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  1. Concussion in Sport and hypopituitarism

    There is a growing body of research highlighting that "sports-related repetitive TBI has a cumulative effect on the development of pituitary dysfunction." [1]

    The Consensus Statement of 2008 did not allude to post-traumatic hypopituitarism (PTHP), but it is an important and treatable complication of concussion which every GP and A&E department should be alert for, for the following reasons:

    - PTHP, particularly growth hormone deficiency, can cause depression [2]as well as impotence, infertility, obesity and chronic fatigue.

    - PTHP could be a contributory factor to the tripled/quadrupled suicide risk after all traumatic brain injury including concussion [3].

    - So many people are potentially affected. Sports concussions are a commonplace event, and some studies put the incidence of PTHP after mild traumatic brain injury as high as 16.8% [4] Sports concussions also affect a section of the population i.e. young men under 35, who are already listed as a high risk group for suicide in the national suicide prevention strategy document [5].

    Being alert for PTHP especially among teenage boys and young men (and girls too) might do much to reduce the suicide rate.

    [1] Dubourg J et al, Sports-related Chronic Repetitive Head Trauma as a Cause of Pituitary Dysfunction, Neurosurg Focus. 2011;31(5):e2 [2] Zenker S et al, Growth hormone deficiency in pituitary disease: relationship to depression, apathy and somatic complaints. European Journal of Endocrinology 2002; 147(2):165-71. http://bit.ly/1aU0cXb [3] Teasdale TW, Engberg AW, Suicide after traumatic brain injury: a population study, J Neurol Neurosurg, Psychiatry 2001) http://jnnp.bmj.com/content/71/4/436.full [4] Schneider HJ et al, Hypothalamopituitary Dysfunction Following Traumatic Brain Injury and Aneurysmal Subarachnoid Haemorrhage: A Systematic Review, 2007, JAMA http://jama.jamanetwork.com/article.aspx?articleid=208915 [5]Preventing Suicide in England 2012, http://bit.ly/1bPblHc

    Conflict of Interest:

    None declared

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  2. More science please

    Dear Editor

    I read with interest the Consensus Statement on Concussion, and believe this worthwhile in furthering scientific knowledge on concussion in sport. However, I have concerns about definitive comments in the consensus statement, given the lack of supporting scientific evidence. Whilst this consensus document is only “a guide and is of a general nature consistent with the reasonable practice of a healthcare professional”, it is also “reflects the current state of knowledge”. This comment does not accurately represent the documents’ contents with definitive statements not evidenced based.

    I agree with the preamble; “management and return to play decisions remain in the realm of clinical judgement on an individualized basis”, as scant high level evidence is available on concussion management. However, Section 2.2 states that “a player with diagnosed concussion should not be allowed to return to play on the day of injury. Occasionally, in adult athletes, there may be a return to play on the same day of injury (see Section 4.2)”, which follows with “adult athletes, in some settings, where there are team physicians experienced in concussion management and sufficient resources…return to play may be more rapid.” These statements have multiple qualifiers, but do not represent the management of concussion in sport. More than “occasionally” do athletes return to play on the same day after medical assessment and symptom resolution, and this appears safe and effective. The return to play decision does not require the “sufficient resources” mentioned, but does require a physician experienced in concussion management. Certainly, there are no scientific studies, and no comparison studies, with high enough level of evidence to definitively support either approach.

    Section 11 states that “the consensus statement is intended to serve as the scientific record of the conference”. Thus, these definitive statements on concussion management, from an expert panel, require supporting scientific evidence and appropriate referencing, as for any scientific paper. To make these statements without quoting relevant high level evidence is not scientific. There are potential legal ramifications for medical practitioners who do not follow these concussion management guidelines.

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