with proper support.
“As a PT and bike fitter, I make it my mission to either modify someone’s bike to accommodate to their needs or make recommendations for the appropriate equipment or refer to our adaptive biking program,” she says. “Issues like musculoskeletal pain from arthritis or other injuries often require modifications to the bike set-up or equipment… People with balance impairments, neurological issues (stroke, multiple sclerosis, head injury, Parkinson’s, spinal cord injury) typically require adaptive or recumbent bikes, either a foot pedal style or hand cycle.”
Patients like Jim benefit from these adaptations. When asked if she was concerned when he wanted to get back on his bike, Jim’s wife, Mary, says,
“No, I wasn’t concerned at all because the hospital was so accommodating…they wanted to get him moving and because he has no balance, it was one of the few things he could do seated in moving himself…it just opened my eyes to the possibilities of a physically challenged athlete.”
Rebecca, a 64-year-old cancer survivor who also participated in the Maine Lighthouse Ride, describes the restorative power of cycling for her own recovery.
“Bicycling very much…puts me back in my body in such a joyful, empowering, strong way that it helps to mitigate all that happened.” Benefits like these seem to outweigh the inherent risks of the sport.
“The main downside you run into with cycling is the potential risk of not only overuse injury, but crashing your bicycle, especially if you’re riding in cities where you might be among faster-moving traffic,” says Kotler.
“But there have been studies that looked at even when comparing those risks to the benefits of cycling, the improvement in all-cause mortality wins out over the potential risks.” Zunti agrees.
“Cycling is a great cardiovascular activity and is easier on the joints than running,” she says. “One can generally ride for a longer duration than walking or jogging so it is heart-healthy. For those with arthritis, it is tolerated more easily than other weight-bearing activities.”
She sums it up with a quote from her great-nephew.
“Biking is easy on the arms, hard on the legs, and fun fun fun for the soul.”
Rebecca Breslow, MD is an expert in road race medicine, has served as a volunteer physician at the Falmouth Road Race and the Boston Marathon (along with numerous other Boston-area road races), and was a USA Track & Field team physician at the 2019 World Athletics Championships in Doha, Qatar.