Concussion Guidelines in National and International Professional and Elite Sports

Comparing return to play protocols after sports-related concussion among international sporting organisations

BACKGROUND

Return to play (RTP) protocols are an important part of recovery management following a sport-related concussion (SRC) and can prevent athletes from returning to competition too early and thereby avoid prolonged recovery times. To assist sporting organizations in the development of RTP guidelines, the Concussion in Sports Group (CISG) provides scientific-based recommendations for the management of SRC in its consensus statement on concussion in sport.

OBJECTIVES

This study investigates commonalities and differences among current RTP protocols of international sporting organizations and examines the implementation of the most recent CISG recommendations.

METHODS

Concussion guidelines and medical rules of 12 international sporting organizations from contact, collision and combat sports were accessed via the organizations websites and compared regarding the management of SRC and the RTP decision.

RESULTS

Only six of the included organizations developed and published their own concussion guidelines, which included an RTP protocol on their website. The number of steps until RTP was similar across the different protocols. Each protocol required at least one medical examination before clearing an athlete to RTP. A high variation among organizations was found for initial resting period after injury, the implementation of sport-specific training drills and the time needed to complete the protocol before returning to competition. At the date of this study (9 September 2023), none of the accessible RTP protocols were updated to include the latest version of the CISG consensus statement.

CONCLUSION

To improve the safety of athletes after a head injury, sporting organizations should develop sport-specific guidelines according to the latest CISG consensus statement, and this should be updated regularly. Implementation is especially important in combat sports, where there is a high incidence of head injury. Thus, there is a requirement for the most up-to-date concussion management protocols in these sports.

Long-term results and surgical strategy development for degenerative disease treatment in athletes: a retrospective single-center study

PURPOSE

To analyze of the results of spine surgical treatment of athletes with lumbar degenerative disease and development of a surgical strategy based on the preoperative symptoms and radiological changes in the lumbar spine.

METHODS

For 114 athletes with lumbar degenerative disease were included in the present study. Four independent groups were studied: (1) microsurgical/endoscopic discectomy (n = 35); (2) PRP therapy in facet joints (n = 41); (3) total disc replacement (n = 11); (4) lumbar interbody fusion (n = 27). We evaluated postoperative clinical outcomes and preoperative radiological results. The average postoperative follow-up was 5 (3;6), 3.5 (3;5), 3 (2;4) and 4 (3;5) years, respectively. The analysis included an assessment of clinical outcomes (initial clinical symptoms, chronic pain syndrome level according to the VAS, quality of life according to the SF-36 questionnaire, degree of tolerance to physical activity according to the subjective Borg Rating of Perceived Exertion Scale) and radiological data (Dynamic Slip, Dynamic Segmental Angle, degenerative changes in the facet joint according to the Fujiwara classification and disc according to the Pfirrmann classification; changes in the diffusion coefficient using diffusion-weighted MRI).

RESULTS

The median and 25-75% quartiles timing of return to sports were 12.6 (10.2;14.1), 2.8 (2.4;3.7), 9 (6;12), and 14 (9;17) weeks, respectively. We examined the type of surgical treatment utilized, as well as the preoperative clinical symptoms, severity of degenerative changes in the intervertebral disc and facet joint, the timing of return to sports, the level of pain syndrome, the quality of life according to SF-36, and the degree of tolerance to physical activity. We then developed a surgical strategy based on individual preoperative neurological function and lumbar morphological changes.

CONCLUSIONS

In this retrospective study, we report clinical results of four treatment options of lumbar spine degenerative disease in athletes. The use of developed patient selection criteria for the analyzed surgical techniques is aimed at minimizing return-to-play times.

A Perspective on the 6th International Conference on Sports Concussion

The International Conference on Sports Concussion, held every four years since 2001, has been instrumental in forming the international consensus on sports-related concussions. However, due to the unprecedented global pandemic of COVID-19, not only the Tokyo Olympics 2020, but also the initially scheduled sixth conference was postponed multiple times. Finally, the 6th International Conference on Sports Concussion took place in Amsterdam at the end of October 2022. In July 2023, the Amsterdam Declaration, reflecting the outcomes of this sixth conference, was released. This paper provides an overview of the conference, in which significant updates were revealed and introduced, including revisions to the definition of sports-related concussions, as well as the latest version of the Sports Concussion Assessment Tool (SCAT), known as SCAT6, the Office Assessment Tool (SCOAT), and the updated staged return-to-play protocol.

Symptom presentation and evolution in the first 48 hours after injury are associated with return to play after concussion in elite Rugby Union

BACKGROUND

Return to play (RTP) in elite rugby is managed using a 6-stage graduated RTP protocol, which can result in clearance to play within 1 week of injury. We aimed to explore how symptom, cognitive, and balance presentation and evolution during concussion screens 2 h (head injury assessment (HIA) 2) and 48 h (HIA3) after injury were associated with time to RTP) to identify whether a more conservative graduated RTP may be appropriate.

METHODS

A retrospective cohort study was conducted in 380 concussed rugby players from elite men's rugby over 3 consecutive seasons. Players were classified as shorter or longer returns, depending on whether RTP occurred within 7 days (allowing them to be considered to play the match 1 week after injury) or longer than 8 days, respectively. Symptom, cognitive, and balance performance during screens was assessed relative to baseline (normal or abnormal) and to the preceding screen (improving or worsening). Associations between sub-test abnormalities and RTP time were explored using odds ratios (OR, longer vs. shorter). Median day absence was compared between players with abnormal or worsening results and those whose results were normal or improving.

RESULTS

Abnormal symptom results during screens 2 h and 48 h after concussion were associated with longer return time (HIA2: OR = 2.21, 95% confidence interval (95%CI): 1.39-3.50; HIA3: OR = 3.30, 95%CI: 1.89-5.75). Worsening symptom number or severity from the time of injury to 2 h and 48 h post-injury was associated with longer return (HIA2: OR = 2.49, 95%CI: 1.36-4.58; HIA3: OR = 3.34, 95%CI: 1.10-10.15. Median days absence was greater in players with abnormal symptom results at both HIA2 and HIA3. Cognitive and balance performance were not associated with longer return and did not affect median days absence.

CONCLUSION

Symptom presentation and evolution within 48 h of concussion were associated with longer RTP times. This may guide a more conservative approach to RTP, while still adhering to individualized concussion management principles.

Sport-related concussion in soccer -a scoping review of available guidelines and a call for action to FIFA & soccer governing bodies

Introduction

Sport-related concussions (SRC) have been a concern in all sports, including soccer. The long-term effects of soccer-related head injuries are a public health concern. The Concussion in Sport Group (CISG) released a consensus statement in 2017 and several soccer governing associations have published their own SRC guidelines while referring to it but it is unclear whether this has been universally adopted.

Research question

We aimed to investigate whether guidelines published by soccer associations have any discrepancies; and the extent to which they follow the CISG recommendations.

Materials and methods

A scoping review of available soccer-specific SRC guidelines was performed via databases PubMed, Google Scholar, and official soccer association websites via web browser Google. The inclusion criteria were soccer-specific SRC guidelines. Comparisons between guidelines were made concerning the following index items: initial (on-site) assessment, removal from play, re-evaluation with neuroimaging, return-to-sport protocol, special populations, and education.

Results

Nine soccer associations with available guidelines were included in this review. Guidelines obtained were from official associations in the United Kingdom, United States of America, Canada, Australia, and New Zealand. When compared to each other and the CISG recommendations, discrepancies were found within guidelines regarding the index items. Additionally, major soccer associations in some countries famous for soccer were found to have not published any publicly available guidelines.

Discussion and conclusion

SRC guidelines from different soccer associations contain discrepancies which may be detrimental to athletes, both short and long-term. We recommend that all major soccer governing associations publish guidelines that are standardised and accessible to all athletes.

Neurosurgery and the World Health Organization Intersectoral Global Action Plan for Epilepsy and Other Neurological Disorders 2022-2031

The World Health Organization's Intersectoral Global Action Plan (IGAP) on Epilepsy and Other Neurological Diseases 2022-2031 is a holistic, interdisciplinary, and intersectoral plan with a strong focus on equity and human rights. The IGAP was unanimously approved by all World Health Organization Member States at the 75th World Health Assembly in May 2022 and provides a framework for researchers and clinicians to study and address national and global inadequacies in the evaluation and management of people suffering from neurological disorders and their prevention. While IGAP has applied epilepsy as an entry point for other neurological disorders, advocacy by neurologists and neurosurgeons has broadened it to include diseases with a large and growing global health footprint such as stroke, hydrocephalus, traumatic brain injury, and brain and spine cancers. The IGAP is important to neurosurgeons globally because it provides the first ever roadmap for comprehensively addressing unmet neurological and neurosurgical care in low- and middle-income countries. Furthermore, it creates an opportunity for neurologists and neurosurgeons to scale up services for neurological diseases in tandem. As such, it provides a structure for the neurosurgery community to become involved in global health initiatives at all levels.

The biomechanical signature of loss of consciousness: computational modelling of elite athlete head injuries

Sports related head injuries can cause transient neurological events including loss of consciousness and dystonic posturing. However, it is unknown why head impacts that appear similar produce distinct neurological effects. The biomechanical effect of impacts can be estimated using computational models of strain within the brain. Here, we investigate the strain and strain rates produced by professional American football impacts that led to loss of consciousness, posturing or no neurological signs. We reviewed 1280 National Football League American football games and selected cases where the team's medical personnel made a diagnosis of concussion. Videos were then analysed for signs of neurological events. We identified 20 head impacts that showed clear video signs of loss of consciousness and 21 showing clear abnormal posturing. Forty-one control impacts were selected where there was no observable evidence of neurological signs, resulting in 82 videos of impacts for analysis. Video analysis was used to guide physical reconstructions of these impacts, allowing us to estimate the impact kinematics. These were then used as input to a detailed 3D high-fidelity finite element model of brain injury biomechanics to estimate strain and strain rate within the brain. We tested the hypotheses that impacts producing loss of consciousness would be associated with the highest biomechanical forces, that loss of consciousness would be associated with high forces in brainstem nuclei involved in arousal and that dystonic posturing would be associated with high forces in motor regions. Impacts leading to loss of consciousness compared to controls produced higher head acceleration (linear acceleration; 81.5 g ± 39.8 versus 47.9 ± 21.4; P = 0.004, rotational acceleration; 5.9 krad/s2 ± 2.4 versus 3.5 ± 1.6; P < 0.001) and in voxel-wise analysis produced larger brain deformation in many brain regions, including parts of the brainstem and cerebellum. Dystonic posturing was also associated with higher deformation compared to controls, with brain deformation observed in cortical regions that included the motor cortex. Loss of consciousness was specifically associated with higher strain rates in brainstem regions implicated in maintenance of consciousness, including following correction for the overall severity of impact. These included brainstem nuclei including the locus coeruleus, dorsal raphé and parabrachial complex. The results show that in head impacts producing loss of consciousness, brain deformation is disproportionately seen in brainstem regions containing nuclei involved in arousal, suggesting that head impacts produce loss of consciousness through a biomechanical effect on key brainstem nuclei involved in the maintenance of consciousness.

Longitudinal Outcomes of Cumulative Impact Exposure on Oculomotor Functioning in Professional Motorsport Drivers

Importance

Professional motorsport drivers are regularly exposed to biomechanical forces comparable with those experienced by contact and collision sport athletes, and little is known about the potential short-term and long-term neurologic sequelae.

Objective

To determine whether cumulative impact exposure is associated with oculomotor functioning in motorsport drivers from the INDYCAR professional open-wheel automobile racing series.

Design, Setting, and Participants

This is a longitudinal retrospective cohort study conducted across 3 racing seasons (2017-2019). Statistical analyses were conducted in November 2021. Data were retrieved from a secondary care setting associated with the INDYCAR series. INDYCAR series drivers who participated in 3 professional level racing seasons and were involved in at least 1 contact incident (ie, crash) in 2 of the 3 seasons were included in the study.

Exposure

Cumulative acceleration and deceleration forces and total contact incidents (ie, crashes) measured via accident data recorder third generation chassis and ear accelerometers.

Main Outcomes and Measures

Postseries oculomotor performance, including predictive saccades, vergence smooth pursuit, and optokinetic nystagmus, was measured annually with a head-mounted, clinical eye tracking system (Neurolign Dx 100).

Results

Thirteen drivers (mean [SD] age, 29.36 [7.82] years; all men) sustained median resultant acceleration forces of 38.15 g (observed range, 12.01-93.05 g; 95% CI, 30.62-65.81 g) across 81 crashes. A 2-way multivariate analysis of variance did not reveal a statistically significant association between ear and chassis average resultant g forces, total number of contact incidents, and racing season assessed (F9,12 = 0.955; P = .54; Wilks Λ = 0.44).

Conclusions and Relevance

In this cohort study of professional drivers from the INDYCAR series, there were no statistically significant associations among cumulative impact exposure, racing season assessed, and oculomotor performance. Longitudinal studies across racing seasons using multidimensional examination modalities (eg, neurocognitive testing, advanced imaging, biomarkers, and physical examination) are critical to understand potential neurological and neurobehavioral sequelae and long-term consequences of cumulative impact exposure.

Sport-related concussion disclosure in women's rugby-A social identity approach

Introduction

Sport-related concussion (SRC) is a risk of collision sports such as women's rugby. To support appropriate SRC diagnosis and management, an understanding of the factors that encourage SRC disclosure is necessary. To date, research has focused on ascertaining individual player knowledge and attitudes towards SRC disclosure.

Methods

We chose to investigate the potential influence of group identification effects by examining the role of social identity on SRC disclosure in elite women's rugby. Seventeen elite players from the United Kingdom and Ireland were interviewed and their transcripts thematically analysed.

Results

The data highlighted that the players shared a very strong social identity as women in rugby and were acutely aware that their experiences were different to their male counterparts. The shared social identity had both positive and negative implications for SRC disclosure. The players interviewed did not feel comfortable disclosing their symptoms to their coach and often felt that medical staff either did not listen to them or were unavailable to them. Mediators such as communication, trust in medical teams, perceived pressure, positive injury management experience, and player role models were identified.

Discussion

This research could be utilised to inform sport psychology interventions to enhance SRC disclosure in elite women's rugby.

Traumatic brain injury: progress and challenges in prevention, clinical care, and research

Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research.

In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents.

Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery.

The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition.

Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers.

In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI.

Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation.

Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority.

This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.

A Scoping Review of Concussion Guidelines in Amateur Sports in the United Kingdom

Objectives To investigate which United Kingdom (UK) amateur sporting organisations have published sports-related concussion (SRC) guidelines, their accessibility and the extent to which they follow the Berlin statement recommendations. This article is targeted at those involved with designing and implementing SRC guidelines in amateur sport. Design Scoping Review. Data Sources The SRC guidelines of 15 sporting organisations were accessed through public materials available from the official organisation website. Eligibility Criteria: To be included in this review, sports must enjoy broad participation by UK amateur athletes with a high risk of athletes sustaining an SRC. Results: 15 sporting organisations were included in this review with two, British Cycling and British Eventing, found not to have published SRC guidelines. There was found to be a large discrepancy between the extent to which the sport-specific guides followed the Berlin statement recommendations. Conclusions: The large discrepancy between the contents of the SRC guidelines may be putting the health of athletes at risk. We recommend the UK government publish standardised concussion guidelines based on the latest scientific research that must be used by all UK amateur sport groups.

[Results of the study of functional recovery of professional athletes after minimally invasive lumbar fusion]

OBJECTIVE

To conduct a comprehensive clinical-neurological assessment and to study the results of functional recovery of professional athletes after minimally invasive lumbar interbody fusion.

MATERIALS AND METHODS

The retrospective study included 27 patients-professional athletes who were operated on using minimally invasive decompression and stabilization techniques in the period 2010 to 2019. Clinical-neurological effectiveness was assessed when returning to previous sports activity was 14 (9; 17) weeks and 4 (3; 5) years after surgery.

RESULTS

The follow-up showed a significant improvement in clinical and neurological parameters: persistent elimination of radicular and muscular-skeletal symptoms, a decrease in the level of pain according to a visual analogue scale in the lumbar spine from 68 (61; 85) mm to 3 (2; 11) mm (p=0.002) and in the lower extremities from 84 (78; 91) mm to 1 (0; 3) mm (p=0.001), change in the physical component of health from 26.18 (23.58; 28.37) to 49.82 (49.03; 53.04) (p=0.002) and the psychological component of health from 27.87 (26.22; 29.29) to 52.18 (49.12; 55.66) (p=0.001), significant improvement in the perception of physical activity according to the Borg RPE Scale from 17 (16; 18) points to 9 (8; 9) (p<0.001). In one case (3.7%), the patient did not return to his previous sports career.

CONCLUSION

The use of minimally invasive rigid stabilization in the overwhelming majority of professional athletes made it possible in the shortest possible time to achieve regression of neurological symptoms, reduce pain, improve the quality of life, restore the functional state and return to previous sports activities.

Concussion in Head Trauma

Concussion in the setting of facial trauma is an entity that can be overlooked. Having a high index of suspicion is critical in initial management and prompt treatment. Clinical signs can be common manifestations of a concussion. Serial examinations are important as these clinical manifestations can occur later in the hospitalization. Cognitive assessment tools can also give a baseline of a patient and can be used to assess recovery from a concussion. Assessment of the vestibular and oculomotor system can play a critical role in treatment. Prompt recognition and immediate treatment can help shorten the symptomatology and course of treatment.

Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight

BACKGROUND

Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI.

OBJECTIVE

To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions.

METHODS

A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted.

RESULTS

Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033).

CONCLUSION

RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

Clinical-Instrumental Results and Analysis of Functional Activity Restoration in Professional Athletes After Lumbar Total Disk Replacement

OBJECTIVE

To analyze the clinical and biomechanical outcome of professional athletes after lumbar total disk replacement, with a focus on restoration of the functional activity.

METHODS

This nonrandomized retrospective single-center study included 11 professional athletes who underwent lumbar disc replacement surgery using the prosthesis M6-L (Spinal Kinetics, Schaffhausen, Switzerland). The average postoperative follow-up was 3.18 ± 1.14 years. The following outcomes were evaluated: intensity of pain in the lumbar spine and lower limbs, Oswestry Disability Index, Short-Form 36, complications, time of return to previous sports activity, range of movement, degree of lumbar lordosis, degenerative changes of the adjacent levels, and degree of heterotopic ossification.

RESULTS

The operated patients reported significant decrease of pain on visual analog scale (P < 0.001) as well as significant improvement of Oswestry Disability Index (P = 0.001) and Short-Form 36 (P < 0.001). For the duration of follow-up, the patients maintained segmental range of motion at L4-L5 (P = 0.04) and L5-S1 (P = 0.03) levels. There was also some statistically insignificant increase of global lumbar lordosis (P = 0.84). We did not identify any significant degeneration of the adjacent intervertebral disks (P > 0.05) or progression of the facet joint degenerative changes at the implantation level and in the adjacent segments (P > 0.05). One patient (9.1%) developed grade I heterotopic ossification 5 years after surgery and in 1 patient (9.1%), a lesion of superior hypogastric plexus was recorded. The average time of return to previous sports activity was 9.72 ± 3.03 weeks.

CONCLUSIONS

Total lumbar disc replacement using M6-L prosthesis in professional athletes made it possible to achieve statistically significant reduction of pain and facilitated early return to normal sports activities. In our opinion, preservation of movement of the operated lumbar segment can help to reduce the mechanical stress with beneficial impact on the rate of degeneration of the adjacent level.

Effects of Stricter Management Guidelines on Return-to-Competition Timeframes Following Concussion in Professional Australian Rules Football: An Exploratory Analysis

Background

Management of concussion remains a serious issue for professional sports, particularly with the growing knowledge on the consequences of repetitive concussion. One primary concern is the subjective assessment of recovery that dictates the time until a concussed athlete is returned-to-competition. In response to this concern, the Australian Football League (AFL) changed its policy in 2020 such that medical clearance for return-to-competition was extended from 1 day, to a minimum of 5 days, prior to the next scheduled match.

Objective

We sought to explore the impact of the AFL policy change by asking whether time to return-to-competition after concussion was increased in the 2020 season relative to previous years.

Methods

Retrospective data on injury and return-to-competition were sourced from publicly available tables published by the AFL. Our primary exploration compared the number of matches missed and the number of days missed in concussed players across 2017–2020 inclusive, with secondary exploration analysing the proportion of players returning to play 12 days or longer.

Results

Analysis of data from 166 concussed players revealed no increase in the number of matches missed in 2020 relative to previous years as would have been expected from an extended recovery protocol. Comparing 2020 relative to 2017–2019, we found that there was an overall moderate reduction in median time to return-to-competition (RTC) in 2020 (10 vs 13 days, respectively d = − 0.345) and a significant reduction in players taking more than 12 days to RTC (p = 0.046).

Conclusion

This exploratory study demonstrates that clubs may not have followed policy change around concussion management designed to increase time to RTC. Ongoing auditing is required to ensure player clearance meets policy goals, highlighting the need for objective measures for RTC after concussion.

Sporting activity after craniosynostosis surgery in children: a source of parental anxiety

PURPOSE

Craniosynostosis correction involves major skull surgery in infancy-a potential source of worry for parents when their treated children begin involvement in sports.

METHODS

Electronic multiple choice survey of parents of children who had undergone craniosynostosis surgery in infancy using 5-point Likert scales.

RESULTS

Fifty-nine completed surveys were obtained from parents of children who had undergone previous craniosynostosis surgery. Mean age of children was 7.8 years (range 3 months to 22 years), with 36 non-syndromic and 23 syndromic cases. The most common surgery was fronto-orbital remodelling (18). Fifty-two of 59 were involved in athletic activity. The most intense sport type was non-contact in 23, light contact in 20, heavy contact in 4 and combat in 5. Participation level was school mandatory in 12, school club in 17, non-school sport club in 21 and regional representative in 2. One child had been advised to avoid sport by an external physician. Mean anxiety (1-5 Likert) increased with sport intensity: non-contact 1.7, light contact 2.2, heavy contact 3.5 and combat 3.6. Twenty-nine of 59 parents had been given specific advice by the Craniofacial Team regarding athletic activity, 28 of which found useful. Three sport-related head injuries were reported, none of which required hospitalisation.

CONCLUSION

Little information exists regarding sports for children after craniosynostosis surgery. This study suggests that parental anxiety remains high, particularly for high impact/combat sports, and that parents would like more information from clinicians about the safety of post-operative sporting activities.