• 
• 

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.
(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]

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Purcell L May 2009 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.
Meehan WP 3rd January 2009 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.

Comment(s)

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.

Clinical 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

1. Purcell, L What are the most appropriate return-to-play guidelines for concussed child athletes? Br J Sports Med 2009; 43(Suppl 1):i51-i55
2. Meehan WP 3rd, Bachur RG Sport-related concussion Pediatrics 2009; 123: 114-123