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Toolbox: Concussions in Cycling
Sport-related concussions (SRC) can occur in almost all sport activities. However, the risk and severity of SRCs can be greater in cycling since crashes often occur at high speeds with only the protection of a helmet.

The recommendations of the 5th International Consensus Conference on Concussion in Sport were recently published in the 2017 Consensus Statement on Concussion in Sport (1) with some changes in the recommendations for management of SRCs.


Dan Martin's helmet after the stage 9 crash with Richie Porte. Thanks to the Quick-Step Floors team for the photo

Diagnosis of a SRC
The diagnosis of a SRC is largely the same as recommended in previous Consensus Statements on Concussion in Sport. The common features that are used to define the nature of a SRC (1) include:

• A direct blow to the head, face, neck or elsewhere on the body which causes an impulsive force to the head.

• Rapid onset of short-lived impairment of neurological function that resolves spontaneously

• Neuropathological changes which reflect a functional disturbance and not a structural injury.

• Different clinical symptoms and findings, which don’t necessarily involve a loss of consciousness, and which resolve in a sequential course.

Evaluation of someone with a possible acute SRC can be challenging as the clinical symptoms and signs can rapidly change. Therefore, anyone suspected of suffering a SRC should immediately stop training or competing and be evaluated by a health professional. The acute symptoms of a concussion can include:

• dizziness
• headache and neck pain
• 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
• sleep disturbance

The Concussion Recognition Tool 5 (2) can also be used to help identify if someone has suffered a concussion. Similar to many sporting events, the decision to return to cycling, especially during a competition, often has to be made quickly. Ideally, a cyclist’s condition should be assessed in a quiet area away free from people and distractions.

An assessment of a cyclist’s orientation, cognitive function and coordination can be done using the Sport Concussion Assessment Tool 5 (SCAT5, 3). The SCAT 5 has been revised from the SCAT 3 to include a 10 word list for assessment of memory dysfunction. If an athlete reports any symptoms, regardless of severity, or if the SCAT5 assessment is abnormal in any way, the cyclist should not return to training or competition.

The athlete should be monitored closely for the next several hours for the development of new symptoms or change of consciousness and be reassessed by a health professional the following day. In the acute phase of a SRC, one should not consume alcohol or use recreational drugs or other medications which may affect one’s level of consciousness or cognitive function. One should also not drive or operate machinery, including a bicycle. If no concerning neurological symptoms develop, then diagnostic imaging of the head for a structural injury of the brain is usually not required. Currently, there are no specific medical tests for diagnosing a SRC.

Management of SRC
Up to now, it has generally been recommended that athletes who suffer a SRC should not return to physical activity until their concussion symptoms had completely resolved. However, the recommendation of 2017 Consensus Statement on Concussion in Sport is now that athletes should be rested from provocative physical and cognitive activities for at least 24 to 48 hours. Thereafter, athletes can start returning to physical and cognitive activities at a level that does not worsen their concussion symptoms.

This usually requires starting physical activity (not training or racing) at a very low intensity for a short period of time. For example, walking or stationary bicycling at low intensity for 10 to 15 minutes per day. The intensity and duration of physical activity can be slowly increased as long as one’s concussion symptoms are not worsened.

During the acute phase of a SRC, one’s symptoms can also be aggravated by work and school-related cognitive activity and should be modified appropriately. Most adults recover from a SRC after 10 to 14 days. During this time, rehabilitation for neck pain, vestibular dysfunction and mental health symptoms should be treated by an appropriate qualified health care practitioner (eg. physiotherapist, chiropractor, osteopathy, massage therapist or psychologist) who is familiar with managing SRC.

Return to Sport
Once one’s SRC symptoms have resolved, an athlete can continue to gradually increase the volume, intensity and complexity of sport-specific training in a step-wise graduated manner. An example of such a step-by-step protocol for a cyclist could be as follows:

Step One: Symptom-limited activity and gradual return to work and school until symptoms have resolved.

Step Two: Low intensity aerobic exercise: Stationary bicycling (NOT rollers) x 30 minutes at low intensity (eg. < 60% max HR).

Step Three: Stationary cycling x 45 minutes at moderate intensity (eg. 60 to 75% max HR).

Step Four: Stationary cycling x 60 minutes at moderate intensity (eg. 60 to 75% max HR) with 60 second maximum effort sprinting at minutes 15, 20 and 25.

Step Five: Solo riding on road, track or trail x 60 minutes at steady moderate intensity (eg. 60 to 75% max HR). Light weight-training can also be added at this time.

Step Six: Solo riding on road, track or trail x 60 minutes at higher intensity with multiple maximum effort prolonged sprints and/or hill riding. Technical riding can be added with BMX and mountain biking.

Step Seven: Regular riding including group ride with sprints, climbing, pace lines, normal technical riding and racing.

Each step of the protocol should take at least one day. If any SRC symptoms re-occur at any step of the protocol, the athlete must reduce their physical activity to a level at which their symptoms are not brought on or aggravated. If one’s SRC symptoms persist more than 14 days and/or if one is unable to progress through the step-wise protocol without bringing on symptoms, they should be assessed by a medical professional who is familiar with the management of SRCs.

Long-term Effects of Repeated Concussion
If one suffers multiple concussions, it may become easier for one to suffer more in the future. One may notice that their SRC symptoms are more severe and take longer to resolve each time a concussion is suffered. Chronic cognitive dysfunction (concentration and memory) and mental health symptoms (depression and anxiety) may develop. Neuropsychological testing could be considered if one’s cognitive function becomes chronically impaired.


A terrible case of concussion - Toms Skujins in the Tour of California

Concussion Prevention
In cycling, essentially the only way to possibly prevent and/or reduce the severity of a concussion is to wear a properly fitting safety-approved helmet. Helmets with the Multi-directional Impact Protection System (MIPS) may have increased protection by reducing rotational forces on the brain resulting from angular impacts. Helmets should always be replaced after sustaining any significant impact, especially if there is a visible damage to the external shell or foam liner or about every 5 years if only exposed to normal wear and tear (4, 5).

Another important but neglected form of prevention is specific skills training on the bike. Too many cyclists focus on the physical training and not enough on specifically working on bike handling skills. On recovery days, consider practicing cornering and slaloming at a safe and quiet parking lot. Try to do a U-turn and figure 8 turns within a parking stall. Work on bunny hops over a white line, progressing to rolled up tee shirts and 2x4s. Get friends together at a grass field and practice making contact with elbows, handlebars, and wheels. For dedicated roadies, try riding gravel roads, CX, or MTB. The increased comfort with wheels sliding underneath you on loose surfaces can come in tremendously handy when that happens on asphalt.

References
1. http://bjsm.bmj.com/content/early/2017/04/27/bjsports-2017-097699
2. http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097508CRT5
3. http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097506SCAT5
4. http://www.bhsi.org/replace.htm
5. http://www.smf.org/helmetguide

WRITTEN BY: Dr. Victor Lun, MSc., MD, CCFP(SEM), Dip. Sport Med. is a Sport Medicine doctor who practices at the University of Calgary Sport Medicine Centre. He is the team physician for the University of Calgary Dinos Football team and several winter and summer sport Canadian national sport teams.

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.

 

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