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The decision to retire after repeated concussive injuries remains a complex and controversial area. For the most part, there are no evidence based recommendations to guide the practitioner. In the absence of scientifically valid guidelines, good clinical judgment and common sense remain the mainstay of management.
It is difficult for a team doctor when an athlete, professional or otherwise, has suffered a number of concussive injuries but has no residual neurological or cognitive symptoms. Concern expressed by the doctor, the patient, and other medical or coaching team members is often raised as the prelude to this decision making process. Far more difficult, and sadly far too common, is the trial “by media” in which anecdotal cases of athletes with poor outcomes following repeated “concussions” are described, often with little or no supporting medical evidence, as the basis for recommendations about the playing future of the player concerned.
There is no scientific evidence that sustaining several concussions over a sporting career will necessarily result in permanent damage. Part of the neuromythology surrounding concussion is the concept of the “three strike rule”: if an athlete has three concussions then, he or she is ruled out of competition for a period of time. On occasions, this can result in permanent curtailment of sporting participation. This anecdotal approach was originally proposed by Quigley in 1945 and subsequently adopted by Thorndike, who suggested that if any athlete suffered “three concussions, which involved loss of consciousness for any period of time, the athlete should be removed from contact sports for the remainder of the season”.1 It is important to remember that this approach has no scientific validity, yet continues to be the rationale underpinning most of the current guidelines on return to play. It may also be worth noting that the …
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