Editor's Note: This article contains graphic images and descriptions of a cycling crash.

I’ve learned to divide my life into two segments. There’s pre-August 3rd, 2014, and post-August 3rd, 2014. That day dawned warm and clear in southern Maine. Four of us gathered for that morning’s sermon at the Church of the Long Ride. It’d be a simple route: 50 miles down, 50 miles back, with good sightlines and wide shoulders.

There’s something magical about a small group ride where everyone trusts their fellow riders. The primary auditory input is the wind whistling through your helmet. Hand signals are the primary form of communication, avoiding road hazards and cars with points, fists, and flicks of the elbow. Visually it’s a trip of neon kit colors, the dull asphalt, and the various mix of greens, browns, and yellows that whiz by in the periphery of fields and meadows.

At 9:05 that morning we approached our turnaround point near the border of Maine and New Hampshire. The last pull had taken its toll on one of our fellow riders, and with the turnaround ahead we decided to split — myself and one rider up the road, and two trailing behind, and we’d regroup at our refueling stop. During the course of that brief decision making, a gap opened between the leading rider and myself. Not overly concerned given we were so close to turning around, I let the gap stay there as we entered the center of town. A blue, or maybe it was gray, minivan wound up in that gap.

That van hitting its brakes, about 30 feet in front of me, is my final memory before the lights went out.

I woke up in the middle of the road. And my life hasn’t quite ever been the same since.

Brain Injuries, Generally

The most common traumatic brain injury is the concussion. Generally caused by a blow to the head of some type, there are approximately 1.7 million to 3 million sports or recreation concussions in a given year. The most glaring example of these come from contact sports like football — although girls soccer and basketball account for the second and third-highest rates of concussion.

Endurance athletes face a multitude of potential sources for concussions. The most obvious is the one that we’ll talk about more through this article — crashing while cycling. But there are other opportunities throughout a triathlon: an elbow or kick received while swimming, or a trip while running. Concussions aren’t necessarily restricted to the blow to the head, either; a violent shake of the head or upper torso can also be enough to cause an injury.

Concussions are graded on a severity scale from 1 to 3. In general, the severity of the symptoms and loss of consciousness will be the determining factor in providing a diagnosis. In the most common type, grade 1 level concussions, there is no loss of consciousness, and symptoms will generally include minor headache, dizziness, fatigue, and difficulty focusing. Grade 2 concussions include the symptoms of grade 1 concussion, but also will include some type of tinnitus, amnesia, and irritability, along with the possibility of loss of consciousness. Grade 3 concussions, meanwhile, will include loss of consciousness and additional symptoms ranging from vomiting and seeing stars. Grade 3 concussions also carry the greatest risk for long-term side effects.

Those long-term side effects can include headaches, vertigo, and post-concussion syndrome. Post-concussion syndrome’s hallmarks are retaining some or all of the symptoms from a concussion for more than three months beyond the initial injury date. Rehabilitation can include vestibular therapy, physical therapy, speech therapy, and more. And unfortunately, not all of those rehabilitation modalities are covered by all insurance plans — for instance, certain plans will not cover speech therapy for post-concussion syndrome related word recall issues. Stack all of this together and it’s no wonder that there’s a tie between brain injury history and mental health issues.

Returning to Life, Let Alone Returning to Sport

For many who have suffered a concussion, it’s less a question of returning to sport, and more a question of how to return to normal day-to-day activity.

Slowtwitch forum member Mark Munro is one such case. According to Munro, he’s suffered four concussions since 2010, with the worst of those being the initial one in a snowboarding accident.

“I was snowboarding and got hit by someone who was out of control, just as the slope was getting much more vertical. So I flew through the air (I could feel myself get airborne) and landed headfirst on a relatively icy patch of snow. I wasn’t wearing a helmet, and it really hurt when I hit the snow. I managed to get down the mountain but felt not with it. Tried to eat something but felt like I was going to throw up. Ended up getting driven home by my brother and went back to work the next day. And then that week, just started feeling weird after work. Like my head was kind of spinning or dizzy.

Eventually, I got referred to a concussion clinic by my GP, saw a doctor and had my work hours halved, with a gradual increase in hours as my symptoms could manage it.
 
My recollection is that it took me close to 10 months to a year or something to get back to full time work. If I overdid it, I would get headaches and this all-encompassing fatigue where I just needed to sleep. I found swimming small amounts could help with symptoms,  but wasn’t really doing much other activity during that time. It took me over 1.5 years before I did my next triathlon.”

Munro also credits an anti-depressant to help with the post-concussion syndrome related mental health issues. The use of anti-depressants with post-concussion syndrome patients is a mixed bag — for some, it can provide a benefit; for others, it may have no impact or can actually exacerbate the condition.

In general, rehabilitation and management involves reducing strain on the brain by limiting work and screen time, and then slowly ramping physical activity to elevate heart rate until symptoms arise, then resting again, and testing. Unfortunately, there are no general healing times indicated. Some, like former NHLer Marc Savard, are never able to fully recover. There's a clean line in life pre-and-post concussion.

Which leads me back to the beginning.

The Post-Crash Life

When the lights came back on, somewhere between 90 seconds to three minutes after I had crashed, I was gasping for air in the middle of the road. My hands were coming out of the fencing response — a sure sign that I’d had a brain injury, although I didn’t know it at the time. It felt like I’d broken a bunch of ribs. I was just so confused as to why I wasn’t on my bike anymore.

I wasn’t on my bike anymore because, for reasons that nobody has ever figured out, I’d used the right side of my head and shoulder to brake from 25.4 miles per hour to zero in under half a second.

The biggest concern that my fellow riders, and then paramedics had, were potential orthopedic injuries. And for good reason, as I’d fractured the anterior bodies of T5 through to T7, in no small part due to my collarbone not snapping when I’d landed on my shoulder. The first sure indicator as to my brain, though, was a paramedic asking if I’d recalled urinating while on the road. (You tend to lose control of those faculties when you’re unconscious.) And I said “no,” and that suddenly seemed like a life-or-death statement, and away we sped to the hospital.

As it turned out, the helmet I’d worn had done a very good job preventing a skull fracture. It didn’t prevent a Grade 3 concussion and subsequent post-concussion syndrome. My primary symptoms that’ll show up include migraine, anxiety, short-term memory loss, speech recall issues, and a minor vision impairment that requires me to wear a specific set of prescription sunglasses while active or driving. For most people, none of what I’ve described above would appear as a deficit; for example, when talking, I’ll occasionally need to pause to search for a word, and it won’t look or sound like much.

But, well, I’m the one who knowswhat I used to sound like while talking. Or that my short-term memory was what powered me through law school and beer soaked trivia nights. Comparison, in these cases, is indeed the thief of joy. It’s in part why I wound up in a multi week intensive outpatient program in 2021, and why I still talk to a therapist bi-weekly today.

Prevention

The obvious statement is this: you can’t fully prevent concussions if you’re going to be active. You could get one, like I have, walking down the stairs to your basement. That being said, there are some obvious actions that you can take to help reduce risk.

Wear a helmet — but not just any helmet. Wearing a helmet for a variety of higher velocity activities — think biking and snow sports, among others — is generally a good idea. That being said, helmets were originally constructed to reduce skull fractures and didn’t seem to reduce incidence rates of brain injury.

That’s where newer technology offerings, like MIPS or Kineticore, come in. These inner shells are designed to help reduce the rotational impact of a crash — the type of impact that is thought to increase risk of brain injury. And now there are rating systems on potential head injury risk when choosing a helmet, developed by Virginia Tech. Some brands, like Lazer, have taken that rating system to heart — all of their road helmets have been rated by Virginia Tech, and their ratings are easily found when shopping to make a determination on risk.

That being said, we’re yet to see ratings for any brand’s aero helmet.

Move to indoor training for some rides. Riding indoors has never been more enjoyable than it is today. There are simply dozens of indoor platforms that you could choose from — Rouvy, FulGaz, RoadGrandTours, Wahoo X, Zwift, to name a few — that add outdoor realism to your indoor training. It’s not a perfect analog for riding outside; there are few greater shocks to a system than that first truly steep climb that you experience outdoors on a ride after being inside for a while. But with distracted driving rates increasing alongside injury rates among vulnerable road users, it can be a worthwhile trade off to prevent a crash.

Sacrificing your body to save your head. Unfortunately, there are going to be times where you fall. And you’re going to be faced with a pretty immediate self-preservation decision as to where you’re going to try to land. My recent distal radius fracture experience was born out of me trying to protect my head; as I was falling backwards my only thought was “do not, under any circumstance, hit your head.” I was successful! The lights stayed on this time.

But I also can’t help but wonder, given the fracture I put in my wrist, what that would have done to my brain.