Re-Entry

So I’ve suffered a significant head injury. Technically, I have an intracranial contusion (bleeding) in the upper left frontal lobe of my brain. There are several small areas of bleeding evident on CT scan, the largest being 9 mm. There is also swelling (fluid build-up) around my brain tissue. Imagine a large bruise on your thigh. After a day or so, it appears purple, then turns deep yellow and fades over time. Those colors represent blood which has escaped from small blood vessels torn when the leg was hit. The area is tender to the touch, and maybe a bit swollen. The same thing is now happening in my brain. That area of the brain is responsible for a number of higher level functions, including some aspects of movement, management of emotions, integration of personality, and awareness.

I have also suffered a concussion, which is a more general “shaking” of my brain. This stretches the nerve fibers (“shearing”), maybe even tearing them. Concussions disrupt the delicate chemistry of the brain, the flow of neurotransmitters between nerve cells which monitor and control every aspect of the body’s function, as well as all thinking and feeling.

Years ago, when something like this happened, we called it “getting your bell rung”. Before the early 70s, we did not have CT scans to quantify the bleeding, or even MRIs to help us better demonstrate the swelling and shearing. So returning an athlete to action was a matter of “shaking it off”, and getting back in the game when you stopped feeling woozy.

Now, we know that the brain needs time to heal just like any other part of the body. Just as you would’t want to start running when your ankle ligaments are swollen or torn (“sprained” ankle), you really shouldn’t try to use your brain too much when it is in the acute phase after an injury like this. The risks are several: repeated direct injury to the head before healing has occurred leads to a higher risk of permanent damage; forcing the brain to work full bore before it’s ready make the recovery process take much longer. So, very recently, protocols have been developed to help guide an athlete back to action. Example: the “concussion protocol” you may have heard referenced in football games.

The tricky part is, the wide spectrum of head injury. The diagnostic terms and studies are still in flux. What do I call my injury? Intra-cranial hemorrhage? Contusion? Concussion? Traumatic Brain Injury? Is it mild, moderate, or severe? What symptoms are relevant? What are the risks of long-term problems? While in the hospital, the neuroscience physicians gave me some broad guidelines to follow: take it easy for a week or two, don’t do anything for two months which might run a risk of re-injuring the head, start back up with easy aerobic activity. But what might that mean specifically for me, a skiing-obseesed, high-functioning world class age group triathlete?

I didn’t get very far when I started discussing that with the neurologist. When I brought up some of my specific concerns, he tried to mollify me be saying, “Well, I guess you could maybe just do some blue or green runs after a couple of weeks.”

“That’s not gonna happened,” was my response. Meaning, if I’m out skiing, I’m going to be skiing to the limits of my ability. It’s the only way I know to have fun. I’m generally in control, and, obviously, if this was the first incident like this in 47 years, then I must be able to handle that “stretch the limits” approach. But we both recognized that the risk of another concussion or, worse, contusion, shortly after the first, would be very risky – meaning, permanent damage or even death. So, no, I shouldn’t downhill ski again this season.

From his perspective, it would be OK to do “aerobic” work within a week of the accident if I had no symptoms, and then work harder after another week without symptoms. I wasn’t sure if we both had the same understanding of either “aerobic” or “symptoms”, and he didn’t seem inclined to spend time with me on the nuances of my particular lifestyle, or even if he would understand it.

So I dove into the inter webs for help. I discovered a CDC “package” for physicians which included a complete set of symptoms to follow in patients with mild TBI. And, a document from an international conference on concussion in sport, which produced a consensus statement on return to activity for athletes. Putting those two together gives me a comforting set of guidelines to follow for my particular needs.

First off, I will not be skiing again this season, at least no downhill skiing. Even if the risk of another accident is low, the risk of complication should I bang my head again is just too high. Luckily, it seems that this has become a terrible snow year. Meaning, my favorite kind of skiing, in fresh new fluffy snow, is likely not gonna be happening in the next two weeks. And the snow on the slopes is harder than normal, raising further the risks should I fall.

Next, when, how much, and how intensely can I return to swimming, biking, running, and weight lifting? For the purposes of the next six weeks, all the biking I will be doing will be inside on a trainer, to reduce the risk of a re-injury soon after the current one. The guidelines are a step-wise progression in both time and effort level, based on being symptom free for the previous 24 hours.

So, what are the symptoms? From the CDC pamphlet for physicians: