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How should we manage an episode of concussion? Over the years the approach has changed significantly. In the summer a new document, "UK Concussion Guidelines for Non-Elite (Grassroots) Sport" was published. Here's my take on this latest approach to managing a condition that remains poorly understood...

Many years ago I spent a week with a friend climbing in the Alps. We based ourselves in the Courvecle Hut and had a great time on the likes of the Moine and the Verte. For our last route we decided upon a traverse of Les Courtes. All went well until the descent. Half-way down, as we were setting up an abseil, my friend was hit on the head by a falling stone. Unfortunately, the blow was hard enough to render him unconscious. I remember him clearly crumpling to the ground and then the long, still silence that followed. When he finally awoke it was clear that something was badly wrong; he didn’t know where he was or what he was doing. Even the simplest instructions were met with a hazy, confused expression. It was obvious that we couldn’t continue and I quickly called for a helicopter. Within an hour we were back in the valley and my friend had been admitted to hospital.

Back then everything seemed to hinge on the results of a CT scan. In my friend’s case this was normal and so, after a night of observation, he was discharged and told that he would be back to normal in a couple of days. But he wasn’t. For months he complained of daily headaches, blurred vision and a sense of “not feeling right”. For much of this time he slept for long periods and often felt tearful and depressed. He quit work and had to move back in with his parents. Within a few weeks he had split up with his girlfriend.

His GP was non-plussed and tried several courses of anti-depressants to no effect. His fitness suffered and as a result, he picked up a series of injuries that proved difficult to shake off. But eventually, after more than a year, his symptoms began to improve and we were finally able to return to the Alps and the climbing we loved.

A recent study in the NEJM has shown that neurological recovery from concussion varies widely. Whilst balance and verbal memory recover most quickly, visual memory and reaction time sometimes takes much longer to resolve. In some cases measurements were still abnormal after 28 days - the time point when the study was stopped!

I was reminded of my friend’s experience whilst reading the recently published, "UK Concussion Guidelines for Non-Elite (Grassroots) Sport". I only wish that we’d had access to this vital document all those years ago. It would have provided a great deal of reassurance and, I suspect it may have also helped him make a more rapid return to the mountains.

My friend’s story is far from unique, particularly in mountaineering where knocks to the head are common. So let’s take a look at these new guidelines and how they might be put into practice by a climber or mountaineer.

Let’s start with what concussion is – put simply, it’s an injury to the brain that results in a disturbance of normal function. There doesn’t have to be broken bones or “bleeding on the brain”. You don’t even need to be “knocked out”. In fact, 9 out of 10 of those who suffer a concussion remain conscious throughout. There doesn’t even need to be a direct blow – a very sudden movement of the head can be enough.

So what does concussion feel like? In the seconds that follow a head injury, victims will be slow and unsteady. They’ll look at you blankly and be unaware of what’s going on around them. Nausea is common. Sometimes they vomit. Most will develop some form of headache. Later, they will feel tired and often sleep for long periods of time. I remember on the long drive back from Chamonix my friend slept almost continuously. On arriving at his girlfriend’s house, he barely said a word before shuffling up to the bedroom and falling straight back to sleep.

In recent years the medical profession has become increasingly aware that concussion presents a real risk of prolonged problems for the victim. This is simply because an injured brain needs time to recover. If you suffer further episodes of concussion during your recovery, then your symptoms are likely to get worse and the odds are that you’ll take much longer to recover. In some cases, symptoms never disappear.

Many years ago I encountered a father and son who were out climbing in the Peak District. The son was leading and took a fall some distance above his last piece of gear. Unfortunately, his feet became twisted in the ropes and he swung in a long arc and hit his head on the rock. Over the course of the next half an hour he never fully regained consciousness and at one point he suffered a seizure. Some time later I heard that he had fractured his skull and needed emergency surgery. Unfortunately he was left with permanent disabilities and was never able to climb again

After an episode of concussion, the guidelines on what to do next are clear – stop, rest and seek medical attention. The latter is particularly important if a “red flag” is present. “Red flags” indicate that the damage is serious and that there’s a real chance that things can get worse. Surgery is sometimes needed and, in some instances, the injury can be fatal. “Red flags” include a loss of consciousness after the injury and a failure to make a quick recovery. On regaining consciousness, those with life-threatening brain injuries often become increasingly confused, irritable and unresponsive.

Fortunately, in most cases, damage is limited and hospital treatment isn’t required. So what should those who don’t have “red flags” do next? In the first 48 hours the guidelines recommend resting. But this doesn’t mean complete bed rest. Day-to-day activities are encouraged. Alcohol should be avoided. The next steps then depend upon the individual. The aim is to return to normal life at a rate that doesn’t significantly worsen symptoms. This process may take days, weeks or even months to play out. Experts in the field talk about the need to pass through six stages of recovery before returning to previous levels of sporting activity. Here, I’ve adapted them to what a climber or mountaineer might pass through after an episode of concussion.

Stage 1 – Relative Rest For 48 hours

At first, you should limit yourself to normal day-to-day activities. These should last for no longer than 10 to 15 minutes. You should rest if your symptoms get significantly worse. Screen time should be kept to a minimum for the first 48 hours.

Stage 2 – Gradually Introduce Daily Activities

If symptoms allow, over the next week it’s time to increase mental activities – reading, television and limited computer use can all take place. Home-based study or work activities can begin. It’s also time to start doing more around the house. Exercise should be limited to walking short distances (10-15 minutes). If activity brings on symptoms then the advice is rest until they’ve settled.

Stage 3 – Increase Tolerance For Mental And Exercise Activities

Once normal levels of daily activity have been reached, then it’s time to increase home-based study or work activities. Blocks of up to 30 minutes can be broken up with brief periods of rest. If these are well tolerated then it’s time to start discussing a gradual return to study or work.

Duration and intensity of exercise can increase. If symptoms are well-controlled, then it’s time to start hill walking again. Intensity should be pitched at a level where it remains easy to speak in full sentences. Any activity that has a significant risk of head injury should be avoided. Body weight resistance training can resume, however the use of weights or high intensity interval training (HIIT) should be delayed for a little bit longer.

Following the publication of these guidelines, the Concussion in Sport Group (CISG) issued their own recommendations. These emphasise the importance of undertaking small amounts of activity in the first 48 hours. This should only be stopped if there is a significant increase in concussion symptoms. As one of the panel members says, "The message is to get patients moving but in a controlled fashion, and that mild symptom exacerbation is OK"  

Stage 4 – Return To Study/Work And Sport Training

It’s time to return to study or work. It's worth being aware that this might be part-time at first. Levels of activity may need to be reduced and built up gradually. No symptoms during hill walking? Then it’s worth starting to scramble and boulder again. Build up the level of difficulty slowly and wear a helmet. Increase duration of body weight resistance training. Rest if symptoms worsen.

Stage 5 – Return To Normal Study/Work And Full Training

Return to previous levels of study or work. Take time out to catch up on missed tasks.

If symptom free during hill walking, scrambling and bouldering then its time to introduce roped climbing. Introduce weights and high intensity interval training (HIIT) gradually. Rest if symptoms worsen.

Stage 6 – Return To Normal

To reach this stage, it's necessary to be symptom-free at rest for at least 14 days. All should also be free of symptoms during hill walking, scrambling, bouldering and climbing. Expect this whole process to take at least 21 days. But remember - up to a third of those who suffer a concussion need longer to recover. This is especially the case with children and young adults. In these instances it’s worth seeking out professional help.

Reading through these stages I now realize that my friend should have spent much longer in Stage 2. By returning to bouldering and climbing within a couple of days he thought he could just “shake off” his symptoms and get back to normal. Instead, I suspect that all he did was irritate an injured brain and delay his recovery. Rather than climb, he should have started walking longer distances before building up slowly to scrambling, bouldering and climbing. When symptoms worsened he should have stopped and rested. At the same time, he should have focused on becoming more independent at home (moving back in with his parents probably didn’t help!) and try, at some stage, to return to work in a carefully managed way.

I suspect that had these guidelines been available at the time, he would have found both guidance and some reassurance. He would have known that recovery would have taken at least 21 days and potentially significantly longer. His GP would have been better informed and may have avoided prescribing anti-depressants. Perhaps those around him would have been more understanding. Overall, armed with these guidelines I think that he may have recovered sooner.

Here’s hoping that, should you be unlucky enough to experience an episode of concussion, these guidelines will help you make a full and speedy recovery.

The full guidelines can be found here.

Next week in Part 2 we'll take a look at a series of real life examples and highlight the many different ways concussion can present. 

This post was first published in the Alpine Club Newsletter. Many thanks to Adam Butterworth for his help in editing it!

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