Developing return-to-play guidelines following mild traumatic brain injury

Abstract

Contact sports, such as the football codes, carry a high risk of head injury and the potential for significant adverse long-term sequelae. In particular, the incidence of mild t raumatic brain injury (mTBI) has received increasing at tention with the recognition that these injuries account for the vast majority of sport-related head injury with the potential for serious consequences following such injuries (ie, concussion and sudden impact syndrome) (1). It has been strongly recommended that sports bodies adopt return-to-play guidelines when players sustain mTBI. Despite the clear potential to significantly reduce the long-term and other adverse outcomes of mTBI, there are conflicting guidelines about when an athlete should return-to-play. Consequently, the practices currently adopted across sporting c lubs / t eams / medical professionals with regards to return-to-play are at best ad-hoc and not yet s tandard practice (2,3). Whilst some at tention has been given to the implementation of return-to-play guidelines for eli te/professional athlete groups, these have not been widely adopted at the broad community-level of participation. There is a part icular need for the development of consistent, evidence-based guidelines for communi ty athletes because these players have a high risk of head injury and the focus is on ensuring that they continue to enjoy safe lifelong participation. Currently, there are in excess of 15 guidelines in the international l i terature tha t provide concussion severity scales with return-to-play parameters. However, these guidelines are limited for a number of reasons namely: i) there are inconsistencies across different sets of guidelines, ii) all guidelines use loss of consciousness (LOC) as their major indicator of severity and there is increasing evidence that LOC is not predictive of outcome following mTBI (Collins et al, unpubl ished data), iii) the guidelines have largely arbitrary cut-offs which, to date, have not been validated in a prospective study, iv) there is an assumption that the guidelines can be applied in a s tandard way across all age-groups and this is unlikely to be the case. It is clearly time to move beyond these largely arbitrary guidelines and to under take a well-designed prospective s tudy to develop evidence-based guidelines. A team of researchers from Australia and the United States have secured funds to under take a longitudinal s tudy over the next five years to address this issue. The cohort study, to be under taken in Sydney, aims to estimate the incidence of mTBI and to develop guidelines for managing return-to-play decisions following mTBI. The s tudy will recruit 2245 Rugby Union players aged 16 to 35 years and follow them through one football season. Demographic