When your brain has had enough

There are so many questions regarding the implications of brain injury (concussion) in sports and so my colleagues and I initiated a paper, published January 2018 in Neurology: Clinical Practice , as a way to systematically approach the discussion with patients about the need to step away from an offending sport before it is too late.  As the diagnosis of chronic traumatic encephalopathy (CTE) becomes more clearly connected to repetitive brain injury in sport practicing physicians must have a means of detecting those potentially at risk.  In this post I will briefly discuss when it is important to consider medical retirement after sports concussion.  The entire article is open-access and a link is available below.

The conversation with athletes and their parents regarding collision sports participation after concussion is often overcast by their concern for long term consequences including CTE, second-impact syndrome, and even death.  Even with a normal resolution of symptoms (< 10 days) and asymptomatic return to play progression, parents often ask about the safety of letting their son or daughter return to the offending sport.  By understanding that there are some clues to increased risk, we can better advise our patients.  So although the science is limited at this time, The simple answer to patients and their families is that a prolonged recovery, incomplete recovery, complicated injury (seizure or prolonged loss of consciousness), abnormal imaging findings, increased severity of injuries after more than one concussion, or decreasing time interval between injuries should prompt a review of the risks and benefits of continued participation.  There is no absolute number of injuries that determines medical disqualification despite prior recommendations for retirement after three concussions.  The only thing special about the number three in this sense is that it is possible to determine if there is a concerning pattern of injury or trend that should prompt a recommendation for retirement.

Important discussion points in my practice are style of play, level of competition, and establishment of trust.  Honest symptom reporting remains the most important determinant of outcomes in my opinion.  Because the tools for diagnosis are very limited, symptoms reporting is the gold standard for diagnosis.  It is well established that athletes under-report symptoms.  Having an awareness of normal and deviation from normal allows participants in sports and those caring for them an opportunity to intervene in a timely way when things are not going well.  Recurrent brain trauma in the setting of persistent symptoms is certainly the most important determinant for deciding on a prolonged or permanent hiatus from sport.

Screen Shot 2018-02-07 at 12.37.37 PM

Screen Shot 2018-02-07 at 12.38.07 PM

The retirement from sport after concussion paper is a collaborative effort from three disciplines: neurology, sports medicine, and orthopedics, bringing together decades of experience seeing patients with brain injury from sports participation at the high school, collegiate, and professional ranks. In my own clinical practice I have found the paper serves both in the discussion of retirement from collision sports after brain injury, and also in everyday practice for sports related concussion as a means of reassurance to athletes and their families that they can return to play and are not within the algorithm for retirement discussion.  While a paper such as this has its limitations, we hope that it will get the attention of practicing physicians and researchers to establish a base from which we can provide sound advice.  More importantly it can serve as a framework for research projects that can answer the clinical questions that remain regarding the time at which the brain can no longer protect itself from repetitive contact in sport.

Read the full article here

In some circumstances a player might be able to play a lower risk position within their sport.  In other scenarios changing the way an athlete engages in their sport to diminish risk can pay dividends.  When these strategies are not possible or proving ineffective, it may be time to step away.  When we have had this discussion and it is agreed that things need to change, I remind our athletes that they are just that, athletes.  Although there will be an emotional response to leaving a sport an individual values, finding another outlet for the competitive nature is a priority.  Setting up support and reestablishing identity after medical retirement from the offending sport is vital.

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