WALK IT OFF:
CHANGING WHAT WE THINK WE KNOW ABOUT CONCUSSIONS

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Four years ago I spent five minutes not remembering who I was – and then I spent six months worrying that I would never be the same again. When I came to after my crash my helmet was broken and my brain was bleeding internally. Breaking your brain, in an instant or cumulatively over many small bumps, can forever change who you are and how you deal with your reality, and progressively we are learning about the dangers involved with concussions. To date, this has mostly been through research funded by other professional sports, but when parallels were drawn between Dave Mirra and the NFL players who have suffered with Chronic Traumatic Encephalopathy (CTE), it brought the reality of brain injuries squarely to our two wheels with an urgency that would be foolish to ignore.

The problem with the human brain is that it is extremely complicated. If you compound fracture your leg you can look down and using your healthy uninjured brain think ‘well, shit, that’s bad.’ When you bump your head however you may look completely fine – but be completely f*cked. It is also important to note that the brain doesn’t have the pain receptors our limbs have, injuries to it may not be immediately felt as they would with a broken bone. Everything from how many concussions you’ve had previously, to the shape of your skull, damage from drug or alcohol abuse, and the force of the impact itself can all play a role in the level of resulting damage. Even how well you have weathered life’s traumas in the past can dictate how much your brain can withstand.


Our frontal lobe is the biggest lobe and also the area most impacted from falls. Here is where we find our conscious thought, voluntary movement, and individual personality characteristics. Damage to this area can impair judgment, attention span, organizational ability, and can cause you to lose motivation. It can also leave you blissfully unaware that there is anything even wrong. The result can be impulsive and rash behavior that is uninhibited and inappropriate, and in the long term patients can experience such things as depression, anxiety, memory loss, and sleep disturbances. Unfortunately, in extreme cases when it is impossible to work or maintain relationships, the sufferer will often turn towards substance dependence in order to cope.

Studies have shown that the biggest improvements relating to recovery happen within the first few weeks post injury, although less rapid improvements have been observed up to three years following. Once a brain is injured however there is no ultimate cure. Any treatments will focus on enhancing remaining skills and honing adaptation strategies to compensate for those that are lacking. And unfortunately, it is the most often affected frontal lobe that is the most difficult and slowest to recover.


Tyler McCaul has experienced his fair share of head injuries over the years. This past season he had an exceptionally bad crash at Rampage and was hospitalized with a pulmonary contusion and bad concussion: “I can definitely attest to how concussions can change you, and although the changes are usually temporary, it’s still a scary thing in the moment.” After the crash, Tyler experienced quick and unexplainable changes in mood that would take him to dark places mentally. He experienced anxiety, confusion and depression, all for no reason apparent to him. Luckily these symptoms have now passed and Tyler feels back to normal but at the time he was embarrassed to talk to anyone about it. He now realizes that it is something people need to be aware of as chances are they or someone they know may one day be dealing with a concussion.

A so-called ‘closed’ head injury often exhibits no outward signs and yet with astounding speed and force, your brain may have just collided with the inside of your skull. And what’s more, impacts taken to the feet or other parts of the body can transmit shockwaves to your brain that cause a concussion without you even having sustained a direct hit to your head. The same goes for impacts to the back of the head resulting in frontal lobe damage because the brain is forced forward and collides with the front of the skull. When Geoff Gulevich fell 45 feet off the Oakley Sender a few years ago he was adamant that he hadn’t hit his head. The medic on site administered a SCAT (Sports Concussion Assessment Tool) based exam anyway, given the shock that had been absorbed through his body on impact. In his case, after two hours of observation, he was cleared to ride. Through that experience though he became aware that head injuries come in all different types of crashes and ‘saves’, and he now believes that “people really don't take concussions seriously enough, and with the research coming out of the NFL, I think we all need to be more aware”.


Just walk it off. This has been every coach’s answer to a non-incapacitating injury for the last century. Really, it wasn’t until a decade ago when Dr. Bennet Omalu discovered CTE – a progressive degenerative disease found in people who have suffered a severe blow to the head - that our thinking began to change. In 2011 both the National Football League (NFL) and the National Hockey League (NHL) changed their Concussion Protocols and developed their own initial testing for all head and neck trauma incidents. The NFL now conducts an evaluation based on the SCAT; a standardized test and focused screening neurological examination that is aimed at excluding cervical spine and intracranial bleeding. There is also an assessment of orientation, immediate and delayed recall, concentration, and a balance evaluation. Much like in other professional sports, doctors in the NFL find themselves in a conflict of interest, not wanting to let down the team or team owner with a diagnosis that would affect play. Due to this an independent neurologist assesses players. In the NHL any player who has sustained head or neck trauma is immediately removed from the ice and placed in a quiet room for a minimum of 15 minutes while they complete testing similar to that followed by the NFL protocol. If they show any signs of concussion they are not allowed to return to play, nor will they be until the can pass future psychological and cerebral tests.


While the steps taken by both the NHL and NFL are impressive and demonstrate the seriousness of such a trauma, perhaps the most progressive of all major sports leagues in this regard is that of Major League Baseball. In 2007, they implemented official sideline tests based on SCAT2 for players and umpires, but they also require that everyone conduct baseline testing following player signing and during spring training. Further, to these baseline measures, there is a 7-day and 15-day disabled list for players with concussions, and the league’s medical director must clear all players who have suffered a concussion before they return to play.

Dr. Rui Avelar, who spent thirteen years as the Team Doctor for the Vancouver Canucks says that it is typical of a sport that is early in its concussion appreciation evolution to not have standardized protocols in place across competitions. A major and important function of a well-designed concussion protocol is that it takes the return to play decision out of the hands of the injured athlete, because as he says “nothing else works.” Not only do professional athletes in our sport already have pressures stemming from career goals, sponsor expectations, cash prizes, and simple pride, to expect the potentially brain injured to make a responsible decision about whether or not to continue in competition is absurd. All aspects of organized mountain biking - events, societies, associations, and clubs - should have a protocol for head injuries in their rulebooks or guidelines. In this way riders would not be wimping out, they would be following the rules.


Gregory Clark, MD, CCFP-EM is the Associate Chief for the Department of Emergency Medicine MUHC at Royal Victoria Hospital in Montreal. Once a year he spends a week of his summer traveling with the BC Bike Race as Medical Director. He, along with Safety Director, Brooks Hogya, have developed a concussion protocol for the seven-day stage race using the SCAT3. The entire medical team (approximately nine people on the course and ten at basecamp) is given information on how to use the tool prior to the event. If a rider has a suspected concussion corroborated by a SCAT3 showing a high likelihood, Dr. Clark will administer the exam a second time before pulling them from the race. This extra step is two-fold. One, while everyone on the medical team is competent to administer the exam not everyone has the same amount of training with it, and two, he understands that disqualifying a rider from the remainder of the race is not something to be taken lightly. As he says, “It is a big deal to tell someone who has trained long and hard that their week of racing is over.”


If a rider breaks their helmet but the SCAT3 isn’t indicative of a concussion, the rider must still liaise with Dr. Clark – and replace their helmet before racing the following day. In order to enforce this rule the attending medics will remove the rider’s race plate. The plate, and attached timing chip, is returned when they have been medically cleared. During this step in the protocol the racer will be put through a progressive series of activities to see if they elicit any concussion symptoms. If they do, they will be pulled from the race. If they do not they will be allowed to return to play.

SCAT3

One of the major challenges that we face in implementing concussion protocols is that mountain biking is not a spectator sport. We do not have a contained field of play, and often these injuries happen on unobserved areas of a racecourse. This is a challenge that Tara Mowat, the High-Performance Team Manager for Cycling BC is up against. This year she will be implementing a newly designed concussion protocol for the Cycling BC Team. Riders will be required to complete a baseline SCAT3 exam at the beginning of their season. The completed exam will then be uploaded to a medical database accessible through a phone app to parents, coaches, and other pertinent personnel throughout the year. As we all vary in our abilities with memory at the best of times, Tara feels strongly that having a baseline to compare further SCAT exams too is key to her program. But her biggest challenge remains how to examine racers who don’t admit or don’t think they have concussion symptoms.

At the root of it all, we need to deprogram generations of thinking. We need to stop applauding racers who finish injured and we need to stop cheering “get back on the bike and finish!” to those racers who crash in front of us. When he was younger Tyler McCaul says he took the gamble and competed at an event even after he hit his head in practice. “I used to think that as long as I didn’t have a broken bone I was fine, so I would be stupid not to compete.” Today riding with a concussion is something he doesn’t take lightly. It slows your responses and causes you to be more likely to make another mistake that could lead to further injury. Post Concussion Syndrome causes your brain to lose its ability to auto-regulate and therefore a second injury could result in a more pronounced brain injury or death. It’s more important to look at the bigger pictures, Tyler says, rather that worrying about getting a result that weekend.


In 2013, Brayden Barrett-Hay was competing in his first ever Crankworx at Whistler when he crashed off a drop at the beginning of his run. “The next thing I remembered was four days later in the hospital.” Brayden had a Traumatic Brain Injury (TBI) with six different bleeds in his brain. Luckily for him, the bleeding stopped before doctors had to operate and induce a coma. Terrified he would never be the same, Brayden struggled with a lack of knowledge in the medical system about what he was experiencing and the diagnosis from three different doctors that he should never ride his bike again. A year later Brayden was back on his bike and feeling like his normal self. During a contest that year, however, he hit his head again and withdrew. “At this stage in my riding, if I hit my head and feel weird at all, like uncoordinated on my bike, that’s when I know. I didn’t hit my head that hard, I just had a headache, but I was scared to push my luck.”


Knowledge is the most important tool we have. We don’t have a cookie-cutter sport; there’s no contained playing field and in most cases, no spectators watching our every move. The protocol we adopt will have to be developed to fit our unique challenges. But the more we educate our riders and community as a whole, the more we broaden the reach of our protocol and shrink our playing field. At this point, concussions are an issue that falls in all of our hands. Event organizers have a responsibility to the riders, but so do parents, coaches, sponsors, teammates, and most importantly, so do the riders themselves. In order to have a cohesive protocol in place, it needs to grow from the bottom up, through the riders themselves, and not just from the top down. And perhaps the most necessary message needs to be that the decision to return to play should never be left to the injured rider.

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MENTIONS: @Gulevich87 / @dbaker / @TMcCaul / @BCBR / @braydenbarr

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