When to Consider Retiring an Athlete After Sports-Related Concussion

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Social and legal implications in the decision to retire

Concussive injury has been observed to manifest in four stages (Table 1) with a distinct temporal association. In the acute concussive stage lasting up to 1 week after injury, physical symptoms, cognitive deficits, and emotional disturbances may be evident. This may be followed by a postconcussive stage consisting of persistent acute phase symptoms, which are nevertheless self-limited to approximately 6 weeks after mild traumatic brain injury (MTBI). A prolonged postconcussion syndrome lasting

Concussion pathophysiology

There is a greater understanding of concussion now than ever before. The pathophysiology of concussion is characterized by a variety of metabolic mechanisms, which are both acute and subacute in nature. On initial insult, a hypermetabolic state is created with excessive release of excitatory neurotransmitters, despite a decrease in cerebral blood flow.3 This is characterized by ion movements, such as influx of calcium and efflux of potassium, causing extensive depolarization of neurons, along

Long-term effects of concussion

The long-term pathophysiology of repeated head trauma is particularly important to the decision to retire an athlete after sports-related concussion. Despite the early recognition of symptomatology in retired boxers with early neurodegenerative changes, many chronic concussive effects are still being explored and are incompletely understood. The first report of chronic, permanent neurologic sequelae in career boxers was by Martland4 in 1928, which he termed, dementia pugilistica (DP). This

Decision-making process

The basic principles of sports medicine and acute concussion management deal with the implications of the pathophysiology (discussed previously), specifically, the predictable, stepwise nature of symptoms, the susceptibility to further injury after initial insult, and the prevalence of physiologic rather than structural abnormalities. The statement of the First International Conference on Concussion in Sport, held in Vienna in 2001, succinctly outlined these principles.15 These basic principles

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      This article explores considerations pertaining to athletes’ own medical and concussion histories, as well as external factors that influence sport participation. A summary of proposed contraindications to continued sports participation after SRC published in the last decade is given in Table 2.15–20 Importantly, these are still based on expert opinion, and retirement after SRC remains an area for future research, which is likely to evolve with the understanding of SRC and related outcomes.

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      Career-ending features included persistent PCS (without a clear definition of persistence), Chiari malformation, intracranial hemorrhage, diminished academic performance or cognitive abilities, lowered threshold for concussion, 3 or more major concussions, computed tomography or MRI evidence of structural abnormality, nonresolving MRI deficits, or symptoms of chronic traumatic encephalopathy (CTE). The investigators emphasized the potential for cumulative and, rarely, progressive symptoms after concussion.14 Concannon and colleagues15 reviewed the subject in 2014, creating a similar list of absolute contraindications to return to play, including persistent PCS (with PCS defined as symptoms lasting longer than 3 months), SAH, permanent neurologic injury, SIS, hydrocephalus, imaging that increases risk for future brain injury (edema, hemorrhage, hydrocephalus, arachnoid cysts), and permanent deficit on neuropsychological testing.

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      An open discussion between all involved parties is necessary when making recommendations. It is clear that athletes with prolonged unresolved postconcussion symptoms, permanent neurologic signs or symptoms, NP testing that has not returned to baseline, or a report of decreased academic performance should not return to sports.63 It is more challenging to make recommendations to the athlete who has fully recovered, but whose history puts him or her at potentially increased risk in the future.

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