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Consent, capacity and compliance in concussion management: cave ergo medicus (let the doctor beware)
  1. Michael Turner1,
  2. David Maddocks2,
  3. Majid Hassan3,
  4. Adrian Anderson4,
  5. Paul McCrory5
  1. 1 International Concussion and Head Injury Research Foundation, London, UK
  2. 2 Centre for Health Exercise and Sports Medicine, University of Melbourne, Melbourne, Victoria, Australia
  3. 3 Capsticks LLP, Wimbledon, London, UK
  4. 4 Aickin Chambers, Melbourne, Victoria, Australia
  5. 5 Florey Institute of Neuroscience and Mental Health – Austin Campus, Heidelberg, Victoria, Australia
  1. Correspondence to Dr Michael Turner, International Concussion and Head Injury Research Foundation, London, UK; michael{at}ichirf.org

Abstract

While the acute effects of concussion and mild traumatic brain injury (TBI) are well understood, the certainty in the medical literature regarding the long-term outcomes of sports-related concussion is limited. Long-term deficits that may result from single, repeated concussions, and possibly subconcussive impacts, include cognitive dysfunction, depression and executive dysfunction. Perhaps most troublingly, repetitive head impacts have been linked to neurodegenerative diseases, including chronic traumatic encephalopathy (CTE), although the precise risk of long-term consequences remains unknown. CTE represents a distinct tauopathy with an unknown incidence in athletic populations; however, a cause and effect relationship has not yet been demonstrated between CTE and concussions or between CTE and exposure to contact sports, as no prospective longitudinal studies have been performed to address that question. Studies of high-school sports exposure and long-term outcomes have not demonstrated consistent findings.

Medical advice regarding return to play and the risk of acute and/or long-term consequences is therefore problematic. It is important that the individual’s right to make their own choices regarding their health is respected. Team, coach, parental, peer or financial pressures should not influence this decision. The choice to return to play after a concussion or mild TBI injury is the athlete’s decision once they have (1) recovered from their injury and have the legal capacity to make an informed decision; (2) been medically assessed and (3) been informed of any possible long-term risks in a language that they can understand.

Given the current lack of certainty in relation to long-term outcomes from concussion, is it possible to provide a framework to inform players of current evidence, as part of a consent process, even if the information upon which the decision to return to sport is based remains uncertain and evolving?

  • concussion
  • assessment
  • brain
  • trauma
  • medical ethics

https://doi.org/10.1136/bjsports-2020-102108

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    Footnotes

    • Contributors MT was involved in the initial conception of the article and MT, MH, DM, AA and PM were responsible for initial writing and drafting of the article, which was reviewed by all authors. All authors revised critically for important intellectual content and approved the final version to be submitted.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests DM is a coinvestigator in research on long-term follow-up of neuropsychological function in former Australian Rules Footballers, funded through the Florey Institute of Neuroscience and Mental Health. He has a legal practice in medical law and has provided legal advice to professional sporting clubs and the Australian Football League (AFL). He is a member of the AFL Grievance Tribunal and the AFL Concussion Working Group. PM is a coinvestigator on competitive grants relating to mild TBI funded by several governmental and other organisations. He is funded under a Fellowship awarded by the National Health & Medical Research Council of Australia and is employed at the Florey Institute of Neuroscience and Mental Health. He has a clinical consulting practice in neurology, including medicolegal work. He has been reimbursed by the government, professional scientific bodies and commercial organisations for discussing or presenting research relating to MTBI and sport-related concussion at meetings, scientific conferences and symposiums. He acknowledges unrestricted philanthropic support from CogState Inc (2001–2016). He is the chair of the scientific committees of the International Concussion and Head Injury Research Foundation in London and the Sports Surgery Clinic in Dublin. MT is employed by ICHIRF as CEO and Medical Director. He has been reimbursed by universities, scientific bodies, and commercial organizations for travel and accommodation related to presenting research relating to concussion at meetings, scientific conferences, and symposiums.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.