Sports Medicine Research: In the Lab & In the Field: On-field Management and Return-to-Play in Concussed Children are Lacking (Sports Med Res)


Monday, March 30, 2015

On-field Management and Return-to-Play in Concussed Children are Lacking

On-field management and return-to-play in sports-related concussion in children: Are children managed appropriately?

Haran HP., Bressan S., Oakley E., Davis GA., Anderson V., Babl FE. Journal of Science and Medicine in Sport. Epub ahead of print.

Take Home Message: Only 58% of concussed children were managed according to recommended guidelines and 13% returned to play while symptomatic. Additionally, 93% of parents and 96% of players were unaware of their organization’s return-to-play guidelines following a concussion.

Sixty-five percent of all sport-related head injuries presenting to emergency departments are children ages 5 to 18 years. Children who return to play while still recovering from a concussion have an increased risk of recurrent injury and related complications. It remains unclear if players and parents are knowledgeable about the general or sport-specific guidelines for concussion management as well as if these guidelines are being deployed in youth sports. Therefore, the authors assessed parent and player awareness of return-to-play guidelines as well as parent and player compliance with on-field management and return-to-play guidelines. The authors collected data from 93 children (5-18 years) who presented with a sport-related concussion at a pediatric emergency department at the Royal Children’s Hospital Melbourne. Data were collected between May 2013 and November 2013 and included both organized and unorganized sports. The hospital provided all families with a return-to-sports factsheet that outlined a graduated return-to-play protocol. The research team followed up with the parents and players between 3 weeks and 3 months after the visit to the emergency department. Forty-two percent of children in an organized sport were not managed properly immediately following the concussion:
  • 19% were not removed from play
  • 27% were not assessed by qualified personnel
  • 29% were allowed to return to play on the same day
  • 8% returned to play within 30 minutes
During the follow-up calls, 65 out of 85 children reported experiencing post-concussive symptoms. None of the patients followed the full return-to-play progression. Seventy percent followed at least two steps within the step-wise return-to-play progression. Twenty-nine percent sought medical clearance before return to play; however, 15% returned to play while still symptomatic. Parents reported that prior to this study 48% knew some concussion information; however, 93% of parents and 96% of players involved in organized sport were unaware of concussion return-to-play guidelines from their own organization.

This study highlights that while many sports adopt concussion guidelines they often inadequately implement or explain the guidelines to parents and players. This study also illustrates alarming deficiencies in the acute management of a concussion; including, not immediately removing the athlete from play, allowing the athlete to return to play on the same day, and not being assessed by qualified personnel. The compliance with return-to-play progression was also poor, while almost 75% of the players completed some part of the return-to-play progression it is evident that only completing 2 steps is not sufficient since 15% returned to play while still symptomatic. These practices potentially expose children to a greater risk of further brain injury. Sports medicine professionals should offer talks to their local youth leagues about recognizing and managing a concussion so that parents, coaches, and players can be better informed. These findings are similar to a study in the United States where parents of 5-15 year-old athletes lacked knowledge in regards to concussion definition, mechanisms, and signs/symptoms (common content in the CDC Heads-Up; Mannings et al., 2014). Sports associations need to improve the transfer of information about the best practice of on-field management and return to play progression plan following a head injury.

Questions for Discussion: How can we improve our concussion education program? Would verbal communication or concussion workshops for parents, coaches, and players be achievable?

Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban

Related Posts:
Predicting the Persistence of Concussion-Related Impairments

Haran, H., Bressan, S., Oakley, E., Davis, G., Anderson, V., & Babl, F. (2015). On-field management and return-to-play in sports-related concussion in children: Are children managed appropriately? Journal of Science and Medicine in Sport DOI: 10.1016/j.jsams.2015.02.009


Ada Weiss said...

One option for educating parents may be to include it as part of the registration process for sports leagues that have an online sign-up system. Many sports camps and club teams have an online process, and a short video explaining what a concussion is and basic management strategies could be inserted into the registration process so it has to be completed before the registration is complete. While information regarding concussions and their management may be available to most parents, it may be more likely that they will access it if the information is placed in front of them rather than having to search for it on their own.
Coaches could potentially have a similar system, where the concussion education is part of their hiring process by the league they work for. As part of these education programs, a link to a medical resource could be included for those who have questions or concerns regarding potential or actual situations. A contact person at an associated sports medicine clinic or out-reach athletic trainer would be a useful resource for prevention, assessment, and management.

Jane McDevitt said...

I think having an online educational video as part of the registration process is a great idea. My only concern is that the parents actually pay attention and not just fast forward through it. There was one study that demonstrated that parents retrained more concussion knowledge from an in person discussion compared to a video. However, this is better than not having any concussion education. A contact person such as an athletic trainer is a definite need. I know many youth leagues do not have athletic trainers on staff that. Does anyone know of anything like this being implemented in youth leagues? Do you believe youth leagues are beginning to staff medical personnel?

Andrea Baellow said...

One issue that isn't addressed here is the education the parents and children are receiving when they visit the emergency room. There is definitely a disconnect somewhere and it seems like a huge part could be failure of the staff at the hospitals to correctly educate the parents of what the next steps are. I know many youth leagues are starting to implement athletic trainers, but if parents aren't communicating with the athletic trainers there is nothing they can do to help. A child may sustain a concussion at a game on Saturday unbeknownst to the athletic trainer, they are evaluated and diagnosed at the emergency room, and the parents think they are fine for practice on Wednesday and don't inform the athletic trainer. There is definitely a disconnect somewhere, this could just be one aspect that needs to be addressed.

Jane McDevitt said...

That is a very good point, more research needs to be from the parents perspective about what do they do after their child suffers a concussion. A lot of the responsibility ends up in the parent's lap since there is not always athletic training coverage at children's game and practices. Identifying the disconnects from the parents perspective would be helpful as medical professionals develop concussion education programs and disseminate concussion information.

Roberta Swanton said...

Lack of education and general knowledge continues to be an issue. Many parents and coaches remain na├»ve to the risks and the seriousness of these risks that their youth face. Participants of youth sport are vulnerable to acute and chronic injury due to their physical immaturity, lack of proper instruction, and lack of proper medical care readily available to them. Coaches and parents should be required to physically attend educational workshops led by local physicians and athletic trainers so that they may ensure that they are attaining the knowledge, may have their questions answered, and may even be quizzed over the information that they are expected to comprehend, rather than allowing them to access the information leisurely online. This should be a requirement in order for coaches to coach and for the parents to allow their youth to play. High schools in my immediate area have been requiring coaches to attend concussion workshops in order to coach for the season. Although this is one step in the right direction, they are only receiving surface level knowledge and lack the recognition and return to play understanding. Additionally, even with this knowledge their job is to coach, so their real concern is playing the game, not always truly about their players’ well-being.
With that being said, there is a broader need for athletic training at the youth and high school levels of sport. Being able to utilize athletic trainers more at this level would not only help to reduce injury and reduce rate of chronic injury for the participants engaged in youth sports, but it would also allow the coaches to coach, parents to be parents, and for athletic trainers to play their role as a health care provider. Athletic trainers’ focus is the well-being of their players and they have the knowledge to recognize, educate others, and restore athletes to full activity. One missing link is the education, but another major link is the absence of appropriate medical coverage, even at the youth level. Athletic trainers have the knowledge and can also hopefully bridge the gap between communication and education that exists between other medical professionals, parents, and coaches for youth sports.

Jane McDevitt said...


I agree there is a definite need for athletic trainers at youth levels and certainly at the high school level. I think you bring up a good point. What about those parent/coaches at the early youth level. I know children can start playing soccer as early as 3 around me and I do not believe they need to go through any training. Another good point you bring up is if they do go through the training are they retaining it from the 1 session for the entire season that could last several months. I think physically attending workshops rather than a online test would be a step in the right direction.

Catherine Donahue said...

I agree that the overall issue is the lack of education- how can athletes/parents be expected to comply with a protocol that they are not aware of? One thing that I have found helpful from working in a high school setting is having a mandated training for coaches on concussion education. It is a basic overview of what a concussion is, signs and symptoms, and what you should do should one of your athletes demonstrate signs of a concussion. Much like CPR certification, coaches are required to complete this training module every 2 years. The first year we implemented it, several coaches told me the videos gave them a much better understanding as to why concussion are a serious matter. Granted, there is always the chance that the coach won't pay attention to the training and dismiss it, but from a legal aspect it held them accountable should they be at a game that did not have an athletic trainer present. That way, should an athlete come to me the following day reporting symptoms and tell me that they expressed this to the coach, the coach is then held accountable for having received training and not adhering to it. Another thing I found helpful was parent education prior to the start of the season. We gave a paper in the registration packet that explains what a concussion is, what our state laws are, and what our school policy is on return to play, that both the parent and athlete had to sign stating that they read and understood the rules. I imagine there were a large number that simply signed it without actually reading it, but I did have a number of parents that did take the time to read it and actually email me with questions. These are just some things that have worked for me, and may work in situation like those described in the article

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