RETURN TO PLAY GUIDELINES AFTER A HEAD INJURY

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The brain and spinal cord are incapable of regeneration. Although many parts of the body can now be replaced with organ transplantation or artificial hardware, this is not possible for the brain. Brain injuries are one of the most common catastrophic athletic injuries and the leading cause of athletic death.

According to the catastrophic sports injury registry, sports that have the greatest chance of causing catastrophic head injury per 100,000 participants include football, gymnastics, ice hockey, and wrestling.6 In football, the use of the head in making a tackle is the most common cause of head injury; in gymnastics, it is the dismount in which one accidentally lands on the head; in wrestling, it is landing on the head in the process of the take-down; and in ice hockey, it is striking the boards head first. Other school sports that entail a significant chance for head injury include the pole vault in track and the head-first slide in baseball.

Although the risk of death appears a third that of football, boxing, especially professional boxing (see the article by Dr. Allan Ryan elsewhere in this issue) is the other sporting activity with a high number of deaths recorded.

Other sporting activities with significant risk for head injury include equestrian sports, especially horse racing3, 4; motorcycle, automobile, and boat racing5, 7; sky diving20, 27; boxing28; the martial arts24; and rugby.23

Sports that carry a risk for catastrophic head injury pose an even greater risk for minor head injuries. Football, because it is participated in by more than 1.5 million high school and college athletes, causes more minor head injuries than any other single sport. The incidence is estimated to be 250,000 per year or approximately 20%.10

Section snippets

Biomechanical Forces That Affect the Brain

An understanding of three principles is necessary to comprehend how biomechanical forces produce skull and brain injury. A forceful blow to the resting movable head usually produces maximal brain injury beneath the point of cranial impact (coup injury). This is the situation when the head in a resting state is forcibly struck by another object such as a left hook or an opponent's football helmet.2 A moving head colliding with a nonmoving object usually produces maximal brain injury opposite the

CONCLUSION

Today there are no universally accepted definitions of the grades of concussion or criteria for when to allow the athlete to return to competition after a concussion. In 1986, in The Physician and Sportsmedicine, I addressed this issue, and those recommendations are summarized in Table 2. I want to make it perfectly clear that these are guidelines for return to competition in contact sports after a concussion or more lethal brain injury based on both the world's literature and on my experience

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    Address reprint requests to Robert C. Cantu, MD, FACS, FACSM, Service of Sports Medicine, Emerson Hospital, Concord, MA 01742

    *

    Neurosurgery Service and the Service of Sports Medicine, Emerson Hospital, Concord, Massachusetts

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