Returning to sport after head injury in children
Date First Published:
April 22, 2009
Last Updated:
April 22, 2009
Report by:
James Gagg, ST3 Emergency Medicine (Bristol Royal Hospital for Children)
Search checked by:
Amy Hughes, Bristol Royal Hospital for Children
Three-Part Question:
In [children who sustain a head injury] does [a 3 week delay in return to sport] [improve outcome]?
Clinical Scenario:
A 13 year old boy attends the emergency department after a clash of heads on the rugby field. He has a mild head injury and is discharged home with a head injury advice sheet based on the NICE guidelines. He is not happy with the advice to abstain from sport for 3 weeks as he will miss the remainder of the season.
Search Strategy:
Medline and EMBASE searches using NHS Evidence Health Information Resources interface.
Search Details:
(return AND to AND play OR return-to-play OR return AND to AND sport OR return-to-sport).ti,ab AND (head AND injury OR brain AND concussion OR concussion OR concuss*).ti,ab. Medline: [Limit to: Publication Year 1950-Current], EMBASE: [Limit to: Publication Year 1970-Current]
Outcome:
Altogether 55 papers were found in Medline and 46 papers in EMBASE. Eight papers were relevant to the question. Two papers were recent review articles, one of which incorporated the other six papers and the other incorporated five papers. These articles are presented here.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| What are the most appropriate return-to-play guidelines for concussed child athletes? Purcell, L May-09 Canada | Paediatric population with "concussion" or "brain concussion". | Review article, 28 papers referenced. | How is concussion different in children, multiple concussions, when ready/allowed to return to play, what guidelines should be used for return to play | Immediate removal from play and not to resume that day. Return to play should be stepwise and individualised in children. | This paper reviews the available literature, but there are no evidence based return to play guidelines at present. |
| Sport-related concussion Meehan WP 3rd, Bachur RG Jan-09 USA | Athletes sustaining a sports related concussion | Review article, 177 papers referenced. | Biomechanics, epidemiology, underreporting, assessment, management, special considerations | Return to play should not be considered until concussion resolved and then proceed in a stepwise fashion | Search strategy is not defined. Although biased towards the younger athlete, this article does not just review evidence specific to children. |
Author Commentary:
The outcomes of these papers are similar. In both cases however, evidence is based on concensus expert opinion (Concussion in Sport Group, International Conference on Concussion in Sport) and scientific data such as neuropsychological and balance tests. At present there are no evidence based return to play guidelines validated for children.
Bottom Line:
There is no evidence to abstain from sport for 3 weeks. Once an individual is completely symptom free at rest, a stepwise exertion protocol should be followed.
References:
- Purcell, L. What are the most appropriate return-to-play guidelines for concussed child athletes?
- Meehan WP 3rd, Bachur RG. Sport-related concussion