Traumatic brain injury: lessons learned the hard way

When people are asked what sports are at high risk for concussions, the first answers are typically American football, boxing, or even slap fighting. Rarely is mountain biking mentioned, but it is about time the sport takes concussions seriously. In gravity mountain biking disciplines like downhill, athletes are speeding down uneven terrain at over 70 kmh. There’s a reason we wear a helmet.

A concussion, or traumatic brain injury (TBI), is a complex injury. It is also a very different type of injury than athletes and coaches typically experience as you cannot see it externally, or even with imaging. And the symptoms can present themselves in any number of ways. Over years of coaching mountain bikers, I’ve had several athletes with concussions. Below are some key points I’ve learned the slow and hard way about how cycling, as well as other sports, needs to improve our approach to concussions.

What is a concussion?

For years we ignored the concussion problem in cycling, just like it was ignored in other sports. The “it’s only a knock” approach was sadly all too common.

Now the pendulum is starting to swing in the opposite direction. With more awareness, however, a “too cautious” approach is also developing. Excessive and unnecessary rest also brings along its own set of risks, such as those created when cyclists return to racing after prolonged periods away from their bike.

We all have an obligation to do better. Over and under diagnosis are two ends of the poor quality care spectrum. Life at either extreme isn’t the answer. We need to embrace the middle more and acknowledge that not every head trauma is a concussion, but every potential concussion should still be taken very seriously. This comes through integrated education, testing, screening, and rehabilitation processes.

Going back to school

Education is lacking in many sports, especially cycling, and more specifically the gravity mountain biking disciples. While top down education initiatives from governing bodies have been launched, an integrated approach where bottoms up meets top down is essential if we want to see real change.

This means education programs need to be more than a slide deck, and should involve high profile athletes as well as key support staff like physios, managers and coaches not just as students, but as participants in defining the holistic approach. For example, systemic changes need to be implemented in parallel with education. Education can teach about the importance of recovery after a concussion, but, if riders see their world ranking plummet, their incentive will always be the opposite. Sporting systems and points allocation need to be adjusted to take into account the longer term effects of concussion and missed races due to symptoms and recovery. The more accepted it is to take the needed time off to recover and rehab from concussion, the less likely riders will try to hide symptoms or return to competition too soon. This behavior would then have a positive downstream effect on concussion awareness at grassroots levels.

Simply put, a coherent bottom up and top down approach to concussion education, awareness, and diagnosis, as well as management is needed.

Taking the tests

In order to measure the impact of an injury, it is extremely helpful to understand that athlete’s starting point pre-injury. Therefore baseline testing is very important. That importance means your “tests” need to be sound. That is they need to be valid, repeatable (inter and intra tester), and sensitive. This point cannot be overstated.

Sensitive and reliable testing is KEY because TBI can cause many connected but distinct symptoms through the multiple connected perceptual systems. Sensitive testing, along with graded and monitored exercise exposure allows us to understand where, and in what systems, short and long term symptoms are presenting themselves.

Somewhat related to testing, technology should also be helping us more than it is. Instrumented mouth guards, earpieces and helmets are available and, depending on the sport in question, are commonplace. Technology like this will not diagnose athletes, but they can help us learn about what levels of impact are likely to cause what type of concussive problems, and then we can tie that into appropriate screening and rehabilitation recommendations. I feel there is a burden for technology companies, researchers, elite level teams and staff to create coherent and integrated systems to help benefit their sports from the top down in the future. Lessons learned at the elite level can inform athletes at all levels of the sport.

Rethinking rest

Traditionally our response to injury has been rest. Break your leg? Put a cast on it and rest. Injury your brain, close your eyes and stop thinking.

The more we learn about injuries, we start to see that rest is not always the best answer. World leading rehabilitation specialists like Bill Knowles have shown that movement can be medicine for soft tissue injuries. More and more research shows that this can also be the case for traumatic brain injuries.

Other than the needed 48-72 hours of rest from exercise, sport, screens and loud or busy environments immediately post head injury, athletes who have had a concussion or suspected concussion should be encouraged by the professionals providing care to start a controlled and monitored exercise program as soon as possible. Rest often hides symptoms, and the longer symptoms are hidden the more challenging a full recovery can be.

While initial exercise may be restricted to safe modalities like stationary cycling, athletes can progressively use more challenging exercise that is related to their concussion testing protocols to help screen for tolerance to and improvement of symptoms. This approach can quickly identify which athletes need more specific post concussion care.

Looking for the hidden symptoms

When people think of concussion they often think of brain trauma like swelling, inflammation and even bleeding; but post concussion syndrome and longer term concussion issues for mountain bikers are most often caused by vestibular, visual or neck issues caused by the trauma of their concussion. Sadly sensitive testing and the required expertise to interpret these tests is hard to source, but it does exist. I’ve had the pleasure of visiting the Swiss Concussion Centre in Zurich and working with the excellent Dr. Nathan Kaiser from the USA, seeing first hand the power of integrating sensitive testing and targeted rehabilitation.

In gravity mountain bikers especially, visual and vestibular integration is the most relied on perceptual-motor subsystem. Balance and vision are crucial when your speeding down uneven terrain. Professionals and teams in any spor,t but certainly cycling, need to do a better job of being educated as to how to spot visual and vestibular issues (as well as the often related cognitive and emotional changes). This, along with a strong referral system, would allow us to screen, identify and if needed refer riders for specific ocular motor testing. Careers have certainly been cut short by the lack of knowledge or access to ocular motor testing and rehabilitation. 

Moving forward

The faster sports get, the more they are played, and the media will cover and pressure athletes to progress. All this will lead to more concussions. No matter how good protection or monitoring equipment becomes, the array of ways in which brain trauma can occur in sports means that us, the coaches, physios and physical preparation staff, have a duty to upskill. We don’t all need to be concussion specialists, but we should be aiming to have enough knowledge and education to safely deal with and help manage acute concussions as well as help identify lingering issues through carefully implemented and integrated RTP protocols.