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The struggling cyclist.

Before I explain where I am let me mention where I came from.
I was always an outsider to sports. I had the determination and heart but I never had the raw skill. In golf they use the term L.O.F.T. Google it . Baseball, football, soccer, whatever, I was not really very good. I came into cycling after an injury. It was meant to be rehab for my back. That lead to the idea of commuting. Well, what it would lead to  was an obsession. At my lowest point I was fighting multiple addictions and cycling was what kept me going the streight path. I began racing and riding daily. I would race for a few years for a few teams and even for myself (unattached) when I lacked the fitness to race for a team .

Fast forward 10 years, I’m now married, a father of 3, and I have a dog to boot. In many ways I have what I want. I still have the drive to go out and test myself when I’m riding but there are many weeks that I just can’t ride, some weeks I’m just too tired, and yet others I’m not willing to make the sacrifice to get a ride in.  The fire is still there but the time/motivation/will is at times lacking. I set goals but get confronted with realities. Sure I could ride Saturday but one son has practice and the other has a soccer game. Did I mention my two-year old? So my choices are 4am ride or no ride. I made my choice before I typed it.

I don’t think I’m alone in my position nor do I think I need a small violin playing “sad romance”. What I need is a spark, something to convince myself to ride when it’s difficult to get going . As it turned out that spark that made me want to ride was a ride. That and something I heard on a podcast, something about second degree fun. It’s fun, just not from the idea or start. Like a climb, not really fun as a idea but as you get to the top, you can look back at the climb as a good time. Albeit a miserable, painful, good time .

So what keeps you going? Do you ever need a break or time to miss riding? Are you the type of rider who just wishes they had more time to ride? Let me know as that’s one of my motivations (I love hearing about others passion to ride).

Wanna race?

And it starts like most races do with a little hesitation, some trepidation, and a lot of anticipation. I roll out and set a steady tempo. I know my fitness is not where it used to be so I decide that a long range attack allá Contador is the way to go. I’m receiving information and it’s telling me I have a 30 second gap. I’m holding steady pushing about 20 miles per hour. I have some luck on my side and I have not had too many reasons to slow down. As I’m approaching the first climb, my first true test, my breakaway has gained me 2 minutes.

The climb shines light on the cracks in my foundation. I’m coming undone and I’m starting to Pedal in squares. The 2 mile climb is pushing my heart rate to 190 beats per minute, I’m bleeding time and fading fast. This climb that tops out at 7% and has taken my two-minute lead down to one minute. In the last mile of climbing I’ve fallen apart and this climb has taken its toll and although the major climb is over there is still more climbing to be done.

I’m feeling confident that I can get some of the time back on the upcoming rolling section. The problem is that this section is much less rolling then I remembered it. The next half mile has not a single negative grade and an average grade of 3%. I begin to lose more time and when I reach the two-thirds marker I’m only 20 seconds ahead. Those 20 seconds dissolve into zero, zero grows to a negative. My second best effort on this section is still about 1mph too slow.  I’m now 20 seconds behind, I’ve been caught, and I don’t have much left in the tank.

My strategy might seem to have failed me but I’m exactly where I want to be. I limp up the rest of the climb and utilize one of my best skills. The descent is my playground. I slowly see my deficit disappear and I even make up a few seconds. In my aerodynamic tuck I’m able to gain one minute and 30 seconds as I turn right, right into the last real climb. From here Colima is only 0.3 miles but with an average grade of over 6%, it can do some damage.  This climb is no test, this climb is a deal-breaker, make or break, win or lose.

My 1 minute and 30 second Advantage disappears yet again I get out of saddle I give it everything I have left to no avail. I’m riding like a man possessed but I’m two minutes behind. In 2 minutes I’ve lost 2 minutes. My lungs feel like raisins, I can feel the burn down my esophagus, my legs are begging me to stop, I consider sitting up. But for every climb there is a descent, so I hold my pace steady and continue up the climb. 2 minutes and 15 seconds is what I have to make up on a 2 mile descent.

I rearranged myself about 3 times trying to find an aerodynamic position I can hold for the entirety of the Hill. Colima Road flattens out and it’s now up to my legs pushing at times 28 miles per hour, holding my threshold as long as I can. I look down and realize I’m 3 minutes ahead. All that is left is to maintain my lead. I want to do more than maintain though, so I push each pedal as hard as I can for the remaining 2 miles. Little by little I’m gaining time, three minutes turns into four, four minutes balloons to 5, and by the time I’m at the finish my lead would tell a different story than my body. I’m a wreck but I’m feeling like an accomplished wreck.

My first race in sometime was not against a Peloton or a friend, it was against myself via my virtual partner on my Garmin 520. I had no idea that this is going to be so much fun, so competitive, and so inspiring. At the time I didn’t think twice I just thought “oh look what I can do” with my Garmin. It seems like my commute has found yet another way to keep my interest.

Watch the video

Bike Racks Are Becoming Rare…

In the immediate area where I live, I’ve started noticing that there are less and less bicycle racks than ever before. It seemed like every grocery store had them and each shopping center used to have a designated area for them. But not I’m venturing out more for casual rides and to find places to eat/drink, I’m having a harder time finding a good place to lock my bike.

Take for example my trip to the grocery store, they used to have a HUGE bike rack. But now it’s gone. So I had to find some metal railing to lock my bike against. What’s interesting is, if I go do downtown Fullerton, the seems to be more of an acceptance to bicycles there. In fact there are actually quite a bit of 2-bike racks peppered around the area. I guess I just don’t get why in some areas, there are racks while others it’s absent.

To Helmet or Not to Helmet; that is the Question.

Actually, it’s not that simple. The issue of bicycle helmet use and practice is complex. That probably explains why no one agrees on it and also why we will argue about this until the end of time. Admittedly, I am a bicycle helmet advocate. I use one myself. As a physician, I see many head injuries from bicycle accidents; many without helmets, some with. And as I researched for this article, I started appreciating the complexities of bicycle helmet use.

What follows is an overview of the main points of contention that I have encountered in my readings. It is neither an argument for or against helmets. As a free thinking adult, you must decide for yourself, unless you live in a helmet-mandatory region.

thumb_main_to_be_or_not_to_be

Theoretical versus Real World Benefit

From a theoretical standpoint, helmets make sense. Much like an airbag for your head, a helmet reduces the extent of deceleration that your head and brain experience when an impact occurs.

Force = mass x acceleration.

The lower the magnitude of acceleration (or deceleration), the lower the force experienced, meaning less injury. There are standards for designing helmets, which are met through testing. These include drop tests involving blunt impact as well as penetration tests with sharp objects. These tests are often performed at different temperatures, in different moisture conditions etc, in an attempt to simulate reality. But of course, these are simulations.

Consider the following when a bicycle accident occurs in the real world:
1. Condition of the helmet (is it already broken, is it the right size, fit)
2. The way a helmet is worn
3. The speed at which a person is riding
4. The type of object and speed of the object into which the bicyclist is colliding (an 18 wheeler going 40 miles an hour vs. a wooden fence)
5. What parts of the body gets injured in the accident (a helmet is not going to protect the cyclist from chest or abdominal trauma).

badhelmet2

These are just some of the issues that can make a huge difference when we are considering the question of whether or not bicycle helmets translate into real-world benefit from head injury.

As a thought experiment, let’s consider two worlds, A and B, both in which everyone correctly wore new helmets and were 100% compliant with their use.

However, in world A, 90% of bicycle accidents involved collisions with 18-wheelers travelling an average of 80 MPH. I can almost guarantee you that a bicycle helmet will make zero difference in preventing head injuries and fatality; with or without a helmet, chances are you will have a devastating head injury if you are involved in such an accident.

Compare that to world B where there are no motorized vehicles, the roads are soft and cushioned, and no one rode above 8mph. Helmets would probably make minimal difference in this world as well; with or without a helmet, chances are you will have no head injury if you are involved in an accident.

Somewhere in between these two extremes is a “sweet spot” where helmet use makes a significant difference in preventing head injury. Where that sweet spot lies on the spectrum of bicycle accident severity remains elusive.

How-to-Wear-a-Bike-Helmet

Show Me the Evidence

So on that note, can we definitively prove or disprove that wearing helmets prevents significant head injury in the world we live in today? The short answer is “probably not, and probably never.” Why? Because we cannot run randomized controlled trials (RCTs) to assess whether or not helmets can statistically significantly lower head injury rates.

Briefly, a RCT is an experiment commonly used in assessing new interventions (e.g. medications) to treat specific diseases. Basically, people with a certain disease are randomly assigned to one of 2 groups: one group that takes the new medicine, and one group that gets a “control” treatment or placebo. At the end of the trial, the outcomes are assessed, i.e. how many in each group are cured. Statistics are then run to see whether or not the new medicine significantly cures more people than the placebo.

To run a RCT on bicycle helmets would be unethical.[i] Such a trial would involve randomly assigning people into two groups, one with helmets, one without, then making these people ride their bicycles into planned collisions. Outcomes would then be assessed, i.e. how many in each group develop head injury, how many end up in comas, how many people end up dead.

Instead of RCTs, what we have are case-controlled studies (a type of retrospective study). Basically, the study looks at cases (people with head injuries following bicycle accidents) and controls (people without head injuries following bicycle accidents).  The cases and controls are then compared based on the exposure, in this case, helmet use. The study then calculates an odds ratio comparing the odds that a helmeted rider ends up as a case versus a control. It is important to note that such a study can only suggest causality and never prove it.

On this note, a recent Cochrane review [ii] found 5 well designed case-control studies and analyzed the data from these 5 studies. They found that helmets provide a 63 to 88% reduction in the odds of head, brain, and severe brain injury for all ages of bicyclists. Helmets provided equal levels of protection for crashes involving motor vehicles (69%) and crashes from all other causes (68%). Injuries to the upper and mid facial areas were reduced 65%.

The main problem with retrospective studies is that an innumerable number of confounding factors can mess with the data, which is why these studies can never prove. For example, one confounding factor might be that people who wear helmets just tend to be more careful and less reckless compared to those who chose not to wear helmets. Therefore, by being more careful, the helmet wearers may have been less prone to accidents in general, or at least less prone to accidents that required a trip to the ER.

 prove-it

Mandatory Helmet Laws

Currently, mandatory helmet laws are enacted for people of all ages in Australia, New Zealand, Finland, several states in the U.S [iii]., and Canada, while the Netherlands only enforces a helmet law for competitive cyclists [iv].

Mandatory helmet laws are far more prevalent for minors in the U.S. and around the world, and for the most part this issue is not as contentious, perhaps because there is more powerful evidence to suggest greater benefit for minors than helmet use in adults.[v] Furthermore, some policy makers would argue that minors may not yet have the ability to make an informed decision about the issue.[vi]

It is the debate over these laws that is particularly engaging because it not only involves the argument of the utility of the helmet itself but also of the encroachment on freedom and liberty.

In a 2012 editorial in the Journal of Medical Ethics, Hooper and Spicer[vii], two authors from the UK, argue against the idea of a mandatory helmet law in the UK. Salient points in their article include their cited figure that overall bicycle related death and injury in the UK in 2008 made up a small fraction of the total number of bicycle related casualties (104 deaths and 2606 injuries out of 17,064 reported cycling accidents). As such, a nationwide mandatory helmet law might end up costing more to implement than would benefit the UK public at large.

Another point that Hooper and Spicer bring up is whether or not a mandatory helmet law actually deters people from cycling, whether due to the financial burden of having to purchase an additional piece of equipment, or the sheer inconvenience of having to wear it before each ride. They mention this point in counter to a 2008 Cochrane review, [viii] which found that mandatory helmet legislation did increase the use of cycle helmets and decrease the head injury rate after implementation. Hooper and Spicer argue that the studies included in this Cochrane review did not look at the total number of cyclists on the road after the mandatory bicycle law was implemented.[ix] Indeed it is conceivable that helmet laws may in fact reduce the total number of cyclists on the road, thereby decreasing the overall frequency of bicycling accidents. This is a point that the Cochrane review article also concedes.

Australia potentially illustrates this phenomenon of lower numbers of cyclists after mandatory helmet laws. When helmet laws were passed in the early 1990s, cycling trips in fact decreased by 30-40% overall. Furthermore, a recent survey from University of Sydney found 23% of Sydney adults would ride more if helmets were optional, which is a significant number given that only about 15-20 per cent of Australians ride regularly.[x]

Interestingly, a “safety in numbers” trend has also been shown such that the injury rates for each cyclist in a given area is lower when there are more cyclists.[xi] This might be because with more cyclists on the road, drivers will be more accustomed to driving safely with cyclists. So decreasing the number of cyclists on the road, even if because of a mandatory helmet law, might end up hurting us in the long run.

strength-in-numbers

The Other Effects of Helmets

The effects of helmets may not just be physical, but also psychological. It has been proposed that drivers may be more cavalier in their driving habits when they drive around helmeted cyclists[xii], one explanation being the faulty logic that a helmeted cyclist is more protected, therefore drivers don’t have to be as careful around them. On the flipside, a cyclist might actually feel that with a helmet on, he/ she is more protected and so is more prone to cavalier cycling habits [xiii].

Other Factors as Important

A recent 2014 paper from Denmark[xiv] reviewed such factors, and determined the most significant ones that are associated with bicyclist injury. Being that Denmark is certainly one of the leading nations in the international cycling community, I found the findings of this paper particularly interesting. However, as mentioned above, this is also case controlled, so it doesn’t prove anything; it just reveals associations. Furthermore, being that it looked at data from Denmark, the noted associations may or may not correlate with other parts of the world. The following is the list of factors listed in this paper:

Age: younger cyclists had a higher probability of lower injury severity. At age 40 years or older, riders had a higher proportion of higher severity injuries, while elderly cyclists had a spike in high severity injuries and fatalities. My take on this is that the older you get, the less hits your body can take.

Intoxication: The study looked at four categories of riders: i. Sober with helmet, ii. Sober without helmet, iii. Drunk with helmet, iv. Drunk without helmet. They found that sober people wearing helmets had 7-10% lower association of severe injuries and fatalities compared to sober people without helmets. Interestingly, compared to sober riders without helmets, drunk helmeted riders had 60% increased odds of death, while drunk riders without helmets had a 457% increased association of death.

Collision partner: In decreasing order of injury severity, collisions with trucks were associated with greatest injury severity, followed by cars, followed by mopeds and other cyclists. Interestingly, drunk drivers were not significantly associated with increased cyclist injury severity possibly because there were so few cases.

Movement conflicts (Note that people drive on the right side in Denmark): In decreasing order of injury severity, collisions involving cyclist going straight and the collision partner turning left had the highest injury severity, followed by both parties going straight, followed by cyclist going straight and collision partner turning right, followed by cyclist moving straight and collision partner not moving.

Infrastructure: Higher speed limits were associated with higher injury severity. Bike lanes were associated with decreased cyclist fatalities, but interestingly were not associated with decreased minor or severe injuries. Multi-lane roads were associated with 10-15% increased association of severe injuries and fatalities compared to single-lane roads.

Environment: Slippery roads were associated with a 21% increase association with light cyclist injuries and a 48% increase in cyclist fatalities compared to dry roads. Darkness had a 10–13% lower association with severe and fatal cyclist injuries, interestingly enough. No significant difference was found between the effect of darkness and artificial illumination.

bicycle-accident-flooded-road

Conclusions

I haven’t given you any proof of anything. But I would still recommend a helmet. They can be pretty inexpensive; and even the most expensive ones for me have costed $90 each. I usually keep a helmet for a good 3-4 years, by which point one of the straps breaks, translating to $20-$30 a year. Not unreasonable. For me, I have already formed a habit of it, so it’s easy to continue wearing one. If you live in an area without a mandatory helmet law, then it’s your decision.

In terms of other factors, try to ride in quiet areas with low speed limits if you are starting out and unsure of yourself on the saddle. Be wary when riding in wet and slippery conditions. Be wary of cars turning left into you as you ride through intersections (for right sided driving areas).

Oh yeah… and don’t ride drunk.

Do good and ride well.



[i] Yilmaz et al. Comparison of the serious injury pattern of adult bicyclists, between South-West Netherlands and the State of Victoria, Australia 2001–2009. Injury, Int. J. Care Injured 44 (2013) 848–854.

[ii] Thompson et al. Helmets for preventing head and facial injuries in bicyclists (Review). Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD001855. DOI: 10.1002/14651858.CD001855.

[iv] Yilmaz et al. Comparison of the serious injury pattern of adult bicyclists, between South-West Netherlands and the State of Victoria, Australia 2001–2009. Injury, Int. J. Care Injured 44 (2013) 848–854.

[v] British Medical Association. Promoting Safe Cycling. London: British Medical Association, 2010.

[vi] Spicer et al. Liberty or death; don’t tread on me. J Med Ethics 2012;38:338e341. doi:10.1136/medethics-2011.

[vii] Spicer et al. Liberty or death; don’t tread on me. J Med Ethics 2012;38:338e341. doi:10.1136/medethics-2011.

[viii] Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries (Review). Cochrane Database Syst Rev 2008;(3): CD005401.

[ix] Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries (Review). Cochrane Database Syst Rev 2008;(3): CD005401.

[xi] Jacobsen PL. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Inj Prev 2003;9:205-9.

[xii] Spicer et al. Liberty or death; don’t tread on me. J Med Ethics 2012;38:338e341. doi:10.1136/medethics-2011.

[xiii] Hilman M. Cycle Helmets: The Case for and Against Them. London: Policy Studies Institute, 1993.

[xiv] Sigal Kaplan, Konstantinos Vavatsoulas, Carlo Giacomo Prato Aggravating andmitigating factors associated with cyclist injury severity in Denmark. Journal of Safety Research 50 (2014) 75–82.