Return-to-play decisions a key challenge in management of sports-related concussion




Privacy laws can present a challenge to physicians managing athletes with concussion, particularly if those athletes push to return to play against the physician’s advice, but waivers may avoid this challenge, according to the authors of a position paper on sports-related concussion.

"Evaluating and managing sports-related concussion raises a variety of distinctive ethical and legal issues for physicians, especially relating to return-to-play decisions," Dr. Matthew P. Kirschen of the Children’s Hospital of Philadelphia and his colleagues wrote in Neurology July 9.

Lack of training is also a major issue in sports-related concussion, with a previous survey by the American Academy of Neurology finding that while most neurologists do see patients with sports-related concussion, few have had formal or informal training on managing concussion.

One of the most challenging components of managing sports-related concussion is the decision about when the athlete can return to play, which can be problematic if the athlete-patient wants to return to play prematurely.

Athletes may ignore their physician’s advice or even "doctor shop" for a physician who will approve their return to play, which may bring the physician into conflict with privacy laws restricting the sharing of personal health information without the patient’s consent.

"Thus, the evaluating physician could find himself or herself in the difficult position of being legally restricted from sharing a concussion evaluation with the athlete’s coaches and school personnel, even though making such a disclosure might be in the best interest of the athlete’s health," the authors wrote in the document, which is an official position paper of the Ethics, Law, and Humanities Committee, a joint committee of the American Academy of Neurology, American Neurological Association, and the Child Neurology Society (Neurology 2014 July 9 [doi:10.1212/WNL.0000000000000613]).

In response, some institutions now require athletes to sign waivers, allowing personal health information to be shared between the physician affiliated with the school department and the coaches and other team or school staff.

While all 50 states have adopted youth sports concussion laws addressing the three main components of education, removal from play, and return to play, statutes differ over who is authorized to clear an athlete to return to the field – some specify a physician while others allow athletic trainers, nurse practitioners, and physician assistants to make the decision. "States do not uniformly require that individuals providing clearance be trained in the evaluation and management of concussion," the authors reported.

However, the authors of the report stressed that physicians responsible for the care of athletes, either on or off the sidelines, should ensure they have appropriate training and experience in recognizing, evaluating, and managing concussion and potential brain injury.

Fortunately, state-based youth sports concussion laws generally have a low "removal from play" threshold to protect young athletes from harm, which the authors said should encourage coaches, parents, and athletes to take the risks of concussion more seriously.

In an editorial commentDr. Ellen Deibert of Wellspan Neurology, York, Pa., said discussion of sports-related concussion was timely, with the Centers for Disease Control and Prevention recently estimating around 1.6-3.8 million sports and recreation-related concussions each year, which has skyrocketed from the previous annual estimate of 300,000.

"Overall, the article is a refreshing reminder of the issues surrounding the treatment of sports-related concussion and the need for continued education and research on this topic," Dr. Deibert wrote.

The position paper authors call for the establishment of a concussion registry to improve understanding of the condition. Such a registry "would need to be interdisciplinary and in collaboration with other subspecialists already involved in concussion management. The role the neurologist plays will eventually be defined during that process. However, in 2014, there remains an immediate need for providers to treat concussion patients. The only question you need to answer is what your role will be in supporting this effort," she said.

Several authors of the paper reported authorship honorariums, royalties, and editorial positions. The editorial author declared no relevant conflicts of interest.

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