The Conundrum of Return to Play after Moderate TBI
Image 1. Example of concussion return to play protocol (courtesy of sycva.com)
Once an athlete is diagnosed with a moderate TBI they will require more advanced imaging, typically an MRI (likely having already received a CT) and evaluation by specialists. In the example of intracranial hemorrhage, the athlete should be seen and evaluated by a neurosurgeon. Following acute management, including any required interventions and subsequent release from the hospital, the return to play decisions and management becomes tricky for the sports medicine physician. Primarily, this is due to a lack of high quality data in the literature and lack of consensus among sports medicine physicians. Thus, the most appropriate way to determine the safety of allowing an athlete to return to play with a moderate traumatic brain injury remains unclear. The following paragraphs will attempt to outline the current data on this highly controversial topic in our athletic population.
The American College of Sports Medicine (ACSM) has made recommendations regarding management of moderate TBI and, most notably, recommended that a minimum of 3-6 months is needed for a skull fracture and, if a brain bleed such as a subdural is incurred, that a repeat scan would need to show resolution of the bleed and re-expansion of the brain tissue. However, this can be a complicated requirement due to the fact that residual hemosiderin can be detected in CT and MRI scans for years after a brain insult (Tamraz 2003). After craniotomy or burr hole procedure, a patient must wait one complete year prior to returning to contact sport. There is no clear guideline on how to proceed if this happens in an athlete looking to return to contact or collision sports. In most cases, athletes do return to playing sports at some level, but no data exists on the athletes ability to return to pre-injury level of play and any further injuries which may occur after a moderate TBI. Additionally, most experts in the field suggest a minimum of one year out of contact sports prior to considering return to play after a moderate TBI.
There have also been recommendations on clinical situations or injury patterns that would warrant retiring from contact sports altogether (Cantu 1996). This information was provided to the medical community by the British Journal of Sports Medicine. The following conditions are recognized as contraindications to playing contact sports:
2. Permanent central nervous system dysfunction
4. Spontaneous subarachnoid hemorrhage
5. Symptomatic painful or neurological abnormalities of the foramen magnum
A recent practical guideline was released from a group of neurologists that suggest a stepwise approach to assist the physician in return to play decisions (Hayes et al 2018). When applying this method, it would suggest that the provider should discuss and perhaps encourage medical retirement. Future management options in patients with moderate TBI from athletics includes diffusion weighted imaging on MRI as a way to evaluate the level of brain recovery and possibly predict individual outcomes (Hou et al 2007). The difficulty of this approach in our resource-strained healthcare system is the high cost burden and the challenges of deploying advanced neuroimaging on a wide scale for assisting in return to play decisions of athletes with brain bleeds. There are also ongoing studies about brain injury biomarkers that may assist in future management and return to play decisions for athletes.