Concussion Care: CTS article

Concussion Care: What to do after you hit your head

Earlier this week Toms Skujins of the Cannondale-Drapac Pro Cycling Team had a high-speed crash on a descent at the Amgen Tour of California. Because I had already finished riding the stage with CTS Athletes, I was watching the race on television. Like so many who watched it live and have since watched it in replays, I was immediately worried for Toms when he got up, struggled to remount his bike, fell over again, and continued to have trouble with balance and coordination. Over the past few days great articles have examined whether he should have continued (no), whether anything else could have been done in the moment (no), and what can be done in the future to prevent similar scenarios (good question). Rather than rehash those articles, I’d rather focus on what you should do if you suffer a concussion.

I am not a physician and therefore cannot provide medical advice, so my coaches and I follow the Medicine of Cycling concussion management guidelinesdeveloped in conjunction with USA Cycling.

BEFORE YOU CRASH: GATHER BASELINE DATA

In order to better understand how a head injury may be affecting you cognitively you need to have baseline data established before you hit your head. I crashed and hit my head in November 2015, but had no pre-injury data for doctors to compare to. Nevertheless, I followed the post-concussion protocol before returning to training and subsequent tests indicated improvement compared to the immediate post-injury test. Medicine of Cycling and USA Cycling recommend seeing a medical profession trained in concussion management for a SCAT2, imPACT, and/or BESS test.

BEFORE YOU CRASH: GET A NEW HELMET WITH MIPS TECHNOLOGY

Any helmet is better than no helmet, a new helmet is better than a year-old (or older) helmet, and a MIPS helmet provides greater safety than a non-MIPS helmet. In my view, best practice is to replace your helmet annually, or sooner if you are involved in a crash. You can debate whether annual replacement is strictly necessary for all cyclists, but I only have one brain so for me the peace of mind is worth the expense of a new helmet.

Why purchase a helmet with MIPS technology? MIPS stands for Multi-Directional Impact Protection System and it enables a helmet to slide relative the head when you impact the ground at an angle. This reduces rotational stress on your head and neck, which may reduce the amount of strain incurred by the brain as a result of a crash. It is not proprietary technology owned by any individual helmet company, so you can now find the technology in a wide range of brands. Through a long-standing relationship with Giro, my coaches and I protect our heads with Giro Synthe MIPS helmets.

WHEN YOU CRASH: BE DONE FOR THE DAY

The Medicine of Cycling concussion protocol includes in-race assessment tools to help anyone at a bike race – not just physicians – recognize the signs and symptoms of a concussion and take appropriate action. The vast majority of athletes reading this article are between the ages of 40 and 65, and virtually none of us are competing or participating in cycling events for anything other than personal goals. So let’s just make the post-crash decision ahead of time:

If you hit your head in a crash, you’re day is done.

To many of us old-school knuckleheads that might seem needlessly overcautious, but take a step back and think about it. We know so much more about the long term and cumulative effects of head injuries than we knew when we were in our teens and twenties racing and crashing without helmets. At this point in our lives and with where cycling fits in with your family, career, and lifestyle priorities, I struggle to find a justifiable reason to get back in the race or finish an event after hitting your head. If you are otherwise stranded and need to ride to get back home or to a place someone can meet you, ride slow and easy, preferably not alone.

AFTER YOUR CRASH: TAKE RECOVERY SERIOUSLY

Lack of follow-up is the biggest problem I see with athletes over 40 after they suffer a concussion. I can tell you from personal experience that following post-concussion protocols is inconvenient and frustrating, but those are not justifiable excuses for ignoring the protocols.

In my view, much of the resistance to follow through on the protocols is generational. If you are over 40 you grew up in an era when you were told to take a few days off – at most – and returned to training or racing as soon as you no longer had a headache. As usual I find it helpful to understand why experts believe prolonged rest is necessary. In a 2012 article in Velonews, neuropsychologist Eric Freitag described the mechanism of injury as a “metabolic dysfunction”. The chemical and electrical transmissions between neurons in the brain get disrupted, and the process of reestablishing homeostasis requires time and energy. Activities that require higher cognitive function direct resources away from this recovery process, which delays your return to normal function.

In the same way you have to balance stress with adequate recovery in order to create positive adaptations to physical training, you have to provide your brain with adequate cognitive recovery in order for it to return to normal function. While I realize this is probably a gross oversimplification of post-concussion recovery, as an athlete and coach I found it much easier to comply with the post-concussion protocols once I was able to relate it to physical training and recovery.

CTE AND CYCLING

The slow-motion epidemic of CTE (chronic traumatic encephalopathy) in retired football players, contact sport athletes, and combat sport athletes begs the question of whether cyclists are also at risk for this degenerative condition. Shortly after legendary BMX athlete Dave Mirra commited suicide in early 2016, Ian Dille wrote an article about cycling and traumatic brain injuries for Bicycling Magazine. In the article, Steve Broglio, director of the NeuroTrauma Researcher Laboratory at the University of Michigan reassured cyclists their risks of developing CTE are quite low. Repetitive trauma, particularly repeated trauma in an already-injured state, presents the biggest danger for developing CTE. To paraphrase Broglio’s comments, although cyclists may incur a handful of concussions over the span of many years, the long recovery intervals between head traumas dramatically reduces the risk of developing CTE.

From a purely anecdotal viewpoint my life experience in cycling leads me to agree with Broglio’s assessment of the risk. I raced as an elite amateur and professional cyclist in the 1970s and 1980s, before cycling helmets offered any significant measure of protection against brain trauma. There were a lot of crashes, a lot of concussions, and little to no post-concussion recovery. Thirty-five years later, however, I am unaware of anyone who raced in that time period who has developed symptoms suggestive of CTE. That’s not to say it hasn’t happened at all, but that at least anecdotally a population of cyclists who endured more head injuries than the average cyclist doesn’t appear to be experiencing CTE at anywhere near the rate of athletes who played full-contact sports during that same time period.

Overall I am highly encouraged by the advances in concussion assessment and treatment, as well as the advances in protective technologies like MIPS, ICE crash sensors, and Strava Beacon. Athletes like Toms Skujins benefit directly from a greater understanding of brain trauma, which reduces the pressure to return to training and competition too early. We only get one brain, so it’s crucial we do everything we can to protect it.

Be safe, wear a helmet, and have fun!
Chris Carmichael
CEO/Head Coach of CTS