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Review Articlereview Article Are Irish Sporting Organisations Neglecting the Safety of Their Athletes? A Narrative Review on Concussion Return-to-Play Protocols M. Beakey1, C. Blake2, S. Tiernan3, K. Collins4 1Department of Science, Institute of Technology, Tallaght, Dublin, Ireland. 2University College Dublin, School of Public Health, Physiotherapy and Sports Science, Health Sciences Centre, Belfield, Ireland 3Department of Engineering, Institute of Technology, Tallaght, Dublin, Ireland 4Gaelic Sport Research Centre, Institute of Technology, Tallaght, Dublin, Ireland Review article Review article ABSTRACT Introduction: Concussion can vary in presentation and requires an individualised clinical assessment and so, it is imperative that the appropriate return to play (RTP) protocols are administered to facilitate the safe recovery of an athlete prior to their return to sport. A 2014 report by the Houses of the Oireachtas (Parliament) Joint Committee on Health and Children (JCHC) proposed several recommendations to tackle issues with current concussion management policies in Ireland. Aims: The aim of this narrative review is to provide an in depth comparative analysis of Irish sporting organisations’ concussion RTP protocols and to assess their compliance with the JCHC’s recommended RTP proposals. Materials & Methods: Fifteen organisations were eligible for review under the inclusion criteria. Information on their RTP protocols was gathered from their official websites and through direct communication with relevant representatives from each organisation. Results: Whilst the majority of the RTP protocols bear resemblance to recent international consensus guidelines, there is a lack of consistency, clarity and detail across the approaches. Key areas in the RTP management of an athlete appear neglected; essential domains are underdeveloped for athletes, coaches and parents such as instructions pertaining to cognitive rest, return-to-learn (RTL), return-to-work (RTW) accommodations and the impact of concussion modifiers. Conclusion: The findings of this review weigh heavily in favour of the establishment of a specialised national “Sports related Concussion (SRC) Taskforce” to regulate the management of concussion in Ireland. Further research needs to be undertaken to evaluate the efficacy of an educational intervention in the graded return-to-play (GRTP) of an athlete. Keywords: Concussion management, return to play (RTP), sporting organisations, taskforce Correspondence to: Mark Beakey, MSc, Department of Science, Institute of Technology, Tallaght, Dublin 24, D24 FKT9, Ireland. Email address- [email protected] Volume 3, Issue 2, March 2016 41 INTRODUCTION Irish culture has always valued the participation in sporting activities with 45% of the population taking part in either a team or individual sport annually.1 Unfortunately, the inherent physical nature of many popular Irish sports carries with it the underlying risk of injury for the athletes. It is incumbent therefore on sporting organisations to ensure that the safest possible conditions are in place for their athletes. Sports-related concussion (SRC) has become a major health burden, affecting an estimated 3.8 million athletes every year in the United States alone, with a significant percentage of these concussions going unreported.2 Over the last 50 years, concussion has garnered substantial interest within the scientific community, however, there has been considerable variability in the definition of concussion within the literature.3 Recently in Berlin, the Concussion in Sport Group (CISG), a panel of international experts at the 5th International Conference on Concussion in Sport were tasked with providing an operational definition for concussion. They described concussion as “a traumatic brain injury that is defined as a complex patho-physiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature”.4 In the absence of a gold-standard diagnostical measure, many clinical questions remain unanswered including the exact recovery and appropriate commencement of return to play (RTP) guidelines. Therefore, the decision to allow an athlete to return to their sport following a concussive diagnosis is based heavily on subjective opinion rather than objective evidence. Following a concussion, if an athlete returns to play before the brain has fully recovered, they are at a heightened risk of exacerbating their symptoms and delaying their recovery.5 If an athlete receives additional brain trauma in their premature return to sport, they may be susceptible to long term cognitive impairment6 and even mental illness and neurodegenerative disease, although current research on the latter is inconclusive.7 In rare cases, further significant trauma to a concussed brain may lead to rapid cerebral oedema known as second impact syndrome (SIS) resulting in probable death or a permanent life altering debilitation.8 The ambiguity in recovery, results in a difficult determination by clinicians as to whether an athlete has recovered or is still suffering the effects of a concussion. Thus, a conservative RTP protocol should be recommended by clinicians and implemented by sporting organisations to minimise the potential risk of severe health complications, especially for younger athletes who are more vulnerable to concussion and its negative effects.4 Major sporting and health organisations worldwide have called for the implementation of a standardised concussion RTP framework for all athletes. However, within this RTP model, these experts have instructed a multidisciplinary concussion management team (CMT: medical staff, teachers/work colleagues, coaches and parents) to take an individualised and tailored approach to the treatment program for each injured athlete.2,5,9 Therefore, if the treatment of the athlete is to be of the highest standard of care, the members of the CMT must have an open dialogue and be appropriately qualified and competent in making RTP decisions. RTP protocols are not in place to test if a concussed athlete can tolerate physical exertion, rather they are to test an athlete’s current health to see if it safe for them to return to their chosen sport.10 HOUSES OF THE OIREACHTAS JOINT COMMITTEE ON HEALTH AND CHILDREN (JCHC) In December of 2014, Houses of the Oireachtas Joint Committee on Health and Children (JCHC)11 released a report on how to tackle the problem of concussion in sport in Ireland. The committee highlighted key issues and provided the following recommendations for Irish sporting organisations: 1. The guidelines put forward by the Concussion in Sport Group (CISG)5 at the 4th International 42 European Journal of Sports Medicine Conference on Concussion in Sport in 2012 should be implemented across all the sports disciplines at all ages and levels. 2. Sporting organisations and schools need to be more proactive with SRC with emphasis on the younger athletes. 3. A more consistent approach among all sporting organisations and educational bodies in the RTP management of SRC is required. 4. There needs to be an improved accessibility of resources including concussion clinics and specialised medical staff. 5. The recording of concussion incidents should be compulsory in all clubs and educational institutions. 6. In collaboration with the sporting organisations and educational institutions, the government needs to establish a “Taskforce on SRC” to address the current problems and to implement the Committee’s recommendations.11 To allow the CMT to effectively manage a concussion, sporting organisations must provide accesible and detailed concussion management and RTP protocols for their members to adhere to.12 In Ireland, there has been limited research evaluating the concussion management policies in place for athletes. There is an innate risk of concussion in all sports, however the risk is heightened in physical and combat sports such as mixed martial arts, boxing, horse racing and rugby.2,4,11 Therefore, increased emphasis on concussion management is necessry for organsiations that govern inherently violent and dangerous forms of sporting activity, particularly if they have a large number of youth members. The aim of this narrative review is to provide an in depth comparative analysis of Irish sporting organisations concussion RTP protocols and to assess their compliance with the JCHC’s recommended concussion management proposals. MATERIALS & METHODS Information pertaining to the concussion RTP protocols was gathered through public material available on the official websites of the relevant sporting organisations under review. An appropriate representative of each organisation was also contacted to ensure an accurate depiction of the protocols collected. Irish sporting organisations: 1) which are recognised as the National Governing Body (NGB) or National Regulatory Body of their respective sport(s) by Sport Ireland and/or Federation of Irish Sport and 2) which govern sport that is categorised as “contact and/or collision based”, or that carry an increased risk of head injury or concussion, were eligible for review. RESULTS After review, fifteen sporting organisations met the inclusion criteria (See Table 1). Of these organisations, no concussion management policy or RTP protocols were found for Gymnastics Ireland (GI),13 Rugby League Ireland (RLI),14 Cycling Ireland (CyI)15 and the Irish Ice Hockey Association (IIHA)16 and thus, were excluded from the review. Compliance with the International Concussion in
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