Concussion Care: What to do after you hit your head


Earlier this week Toms Skujins of the Cannondale-Drapac Pro Cycling Team had a high-speed crash on a descent at the Amgen Tour of California. Because I had already finished riding the stage with CTS Athletes, I was watching the race on television. Like so many who watched it live and have since watched it in replays, I was immediately worried for Toms when he got up, struggled to remount his bike, fell over again, and continued to have trouble with balance and coordination. Over the past few days great articles have examined whether he should have continued (no), whether anything else could have been done in the moment (no), and what can be done in the future to prevent similar scenarios (good question). Rather than rehash those articles, I’d rather focus on what you should do if you suffer a concussion.

I am not a physician and therefore cannot provide medical advice, so my coaches and I follow the Medicine of Cycling concussion management guidelines developed in conjunction with USA Cycling.

Before You Crash: Gather Baseline Data

In order to better understand how a head injury may be affecting you cognitively you need to have baseline data established before you hit your head. I crashed and hit my head in November 2015, but had no pre-injury data for doctors to compare to. Nevertheless, I followed the post-concussion protocol before returning to training and subsequent tests indicated improvement compared to the immediate post-injury test. Medicine of Cycling and USA Cycling recommend seeing a medical profession trained in concussion management for a SCAT2, imPACT, and/or BESS test.

Before You Crash: Get a New Helmet with MIPS Technology

Any helmet is better than no helmet, a new helmet is better than a year-old (or older) helmet, and a MIPS helmet provides greater safety than a non-MIPS helmet. In my view, best practice is to replace your helmet annually, or sooner if you are involved in a crash. You can debate whether annual replacement is strictly necessary for all cyclists, but I only have one brain so for me the peace of mind is worth the expense of a new helmet.

Why purchase a helmet with MIPS technology? MIPS stands for Multi-Directional Impact Protection System and it enables a helmet to slide relative the head when you impact the ground at an angle. This reduces rotational stress on your head and neck, which may reduce the amount of strain incurred by the brain as a result of a crash. It is not proprietary technology owned by any individual helmet company, so you can now find the technology in a wide range of brands. Through a long-standing relationship with Giro, my coaches and I protect our heads with Giro Synthe MIPS helmets.

When You Crash: Be Done For The Day

The Medicine of Cycling concussion protocol includes in-race assessment tools to help anyone at a bike race – not just physicians – recognize the signs and symptoms of a concussion and take appropriate action. The vast majority of athletes reading this article are between the ages of 40 and 65, and virtually none of us are competing or participating in cycling events for anything other than personal goals. So let’s just make the post-crash decision ahead of time:

If you hit your head in a crash, you’re day is done.

To many of us old-school knuckleheads that might seem needlessly overcautious, but take a step back and think about it. We know so much more about the long term and cumulative effects of head injuries than we knew when we were in our teens and twenties racing and crashing without helmets. At this point in our lives and with where cycling fits in with your family, career, and lifestyle priorities, I struggle to find a justifiable reason to get back in the race or finish an event after hitting your head. If you are otherwise stranded and need to ride to get back home or to a place someone can meet you, ride slow and easy, preferably not alone.

After Your Crash: Take Recovery Seriously

Lack of follow-up is the biggest problem I see with athletes over 40 after they suffer a concussion. I can tell you from personal experience that following post-concussion protocols is inconvenient and frustrating, but those are not justifiable excuses for ignoring the protocols.

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In my view, much of the resistance to follow through on the protocols is generational. If you are over 40 you grew up in an era when you were told to take a few days off – at most – and returned to training or racing as soon as you no longer had a headache. As usual I find it helpful to understand why experts believe prolonged rest is necessary. In a 2012 article in Velonews, neuropsychologist Eric Freitag described the mechanism of injury as a “metabolic dysfunction”. The chemical and electrical transmissions between neurons in the brain get disrupted, and the process of reestablishing homeostasis requires time and energy. Activities that require higher cognitive function direct resources away from this recovery process, which delays your return to normal function.

In the same way you have to balance stress with adequate recovery in order to create positive adaptations to physical training, you have to provide your brain with adequate cognitive recovery in order for it to return to normal function. While I realize this is probably a gross oversimplification of post-concussion recovery, as an athlete and coach I found it much easier to comply with the post-concussion protocols once I was able to relate it to physical training and recovery.

CTE and Cycling

The slow-motion epidemic of CTE (chronic traumatic encephalopathy) in retired football players, contact sport athletes, and combat sport athletes begs the question of whether cyclists are also at risk for this degenerative condition. Shortly after legendary BMX athlete Dave Mirra commited suicide in early 2016, Ian Dille wrote an article about cycling and traumatic brain injuries for Bicycling Magazine. In the article, Steve Broglio, director of the NeuroTrauma Researcher Laboratory at the University of Michigan reassured cyclists their risks of developing CTE are quite low. Repetitive trauma, particularly repeated trauma in an already-injured state, presents the biggest danger for developing CTE. To paraphrase Broglio’s comments, although cyclists may incur a handful of concussions over the span of many years, the long recovery intervals between head traumas dramatically reduces the risk of developing CTE.

From a purely anecdotal viewpoint my life experience in cycling leads me to agree with Broglio’s assessment of the risk. I raced as an elite amateur and professional cyclist in the 1970s and 1980s, before cycling helmets offered any significant measure of protection against brain trauma. There were a lot of crashes, a lot of concussions, and little to no post-concussion recovery. Thirty-five years later, however, I am unaware of anyone who raced in that time period who has developed symptoms suggestive of CTE. That’s not to say it hasn’t happened at all, but that at least anecdotally a population of cyclists who endured more head injuries than the average cyclist doesn’t appear to be experiencing CTE at anywhere near the rate of athletes who played full-contact sports during that same time period.

Overall I am highly encouraged by the advances in concussion assessment and treatment, as well as the advances in protective technologies like MIPS, ICE crash sensors, and Strava Beacon. Athletes like Toms Skujins benefit directly from a greater understanding of brain trauma, which reduces the pressure to return to training and competition too early. We only get one brain, so it’s crucial we do everything we can to protect it.

Be safe, wear a helmet, and have fun!
Chris Carmichael
CEO/Head Coach of CTS

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Comments 11

  1. After having watched the movie ‘Concussion’ and having taken quite a spill a few days back, I find myself in good company. I say that because anyone who seeks health knowledge & wants to help themselves & others with issues is a good thing to see. It’s odd to me how the previous article presumes everyone who does this has to be older? Yes take breaks, but how are you going to progress and learn if you stop your riding session. It’s certainly a case by case basis. I put my first helmet on after flipping over handle bars doing a complex bmx trick, at 19. I became acutely aware that things can change quickly. Now, how do we balance that with our love for sport. Keep going. Agreed that recovery time is necessary for certain levels of injury. When you live for what you do, quitting is rarely an option. Be careful out there. Much like road conditions…do what’s best for your current situation, health-wise. Anything can happen – Know that. yet also know that life is for the living. I hope speedy full recoveries for all. Cheers.

  2. I was riding my bike with my brother and sisters and two friends and I went to turn a curb but (Confidential name) was riding the same way and I tried to turn my bike and it wouldn’t turn so I ended up crashing right into his bike and both of us got knocked down but I got the worse of the crash and I hit my head on the asphalt and scraped my knee and before I knew it, my brother and (Confidential Name) were telling me I better go home because blood was streaming all around the back and side of my neck. Then all of a sudden I felt a sharp pain in my head and I put my hand on the back of my neck and looked at my hand and it was covered in blood.

  3. Emergency Department NP and avid cyclist here. I agree with CT scanning for head injuries (especially in patients with neurologic symptoms and significant mechanism of injury), but it can only “see” gross structural issues (bleeding, fractures, masses, etc.). No form of imaging shows evidence of concussion; the diagnostic criteria for concussion are also not formally agreed upon. The most helpful testing is neurocognitive testing, ideally comparing post-injury performance to pre-injury/baseline testing.
    So, by all means, get checked out in a local ED after injury, but expect the ED provider to be somewhat vague about whether you have (or haven’t) suffered a concussion. Follow up with neurology and/or sports medicine, ideally someone with concussion management experience, for a definitive treatment plan.

  4. In 2002 I was on a training ride, riding properly and was hit from behind by a car traveling approximately 50 mph. The person driving thought I was a construction cone.
    This resulted in a coma in the hospital but I was lucky I was wearing my helmet, even though I still fractured my skull.
    During the crisis and my recovery my wife kept a diary which resulted in a book which was published.
    As we are the cyclist and as noted above we think of ourselves but these injuries can a tremendous and devastating impact on our families. The book was written to help get the word out of issues that arise in caregiving for TBI survivors while also describing what I went through on my way to recovery My wife has given numerous presentations over the country on the subject. A good source for information regarding injuries to the brain is

  5. I’ve had multiple concussions over my riding and racing career. The most recent one was 8 weeks ago in a crit. The worst one was when I got hit by a car in 2008. I still don’t remember about 2 minutes before that crash or about 15 minutes after it. I have a lot of problems with memory and concentration, plus I still get a lot of headaches. I’m pretty diligent about replacing my helmet every other year, and all future helmet purchases will be MIPS helmets. I even bought Giro Scamp MIPS helmets for my kids (ages 7 and 4). Now I’m reevaluating whether or not I want to continue racing. But I realize that I could get another concussion from a fairly benign everyday ride. Or I could get into a motor vehicle crash. Or I could fall down the stairs. There are multiple ways to get a concussion. This is something I try to explain to all of my non-cyclist friends and co-workers when they ask me if I’m going to quit riding every single time I get injured on the bike.

  6. I was hit by a careless motorist back in 2014–broke several ribs and wound up in the hospital for observation, but my MIPS helmet saved me from a concussion (or something worse). I’ll never ride without one.

  7. Everyone take heed. The concussion concern is valid. My crash was 7 years ago, 5 ribs, 2 vertebrae (ladder in my back) and a concussion determined to Traumatic Brain Injury. Spent two months in a recovery hospital; their goal was to ensure that I could take care of myself before release. 10 months before returning to work. I was allowed to ride after 6 months (indoors on a stand), outside after 13 months. Helmet? yep, barely a ding. Mine was a face plant. MIPS is an awesome idea, but need a better one too. Helmets seem to be too rigid, and spread impact. Good to a point. They need to absorb impact. My helmets are “one use (impact) and your out.”
    Plus, and this is important, lots of studies also show that intense exercise/intervals prompt our brain to ‘reconnect.’ My time indoors was led by some CTS Videos, and as my physical fitness improved, so did my cognition. Makes sense, blood and oxygen play a big part in our brains.
    I want to help all athletes, all people, who suffer any brain injury, no matter what grade. Take care all, ride safer than cars. WHERE A HELMET.

  8. My advice is to listen to your body and follow the doctors recommendations. I collided with a truck in December resulting in a concussion, broken clavicle, partial rotator cuff tear and separation, 2 broken ribs, 30 stitches and 4 knocked out teeth. I had a CAT scan done of my head and went through concussion protocol before being released. It took 7 weeks to find out about the fractures. I then started treatment and rehabilitation that I am still going through. But being the competitor that I am, rode for 10 days in mid January until told to stop until April. I have resumed riding but just found out my clavicle is still fractured. I bought a Giro Synthe Mips helmet since my other helmet was broken in half. I do believe the helmet saved my life. The helmet is a wise and smart investment. Listen to your doctor, therapist and spouse when it relates to medical care and resumption of activities.

  9. Very good summary and “fatherly” advice. Another contributing factor to the falls that result in concussion, especially in the summer, is the effects of heat and dehydration on cognitive function. I hear all the time from cyclists I get this “heat headache” and can’t focus as well. Very important to keep in “mind” at high speeds and steep descents. Stay hydrated, cool, calm and collected.

  10. I fully support the use of MIPS helmets and taking more time, not less, to get over concussion. Fortunately I broke my leg in the crash that resulted in concussion so there was no chance of rushing back on to the bike. As the crash also fractured four vertebrae it gives you some idea of the brain injury (yes, I landed on my head). Anyway, zero work for two weeks then a gradual return to full-time over the six weeks after that meant that (also fortunately) I have suffered no long-term damage. I would commend others to follow the same cautious plan.

  11. Great article, this is important information. I had a crash nearly a year ago resulting in a traumatic brain injury. My new helmet has MIPS. One thing I learned is that if you hit your head, always go to the ER and request a CAT Scan. I lost consciousness at the scene but my helmet did not have any visible damage so the ER docs were not focused on checking my head. It wasn’t until I observed a bump with dried blood on the back of my head that they had me get a CAT Scan which identified the brain bleed,
    The second recommendation is to start a meditation practice now, before a crash. My meditation practice was instrumental in healing my brain. The headaches, balance difficulties and cognitive issues that were debilitating for the first few days, were completely gone within two weeks. That’s very fast healing for the level of injury I incurred and I truly believe it was my regular meditation through the healing process that was the key.

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