Medical retirement from sport after concussions

Abstract

Purpose of reviewIn patients with a considerable history of sports-related concussion, the decision of when to discontinue participation in sports due to medical concerns including neurologic disorders has potentially life-altering consequences, especially for young athletes, and merits a comprehensive evaluation involving nuanced discussion. Few resources exist to aid the sports medicine provider.Recent findingsIn this narrative review, we describe 10 prototypical vignettes based upon the authors' collective experience in concussion management and propose an algorithm to help clinicians navigate retirement discussions. Issues for consideration include absolute and relative contraindications to return to sport, ranging from clinical or radiographic evidence of lasting neurologic injury to prolonged concussion recovery periods or reduced injury threshold to patient-centered factors including personal identity through sport, financial motivations, and navigating uncertainty in the context of long-term risks.SummaryThe authors propose a novel treatment algorithm based on real patient cases to guide medical retirement decisions after concussion in sport.

Considerations for Pediatric Retirement from Athletics Following Repetitive Concussive Traumatic Brain Injury: Incorporating the Right to an Open Future

“…In their 2018 guidelines for medical retirement from sports after a concussion, Davis-Hayes et al describe specific clinical characteristics as absolute and relative contraindications to RTS [ 9 ]. Absolute contraindications include evidence of structural brain injury identified on neuroimaging.…”

“…Relative contraindications include (1) post-concussive signs lasting more than 90 days or increasing in severity, (2) cognitive impairment (as demonstrated on neuropsychological testing), (3) diminished academic performance or social engagement, and (4) decreased concussion threshold or decreased interval between concussions [ 9 ]. While the authors say that any one of these may be managed and does not necessitate retirement, the totality of clinical factors present may lead to the clinical recommendation for medical retirement.…”

“…Equally challenging is when parents or guardians disagree, particularly if one parent has a strong preference in continuing participation while the other parent strongly opposes—in many situations, having all stakeholders discuss their priorities and which factors they deem to be most important may be helpful reducing intuitive or emotional decision making. The use of decision-making trees can provide families and clinicians a more structured approach to discussing medical retirement [ 9 ].…”

“…However, despite these crucial efforts, empirical evidence demonstrating long-term success is still lacking [ 4 ]. The decision to medically retire an athlete can be complicated, emotionally charged, and should be based on much more than merely the number of concussions the athlete has sustained [ 5 , 6 , 7 , 8 , 9 ]. The decision can be even more problematic when the athlete is an adolescent.…”

“…The factors relevant to the medical retirement decisions are numerous, and the risks and benefits of each must be weighed in light of the individual player’s circumstances. Much of the literature published on this topic, and many others in clinical ethics, reduces these deliberations to mere benefit and harm balancing [ 9 ]. In this paper, we suggest framing the problematic decision of a pediatric athlete’s medical retirement from participation in sports due to concussive injuries in relation to the adolescent’s right to an open future [ 10 , 11 ].…”