Concussion is tricky to diagnose but should never be ignored; EWS’s new pocketbook is a great way to educate yourself

Concussion. It’s the elephant in the room when it comes to mountain biking. We’ve all got used to taking a tumble every now and then, enduring scrapes, broken bones and peals of mocking laughter from our so-called-friends. We’re not so used to talking about concussion, though. Until relatively recently, this type of brain injury was cloaked in mystery, while most of us who suffered a blow to the head would think nothing of riding again the next day. Now though, with more research detailing the damaging effects of concussion, we all need to get better at spotting it and taking the right action.

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Concussion red flags

  • Loss of consciousness/deteriorating conscious state n Lying motionless on the ground
  • Confusion/unusual behaviour change
  • Increasing confusion or irritability
  • Severe or increasing headache n Severe neck pain/tenderness* n Repeated vomiting
  • Double-vision
  • Seizure or convulsion
  • Weakness, tingling or burning in the arms or legs *NB: if a neck injury is suspected, the rider should only be removed by a healthcare professional

Taken from the EWS Concussion Pocket Guide – check it out for the full rundown, and how to return safely to riding afterwards.

What is concussion?

The brain is very complex and every brain injury is different; as such, confusion over definitions and terminology still exists even today.

In 2017, the Concussion in Sport Group Consensus Statement released a unified definition, describing it as a “traumatic brain injury induced by biomechanical forces”. It can be caused by a bump, blow, or jolt to the head or by a hit to the body and doesn’t have to involve a loss of consciousness. Some symptoms may appear right away, while others may not show up for days or weeks after the concussion.

Sometimes, the injury makes it hard for people to recognise, so diagnosis isn’t simple, with symptoms varying from person to person. And because all brain injuries are different, so is concussion recovery. Most people with mild injuries recover fully, but it can take time. Some symptoms can last for days, weeks, or longer. Those who have had a concussion in the past are also at risk of having another one and may find that it takes longer to recover if they do.

Katy Curd, former 4X world champion and elite downhill rider, has spoken openly about the effect a series of concussions had on her. “It’s such a serious injury yet so invisible and so varied. From killer headaches, to not being able to process thoughts into words, loss of eyesight, memory loss, to severe depression.” For Katy it was so much more than a bang to the head and a headache. “It has been by far my biggest injury to date and took me the best part of two years to fully recover from and a crazy amount of intense rehab to get there”.

How big a problem is it anyway?

Just how many instances are there of concussion across our sport? The truthful answer is we have no accurate idea. Research into concussion, particularly in mountain biking, is incredibly scarce. However, there are some positive steps being made. In 2019, the Enduro World Series released findings from the largest ever medical study in mountain biking, looking at injuries and rider health across the professional EWS field, and a second arm looking at rider health from a mix of elite athletes, amateur racers and recreational riders. “We’ve been in charge of the creation of this discipline [enduro]; now we’ve got a chance as an independent body to do what we want and actually have an evidence-based approach to the sport’s development, and for all riders,” says Chris Ball, one of the study’s authors.

Just 0.6 per cent of riders competing in the 10 EWS rounds in 2017/18 suffered a concussion, while four per cent of respondents riding just for fun experienced one – and half of those reported significant reoccurrences.

The results seem fairly positive, but do they paint a true picture? Harrison Brown is the CEO of Headcheck Health, a software company providing digital health tools to sport organisations that enable them to execute and monitor concussion protocols.

“The bigger problem is the recreational space. I feel a little nervous. Probably the most concussions in the world are received by cyclists, just because of the sheer number of people who ride bikes and fall off them.”

So how can we go about making an improvement to our understanding and handling of concussion across the spectrum of cycling?

New protocols

Concussion returned to the sports pages back in December 2020, when a group of former rugby internationals, including England’s World Cup winner Steve Thompson, announced they were planning legal action against the game’s authorities, alleging they were negligent over the brain injuries that the players suffered.

Less than a week later, the UCI released a new concussion-specific protocol that will apply to all disciplines. The protocol recognises the challenges to our sport, including the length of time it can take to get to injured riders, and sets out steps to make improvements. These include the need to increase training among non-healthcare professionals to diagnose and identify concussion, return-to-race recommendations following a concussion, and compulsory notification of instances in competition.

Using riders’ voices

The new protocol takes a step towards improving behaviours in competitive circles, but how can we reach out to those of us who just ride for fun, or for commuting? For Chris Ball, the responsibility is shared but should be driven from the top. “Everyone has a part to play, the culture and tone needs to be set by the sporting bodies and then reinforced by the general population.”

Riders such as Martin Maes and Katy Winton have both missed races due to team or personal decisions following concussions. “It’s one thing a group like us [EWS] saying this stuff”, say Chris, “but when a sporting idol like Martin Maes or Katy Winton is seen dealing with our advice and carrying it out, that has a cascading effect through the riding population.”

A stand-out finding flagged up by Chris following the study was a lack of tools to support riders’ knowledge. “There’s no education out there at all,” he says. Off the back of this, the EWS produced a Concussion Pocket Guide, outlining symptoms, red flags and what to do if you suspect you’ve sustained a concussion. “It’s a general awareness shift that’s needed. A real simplification of what you do when it happens. People don’t necessarily have the time, care or wish to really become an expert in an area. We all love bike riding because it’s a very free sport in its field of play and its boundaries. We need to simplify it and not risk overly legislating and taking away the good stuff in the process.”

So where now?

For Harrison, implementation and enforcement of protocols is key to avoiding troubles down the line. “That’s what the lawsuits are about, it’s negligence lawsuits,” he says. “It’s because you said something, you said you were going to do it and you didn’t do it.”

For Chris, it’s a focus on us as riders taking ownership for ourselves, “There needs to be a general understanding that it’s an outdoor sport that will always take a level of self-care, self-reporting and self-awareness,” he says.

And for Katy: “It’s essential we as riders and athletes spread awareness about the severity of concussion, show the rehab process, show the in-depth process it takes to come back from such an injury and show that taking time out of the sport is a must and not deemed as a weakness but something essential that could save your life.”

Citation: D Palmer, G Florida-James, C Ball. Enduro World Series (EWS) Mountain biking injuries: A two-year prospective study of 2010 riders. International Journal of Sports Medicine. DOI: 10.1055/a-1320-1116