by Dr. Nikita Fensham
When you think of swim, bike, run, you don’t typically associate it with being a dangerous sport; that’s reserved for contact sports like rugby or boxing, or extreme sports like ski jumping or gymnastics. But, as we emerge, albeit slowly, from lockdowns and the safety of Zwift in our pain/gain caves, readjusting to real environments -- with precarious terrain, surrounding road users, and vicious magpies -- brings with it an increased risk of getting a bit more acquainted with the ground than you may have wished.
With that in mind, it’s time for a short discussion about concussion: what it is, the symptoms to watch out for, and how to return to work and sport safely after it.
What is a concussion?
Concussion is a traumatic brain injury resulting from any direct blow to the head, face, neck, or body that results in a transmitted force to the head; so, just because your head was not directly involved does not necessarily mean that you could not have sustained a concussion. In addition, contrary to popular belief, loss of consciousness is not a requirement for diagnosis and may or may not occur, and the related symptoms may not be immediately apparent.
In effect during a head trauma, your brain moves within your skull cavity. While it is somewhat cushioned by the cerebrospinal fluid surrounding it so the movement is like slow motion, this movement still causes injury. The immune system responds by causing inflammation near the site of injury to promote healing. However, during the time those parts of your brain are swelling, they are unable to carry out efficiently the functions they’re in charge of. Other neural pathways take on the work until you’ve fully recovered.
The resulting impairment is functional rather than structural and so typical imaging techniques are not usually helpful, unless to rule out something more sinister; there is currently no objective diagnostic test specific for concussion.
How to recover from a concussion
In most cases, the pathology resolves if interruptions in recovery are avoided. So, following the steps to recovery are very important, because one typically feels well before everything has returned completely to baseline from a physiological point of view.
The first step is RECOGNITION OF SYMPTOMS. Following an injury, if any of the following “red flags” are experienced, it is important to seek immediate medical attention at an emergency centre: neck pain/tenderness, double vision, weakness or tingling in the legs, headaches increasing in severity, seizure, loss of or reduced consciousness, vomiting, or increased restlessness or agitation.
Furthermore, if you or someone else witnesses you lying motionless on the ground, struggling to get up or maintain balance, being disorientated or having a blank/vacant stare, these are signs that increase the likelihood that you have sustained a concussion.
Finally, symptoms that you may notice following a concussion are: headache, dizziness, nausea, light or noise sensitivity, difficulty concentrating or with memory, fatigue, and fluctuations in mood.
Therefore, after an injury where you potentially sustained a concussion, you should not be left alone for two hours afterwards, you should not drive, you should not consume any alcohol or drugs, and you need to seek medical attention even if your symptoms resolve.
The next step is to REST. Complete physical and cognitive rest is advised for 24-48 hours after injury, after which you can gradually increase activity. This involves resting at home in a quiet environment, limiting screen time and social events, and sleeping as needed. Evidence now suggests that complete rest beyond 48 hours is not recommended.
The next stage is to RETURN TO ACTIVITY, including both physical and cognitive. Progressing to the next step is based on 24 hours between with no further worsening of activity; if symptoms persist, it is suggested that you go back to the previous step.
Step 1: Light physical activity keeping heart rate less than 50% of max, including walking or stationary cycling. Daily activities such as shopping, using a computer, and reading.
Step 2: Increase activity levels with things like jogging. Return to working part-time, taking regular breaks every 20-30min.
Step 3: Activities involving resistance or co-ordination can now be introduced. Less frequent breaks may now be tolerated, although you may need to make some modifications at work, such as a quieter room.
Step 4: Now it’s time to chat to your doc again and get full clearance to go back to training. Full-time work should now be tolerable, although it is advised that those operating heavy machinery or working from height get cleared by a medical doctor first.
If at any time your symptoms get worse, you experience any of the red flags, your symptoms last longer than 10-14 days (4 week in children), or you are just concerned at any time, please consult a doctor. They will be able to conduct a full assessment as well as refer you to other professionals, such as physios or neuro-psychologists, who can facilitate your recovery.
Don't rush the recovery!
If you’ve previously suffered from concussion, you become more susceptible to concussions especially during the first year after head injury. Repeated brain trauma can result in the brain failing to heal completely, resulting in post-concussion syndrome: headaches, forgetfulness, personality changes, or worse.
Remember, the long-term consequences of returning to activity too soon or risking a second blow are not worth that sneaky session you decide to do to satisfy the obsessive persona of a triathlete! If this year has taught us anything, it’s to be patient.
P.S. It goes without saying, I hope, but remember to always wear a helmet while riding – they do not prevent concussions, but they do reduce the risk of something even worse happening to your head!
P.P.S. If you want to learn more and download some resources, check out www.cattonline.com
This article should not be considered medical advice and is instead intended to be the opinions of the author. Always seek independent medical advice before making any decisions based on your health.