Return-to-play decisions: are they the team physician's responsibility?

Division of Sports Medicine, Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St., Stanford, CA 94305, USA.
Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine (Impact Factor: 2.01). 01/2011; 21(1):25-30. DOI: 10.1097/JSM.0b013e3182095f92
Source: PubMed

ABSTRACT Return-to-play (RTP) decisions are a central component of the Team Physician's clinical work, yet there is little more than anecdotal reference to these in the literature. We recently published a 3-step model for return-to-play medical decision making and, in the current paper, undertook a systematic review of the literature to determine the level of evidence in support of this model.
PubMed, Web of Science, and CINAHL electronic databases. Any article specifically related to concussion, head injuries, neck injuries, illness, medical conditions (including cardiovascular and renal), and preparticipation in sport or that reported RTP as a clinical outcome was excluded. Any article that contained a discussion on one of the components of the 3-step decision-based RTP model was included.
We reviewed 148 articles that met the criteria for inclusion and found 98 review articles, 39 original articles, 6 case reports, and 5 editorials. Of these, 141 articles mentioned Step 1 of the medical decision-making process for RTP (Medical Factors), 26 mentioned Step 2 (Sport Risk Modifiers), and 20 mentioned Step 3 (Decision Modifiers). Of the 148 articles in total, only 13 focused on RTP as the main subject and the remaining 135 mentioned RTP anecdotally. Of these 13 articles, 5 were reviews, 4 were editorials, and 4 were original research.
Although 148 articles we retrieved mention RTP in relation to a specific injury, medical condition, or specific topic, only 13 articles focused specifically on the RTP decision-making process, and 6 of 13 were restricted to Step 1 of the 3-step model (Medical Factors). Return-to-play is a fertile field for research and thought leadership beginning with a focus on the Team Physician's appropriate role in RTP decision making, particularly considering the factors identified in Step 3 (Decision Modification).

1 Follower
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Zusammenfassung Hintergrund Die Wiederaufnahme von Wettkampfaktivitäten ist für Athleten nach Spondylodesen von zentraler Bedeutung. Empfehlungen zu Bedingungen und Zeitpunkt auf Basis systematischer Untersuchungen liegen bis dato nicht vor. Ziel Das Ziel der Arbeit ist es, eine Übersicht hinsichtlich Zeitpunkt und Kriterien der Rückkehr zur sportlichen Aktivität bei Erwachsenen nach degenerationsbedingter Fusionsoperation im LWS-Bereich bereitzustellen. Material und Methode Zwei unabhängige Untersucher recherchierten relevante Literatur unter Einbezug von MeSH-Terms in MEDLINE. Zielgrößen waren der Zeitpunkt sowie die Entscheidungskriterien für die Rückkehr zu sportlicher Aktivität („return to play“, RTP). Ergebnisse Aktuell sind keine randomisiert kontrollierten Studien zu RTP nach spinaler Fusion unter Beachtung der Ein- und Ausschlusskriterien veröffentlicht. Fünf der eingeschlossenen Studien basieren auf Originaldaten, größtenteils handelt es sich um narrative Übersichtsarbeiten mit geringem Evidenzniveau. Zusätzlich zu den Übersichtsarbeiten liegen eine Beobachtungsstudie, zwei Expertenbefragungen und zwei Modellentwicklungen bzw. -bewertungen vor. Schlussfolgerungen Patienten müssen nach einer spinalen Fusionsoperation für eine positive RTP-Entscheidung literaturbasiert folgende Kriterien erfüllen: 1) Abgeschlossene Remodellierung der betroffenen Gewebe, 2) Gewährleistung der Sicherheit des Athleten und anderer Personen im Rahmen des Trainings und Wettkampfes, 3) Wiederausbildung sportartspezifischer Fähigkeiten und 4) psychosoziale Bereitschaft für RTP. RTP kann bereits 6 Monate postoperativ angestrebt werden; evtl. ist eine Rückkehr zu Vollkontakt- bzw. kollisionsgefährdeten Sportarten kontraindiziert. Abstract Background Return to play (RTP) and competition following spinal fusion is of particular importance for athletes. There is a lack of guidelines for decision making in RTP processes. Objective The purpose of this work was to provide a systematic review of the criteria and time of return in the RTP decision process for adults undergoing lumbar spinal fusion. Methods Two independent investigators searched MEDLINE using MeSH terms. Targeted outcomes were criteria for return to play decisions and total duration of the RTP process. Results So far, no prospective randomized controlled trials on RTP after spinal fusion considering inclusion and exclusion criteria are available. Five of the included studies are based on original data. Most of the identified studies are narrative reviews and, thus, exhibit low evidence levels. In addition to the narrative reviews, one observational study, two expert opinion surveys and two model development studies were found. Conclusion Based on the literature research, a positive RTP decision can be made if the following criteria are fulfilled: (1) anatomical and functional healing is complete, (2) safety of the athlete and secondary subjects during training and competition is guaranteed, (3) sport-specific skills are regained, and (4) patient is psychosocially ready. The RTP process can often be successfully initiated 6 months after surgery; some patients however, will never manage the return to full-contact sports and/or sports with risk of collision.
    Der Orthopäde 11/2014; 43(12):1100-5. DOI:10.1007/s00132-014-3038-z · 0.67 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Although guidelines based on expert opinions have been developed for the immediate management and return to play of athletes after a concussion, data are lacking on this issue. Objectives: Evaluate a standardized management of brain concussion among rugby players to prevent the recurrence. Patients and Methods: A prospective study was performed from September 2009 to June 2012. All rugby players who had a concussion when playing rugby were included. Patients were managed by a specialized hospital team with a specific protocol developed in collaboration with the medical staff of the rugby clubs included in the study. The series included 35 rugby players, with 23 professionals and 12 high-level players, 30 men and 5 women, mean age 23.1 ± 5.5 years old. The median number of previous concussions was 2 (0-30) episodes. According to the Cantu concussion severity classification, 3 athletes were grade 1, 12 were grade 2 and 20 were grade 3. None of the injured athletes was lost to follow-up. The primary endpoint was the occurrence of a new concussion within 3 months after the first in patients who returned to rugby. Results: Thirty-three patients returned to rugby after a mean 22.1 ± 10 days. The recurrence rate within 3 months was 2/33 (6.1%). The median delay before returning to rugby was 21 (7-45) days. Factors associated with a delayed return to play were young age, initial loss of consciousness, severity Cantu grade 3 and post-concussive syndrome of more than 5 days. Analysis of two failures showed that the initial injury was grade 3 and that both were professional athletes and had a history of concussion. Conclusions: This prospective study validated the study protocol for the management of concussion in rugby players.
    11/2014; 5(4). DOI:10.5812/asjsm.24042
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.
    British Journal of Sports Medicine 01/2014; 48(4):289-289. DOI:10.1136/bjsports-2013-093218 · 4.17 Impact Factor

Full-text (2 Sources)

Available from
Jun 4, 2014