By Victor Lun, MD
Concussions can occur in almost any sport. However, the risk and severity of concussion injury can be magnified by the high-speed nature of cycling. The mechanisms of brain injury associated with concussion injury are not completely understood. However, It is important to know that one can suffer a concussion without losing consciousness or having memory loss. Once someone has experienced one concussion, it is easier to suffer more in future and symptoms can become more severe and last longer each time a concussion is suffered.
The acute symptoms of a concussion can include:
• nausea and vomiting
• ringing in the ears
• slurred speech
• feeling ‘in a fog’
• double or blurred vision
• sensitivity to light or sound
• difficulty with memory and concentration
• poor co-ordination and balance
Tools for Diagnosing Concussions
Similar to many sport events, the decision to return to cycling training and/or competition often has to be made quickly. Ideally, a cyclist’s condition should be assessed in a quiet area away from teammates and other distractions. A rapid assessment of a concussed cyclist’s orientation, memory, concentration and co-ordination can be done using the Sport Concussion Assessment Tool 2 (SCAT 2), which was developed by the Zurich Concussion Consensus. The SCAT2 can be completed using a paper copy, on a web-based progam, or as an iPad, iPhone, or iTouch application.
If an athlete reports any symptoms, regardless of severity, or if the SCAT2 assessment is abnormal in any way, the cyclist showed immediately be removed from training/competition. The athlete should not be left alone and must be watched for the development of new symptoms or change of consciousness. The cyclist should be evaluated by a physician. If there is any doubt, keep the cyclist out!
What not to do immediately after suffering a concussion:
• Any physical activity
• Consume alcohol or take sleeping pills or anti-anxiety medications
• Taking acetominophen, ibuprofen (or other anti-inflammatory medication), narcotics or any other medications to treat headache pain. One should actually use headaches to monitor the possibility of a more serious head injury. If the severity of headache progressively increases or becomes unbearable, then one should immediately seek medical attention.
• Driving or operating machinery, including their bike
Getting Back on the Bike
Once a cyclist has been diagnosed with a concussion and removed from training and competition, regardless of perceived severity, safely returning to cycling is a critical aspect of properly managing a concussion. Return to exercise activity before symptoms have resolved will prolong the time that it takes for the concussion to resolve and potentially lead to more chronic symptoms of concussion including headache, concentration and memory dysfunction, and balance problems.
A cyclist should completely rest from all physical activity (including weight training and non-sport specific crossing-training, etc.) until they are completely symptom-free for at least 24 hours. The time required to become asymptomatic can vary greatly so there is no pre-determined time that a concussed athlete has to rest, as long as they are asymptomatic prior to returning to physical activity. The duration of this asymptomatic period may also be extended depending on a cyclist’s past concussion history. Minimizing cognitive stimulation (e.g. school work, computer work and games, etc.) may also be needed if these activities aggravate one’s concussion symptoms.
Ideally, the concussion should be managed by a physician who is experienced with concussion injury and clears the cyclist to start a graduated return to exercise protocol. An example of such a step-by-step protocol could be as follows:
Step One: Complete rest until no symptoms are experienced for at least a 24-hour period
Step Two: STATIONARY cycling (not rollers) x 15 minutes at low intensity (e.g. < 60% max HR)
Step Three: Stationary cycling x 30 minutes at higher intensity (e.g. ~ 75% max HR)
Step Four: Stationary cycling x 30 minutes at higher intensity (e.g. ~ 75% max HR) with 30 second sprinting at minutes 10, 15 and 20.
Step Five: Solo riding on road x 30 minutes at steady intensity (e.g. ~ 75% max HR)
Step Six: Solo riding on road, track or trail x 45-60 minutes at higher intensity (e.g. ~ 75% max HR) with sprinting. Low-level technical riding can be added with BMX and MTB. Light weight-training can also be added at this time
Step Seven: Group ride with sprints, climbing, pacelines, and normal technical riding.
Each step of the above protocol should take at least one day in between. If any concussion symptoms re-occur at any step of the protocol, the athlete must immediately stop all physical activity again until they are free of symptoms for at least 24 hours before trying the protocol from step one again!! It may seem a frustrating game of snakes and ladders, but remember that rushing the process only prolongs the overall recovery time while putting you at long-term risk for damage.
If an athlete is unable to progress through the return-to-exercise protocol without symptoms, they should be assessed by a physician again.
Given the nature of sports it is hard to prevent all concussions. In cycling, essentially the only way to prevent and/or reduce the severity of a concussion is to wear a properly fitting safety-approved helmet. Remember that helmets are not meant to last forever, and should be replaced regularly or after sustaining any significant impact.
Some useful references regarding concussion injury:
1. P McCrory, W Meeuwisse, K Johnston, J Dvorak, M Aubry, M Molloy, R Cantu. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009;43:i76-i84 doi:10.1136/bjsm.2009.058248.
Dr. Victor Lun, MSc., MD, CCFP, Dip. Sport Med (CASEM is a Sport Medicine doctor who practices at the University of Calgary Sport Medicine Centre. He is the team physician for several the winter and summer sport Canadian national sport teams and a medical director at the Canadian Sport Centre Calgary.
Medical Advice Disclaimer
The information included in this article is for educational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult their healthcare provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a medical condition or treatment plan. Reading the information on this article does not create a physician-patient relationship.