Return To Play Protocol Research Articles

Sport-Related Neurotrauma and Neuroprotection: Are Return-to-Play Protocols Justified by Paternalism?

Sport-related neurotrauma annually affects millions of athletes worldwide. The return-to-play protocol (RTP) is the dominant strategy adopted by sports leagues and organizations to manage one type of sport-related neurotrauma: concussions. RTPs establish guidelines for when athletes with concussions are to be removed from competition or practice, and when they can return. RTPs are intended to be neuroprotective, and to protect athletes from some of the harms of sport-related concussions, but there is athlete resistance to and noncompliance with RTPs. This prompts consideration of whether RTPs, as employed in adult, professional sports, are paternalistic, and if they are, whether they are objectionably so. If RTPs are uniquely effective at protecting current or future athlete autonomy, they might be justified by paternalism. I conclude that RTPs are paternalistic in their effects, but are not adequately justified, and thus they are objectionable.

Comparative incidence of concussion and return to play time in two Canadian minor hockey groups over the 2011–2012 season

ObjectiveReport concussion incidence and Return to Play (RTP) times over a minor hockey season (2011–12) in two sub-groups, a community hockey association (A) and a private hockey academy (B).DesignRetrospective, cohort...

Neuropsychological Testing and Concussions

R and clinicians have raised awareness about the serious consequences of sport-related concussion, which occur 1.6 to 3.8 million times per year in the United States alone. Although the concept of the second-impact syndrome (a second head trauma causing brain swelling and death) remains controversial, the published cases do raise concerns. Short-term concussion disabilities (eg, mood, memory, concentration) may last months and have detrimental effects on quality of life at home, school, work, and sport. Repeated concussions may affect cognition decades later. Despite this evidence, it remains unclear when physicians should allow return to play (RTP) after a concussion. More than 20 years ago, Cantu recommended RTP only when a patient had been symptom free for 1 week, both at rest and with exertion; similar recommendations have followed. The results of neuropsychologic (NP) testing, however, suggest that cognitive deficits may persist long after symptoms have resolved, and some question whether the older recommendations are appropriate. The most recent international consensus conference considered NP testing to be “an important component in any RTP protocol.” Others (with some conflict of interest) suggest that NP testing is a “cornerstone of concussion management” and, in addition, that baseline neuropsychologic (BNP) testing should be performed whenever possible. The National Football League began BNP in 1995 and the National Hockey League in 1997, and some have recommended it for university, high school, and other sport organizations. At least 1 jurisdiction in the United States has considered legislating BNP for athletes (State of New Jersey 214th Legislature Senate Resolution No. 74). Given these recommendations, NP with or without BNP may come to be perceived as a “standard of medical care,” with obvious medicolegal implications for both the sport medicine practitioner and sport organizations. But do the results of NP testing change patient management or provide other clinical benefit to the patient? Is there sufficient evidence to mandate it as standard of medical care?