Training tips: Concussion management

Understanding Concussion
Despite concussions becoming a hot topic in the media, concussion remains one of the most complex and misunderstood injuries amongst the general population. There are many concussion myths that have long confused patients and professionals alike. Contrary to popular belief, a concussion is not a bruise on the brain and does not require a loss of consciousness. In fact, it is not necessarily structural damage to the brain at all. Concussions are a functional disturbance of the brain, altering ionic balance and metabolism¹. Think of a snow globe. When you shake a snow globe, nothing inside breaks, but everything becomes fuzzy and confused. For this reason, concussions cannot be diagnosed with typical diagnostic tests such CT-scans or MRIs.

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The lack of diagnostic tests adds to the challenges of concussion management. Missing or misdiagnosing a concussion is not only dangerous, but can even be life-threatening. Keep in mind that concussions are classified as mild traumatic brain injuries and should not be diminished with phrases such as ‘getting your bell rung.’ Concussion management should be handled with caution and an educated approach.

Signs and Symptoms
The first step in concussion management is recognizing that a concussion has occurred. Concussions can happen anytime that the head encounters a force directly or indirectly. Following the mechanism of injury or in a cycling case, likely a crash, you may begin to experience a variety of signs and symptoms.

The most typical concussion symptoms include but are not limited to headache, nausea, balance problems or dizziness, fatigue, irritability, difficulty concentrating or remembering, sensitivity to light or noise, blurred vision, or general discomfort or uneasiness. Following head trauma, you should be observed for any of these disturbances as well as directly questioned as to the intensity of these signs or symptoms on a scale of none to severe.

The best way to detect these symptoms is by performing a baseline test prior to participating in sports and comparing the results of the baseline test to the results of the post-trauma test. Baseline concussion tests should ideally be performed by a qualified medical professional and will usually utilize a SCAT3 form or an online ImPACT test. These tests will account for individual differences in day to day memory, concentration, coordination, and balance.

Immediate Concussion Management
Once diagnosed with a concussion, you should immediately discontinue exercise. Most concussions do not require immediate referral nor do they usually need a visit to the hospital. Most concussions can be managed from home with appropriate rest. You may rest, sleep, and take acetaminophen (e.g., Tylenol). Do not take ibuprofen, aspirin, or Advil because if there is an unknown brain bleed these could increase the bleed. You should be monitored, but there is no need to have someone wake you up every hour throughout the night.

While immediate referral is usually not necessary, you should take immediate action and go to the hospital if your condition worsens, if memory does not return within 15 minutes of the trauma, if there is a loss of consciousness, vomiting occurs, or other necessary bodily functions such as breathing or pulse begin to change.

Return to Play Guidelines
After sustaining a concussion, you should not complete any exercise for a minimum of 24 hours. After 24 hours, or when the symptoms begin to improve, a qualified health care professional should be consulted before returning to cycling or other activities.

As long as you are experiencing any form of concussion symptoms, physical activity is off the table. Once symptoms are fully resolved, you may begin a progression of Return to Play. Each stage in the progression should be separated by 24 hours. If symptoms are experienced during one of the stages in the Return to Play progression, wait 24 hours before you attempt to repeat the stage.

The National Athletic Trainers’ Association outlines the Return to Play progression as follows: (1) no activity, (2) light exercise, (3) sport-specific activities without the threat of contact, (4) noncontact training (such as strength training), (5) un-restricted training, and finally (6) full return to play¹. From a cycling standpoint these stages might be translated as follows: no activity, an easy spin on a stationary bike or trainer, a normal or more strenuous workout on a stationary bike or trainer, a road ride with one to two other people, mountain biking or group/pack riding on the road, and finally, return to normal or unrestricted training.

Simply put this means that once you are completely symptom-free from a concussion you should still wait six to seven days before going full-gas on your bike.

Concussion Complications
Why is there so much concern and precaution surrounding concussions? The answer is that there is still a lot unknown about the long-term impacts of concussions and the short-term dangers can be extremely significant.

The main danger and fear of returning to sports too soon after a concussion is the risk of Second Impact Syndrome. Second Impact Syndrome occurs when a second concussive force occurs before the initial concussion has healed. When this happens, major neurological disturbances may develop and can lead to the swelling of the brain and even death. When vision, coordination, and balance are impaired during any concussion, the likelihood of sustaining a second concussion increases and so should the fear of Second Impact Syndrome.

Furthermore, returning to sport too soon after a concussion may ultimately lead to a longer recovery or prolonged symptoms that can linger for weeks or even months.

Play It Safe
When it comes to concussions, the bottom line is the classic, ‘better safe than sorry.’ Since signs and symptoms are the best indicators of concussions, education may be the most powerful tool of all. The sooner we all understand the potentially life-altering risks of returning to our bikes too soon, the more likely we will listen to the signals our bodies are giving us to recover.

Sources
1. Broglio, Steven P., et al. “National Athletic Trainers’ Association Position Statement: Management of Sport Concussion.” Journal of Athletic Training, vol. 49, no. 2, 2014, pp. 245–265., doi:10.4085/1062-6050-49.1.07.