Journal of Science and Medicine in Sport 19 (2016) 194–199
Contents lists available at ScienceDirect
Journal of Science and Medicine in Sport
journal homepage: www.elsevier.com/locate/jsams
Original research
On-field management and return-to-play in sports-related concussion
in children: Are children managed appropriately?
Harini P. Haran a,b,c , Silvia Bressan a,b,d , Ed Oakley a,b,e , Gavin A. Davis b,e ,
Vicki Anderson b,e , Franz E. Babl a,b,e,∗
a
Emergency Department, Royal Children’s Hospital Melbourne, Victoria, Australia
Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
c
Monash University, Clayton, Victoria, Australia
d
University of Padova, Italy
e
Department of Paediatrics, University of Melbourne, Victoria, Australia
b
a r t i c l e
i n f o
Article history:
Received 8 November 2014
Received in revised form 20 January 2015
Accepted 14 February 2015
Available online 24 February 2015
Keywords:
Concussion
Traumatic brain injury
Head injury
Sport
Child
Return to play
a b s t r a c t
Objectives: On-field management and return-to-play guidelines aim to ensure the identification and
appropriate management of the concussed athlete. Compliance with current guidelines in many settings
is unknown. We assessed whether key components of current concussion guidelines are being followed
in child athletes.
Design: Prospective observational study.
Methods: Data were collected from children (5–18 years) presenting to a paediatric emergency department with sport-related concussion via researcher-administered surveys in the emergency department
and during a follow up phone call. On hospital discharge all patients received a return to sports fact sheet
based on the International Concussion in Sports Group.
Results: Ninety-three had sustained a concussion (mean age 12.7 (±0.27) years, 83% male). Sports played
included Australian Football (47%), soccer (12%), rugby (9%) basketball (8%), other (25%). 82% participated
in organised sports. Concussive signs or symptoms included loss of consciousness (41%), disorientation (36%), vomiting (23%), amnesia (30%), headache (60%). For concussive injury in organised sports
(n = 76), overall 42% were not managed according to recommended guidelines: 19% were not immediately removed from play, 29% were allowed to return to play on the same day and 27% were not assessed
by qualified personnel. 93% of parents and 96% of patients were unaware of concussion or return-to-play
guidelines from their organisations. Overall, 72% were compliant with provided return-to-play guidelines.
Conclusions: Many children with sports related-concussion are not formally assessed on-field and continue to play. On-field concussion management and return to play practices are often suboptimal.
Awareness and education of coaches, teachers, parents and children need to be improved.
© 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Sports-related concussion has received growing media and scientific attention in recent years for its increasing incidence and
possible short and long-term sequelae.1 Children are particularly
vulnerable with 65% of all sport-related head injuries presenting
to US emergency departments (EDs) being in persons aged 5–18
years.2 In Australia, the impact of concussion on the child and on
the health sector is not well described, despite 63% of school-aged
∗ Corresponding author.
E-mail address: Franz.babl@rch.org.au (F.E. Babl).
children participating in at least one organised sport outside school
hours.3
Concussed athletes, who return to play whilst still symptomatic,
have an increased risk of recurrent injury and associated complications. This is due to a pathophysiological window of brain
vulnerability post-concussion, as well as a post-concussion reduction in reaction time, information processing and speed, exposing
the athlete to the demands of sport with a reduced capacity for
evasive and defensive actions, with resultant increased risk of
recurrent brain injury.4,5
The main issues of concern therefore are concussion management at the time of injury and timing of return to play.
The International Concussion In Sport Group (CISG) consensus
statement,5 and position statements from the American Medical
http://dx.doi.org/10.1016/j.jsams.2015.02.009
1440-2440/© 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
H.P. Haran et al. / Journal of Science and Medicine in Sport 19 (2016) 194–199
Society for Sports Medicine (AMSSM)6 and the American Academy
of Neurology (AAN)7 all advocate prohibition of athletes returning
to play/train on the same day as their injury.
In Australia, both the Australian Football League (AFL) and the
National Rugby League (NRL) recommend immediate removal from
play, first aid management and assessment by medical personnel for athletes with suspected concussion, as per the CISG 2012
Consensus Statement on Concussion in Sport.5,8,9 In Australian
Football, junior leagues are required to have a person with current first aid qualifications available at all games.8 Once concussion
has been diagnosed, both sporting bodies mandate a graduated
return-to-play process commencing once the athlete is asymptomatic, progressing to normal game play in a minimum of 6 days.
No evidence based guidelines for safe return-to-play following
sport-related head injury have been validated for children, and the
current guidelines are modelled on those for adults recommended
in the CISG 2012 Consensus Statement.5,10
It remains unclear if general or sports specific guidelines for concussion management translate into changed on field practice, and
how much players and parents know about the management of
concussion and return to play instructions. There have been few
studies assessing on-field management of head injuries in children
and youth, or coach awareness and understanding of recommended
guidelines. A recent survey of community AFL and NRL coaches and
sports trainers identified knowledge gaps in key aspects of on-field
management and the importance of a graduated return-to-play.11
International studies have recognised similar gaps in both coach
and player knowledge.12,13
Involvement in sport is highly encouraged for children to
improve health, fitness, confidence and teamwork skills. However it
is crucial that sport is also safe for children who are rapidly developing both cognitively and physically. This study aimed to identify: (1)
compliance with on-field management guidelines for concussion;
(2) parent and player awareness of return-to-play guidelines; and
(3) parent and player compliance with return-to-play guidelines
supplied to them. We also planned to assess differences between
sports, and between organised and unorganised sporting activities.
2. Methods
Children aged between 5 and 18 years presenting to the
emergency department (ED) at The Royal Children’s Hospital Melbourne (RCH) with sport-related concussion between May 2013
and November 2013 were recruited for the study. The RCH is a paediatric tertiary referral hospital and paediatric trauma centre for
the state of Victoria, Australia, with an annual ED census of 82,000
patients. The study was approved by the RCH human research
ethics committee.
Sports included both organised and non-organised sports, and
included recreational activities such as motor-cycle and bicycle riding, skateboarding, horse-riding and ice-skating. Injuries sustained
while playing on a playground or during games involving running
but not involving a ball were not included.
We enrolled concussive injuries defined as a blow to the head
resulting in one or more of the following: loss of consciousness, headache, vomiting, amnesia, disorientation, seizure or focal
neurology.5 We excluded lacerations or bruises to the head or face
without concussive signs or symptoms.
Eligible children were identified at initial presentation to the ED.
Verbal consent was obtained for initial data collection and followup phone call, which was completed with parents between 3 weeks
and 3 months after recruitment. Refusal to participate would not
impact on the patient’s clinical management and parents/guardians
were able to withdraw their child from the study at any time.
195
All families were provided with the hospital’s return-to-sports
fact sheet,14 outlining the graduated return-to-play protocol recommended by the CISG 2008 Consensus Statement,15 and a fact
sheet providing general advice for head injury post-dicharge.16
Though both the CISG statement and head injury fact sheet were
more detailed in their recommendations, we defined a patient as
“compliant” with CISG on field management if they were removed
immediately from play, assessed by qualified personnel and not
allowed to return to play on the same day. We defined a patient as
“compliant” with CISG RTP if they at least followed two of the steps
of the step wise return to play and did not return to play while still
experiencing symptoms.
Analysis was descriptive with categorical variables presented
as percentages and 95% confidence intervals for relevant key percentages, and continuous variables described as mean and standard
deviation or median and interquartile range according to their
parametric or non-parametric distribution. Results for Australian
Football (AF) and non-AF sports played were dichotomised.
3. Results
During the study period, there were 1115 head injuries (HIs) of
any severity that presented to the ED. A total of 271 sport-related
HIs among children aged 5–18 years were identified. Of these,
169 were missed during prospective recruitment, mostly while
researchers were unavailable to approach patients for enrolment.
A total of 102 patients with sports related HIs were approached;
9 were excluded as they had soft tissue or neck injuries without
concussive symptoms and 93 had concussion (the study group).
No patient who was approached refused consent for participation.
Of enrolled patients with concussion, 8 were lost to follow up. The
average number of days until follow up was 32 (±5.2) days.
Demographics and signs and symptoms at presentation of the
93 enrolled children are presented in Table 1. Children arrived by
ambulance in 50.5% of cases and apart from one patient arriving
by air ambulance the remainder arrived in private car. Mean age
of the children with concussion was 12.7 (SD ± 0.27) years. Sports
played were AF (47.3%), soccer (11.8%), rugby (8.6%) basketball
(7.5%) and other sports (24.7%). which included baseball, gymnastics, ice-skating, speed ice-skating, horse-riding, handball, hockey,
taekwando, motocross, and riding a scooter, bicycle, skateboard or
quadbike. Most children (81.7%) were involved in organised sports.
Of the organised sports, 53.9% (95% CI 42.1–65.5%) were playing AF.
Children had been competing in their sport on average 3.7 years
(SD ± 0.3). Overall, protective equipment was worn by 51.6% (95%
CI 41.0–62.1%), mainly mouth guards (41.9%) and helmets (12.9%).
All participants were asked whether they wore a helmet at the time
of injury, with only 2.3% of AF players and 22.4% of non-AF players
wearing a helmet.
Signs and symptoms of concussions and management of children prospectively enrolled who were playing AF is compared
with those playing non-AF sports in Table 1. The most frequent
concussive symptoms and signs were headache (60.2%), and LOC
(40.9%). Neuroimaging was performed in 18/93 (19.4%) of patients
with none showing intracranial pathology. Forty-five percent were
observed in a short stay unit (30.1%) or admitted to an inpatient
ward (15.1%).
Important factors regarding on field management of concussive
injuries are shown in Table 2. For most injuries a coach or medical
staff attended and assessed the patient. Ten percent of patients did
not report their head injuries at the time and were therefore not
assessed on field. Symptom checklist use could only be determined
definitively in ∼50% of cases overall as 20% of patients did not know
if the checklist had been used.
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H.P. Haran et al. / Journal of Science and Medicine in Sport 19 (2016) 194–199
Table 1
Demographics, signs and symptoms of children with sports related concussion.
Gender
Male
Female
Age (years)
5–7
8–10
11–15
16–18
Organiser
Club
School
Non-organised
Nature of organised play
Competition
Friendly
Training/Physical Education
NA
Competition level
Suburban
Interschool
Other
NA
Competition experience
Nil
≤1 year
1–5 years
>5 years
Concussive signs and symptoms
Loss of consciousness
Disorientation
Vomiting
Amnesia
Headache
Seizure activity
Focal neurological deficit
Disposition
Treated and discharged
Observed in Short Stay
Inpatient admission
Australian Football
(n = 44)
Non-Australian Football
(n = 49)
Total
(n = 93)
43 (97.7%)
1 (2.3%)
34 (69.4%)
15 (30.6%)
77 (82.8%)
16 (17.2%)
3 (6.8%)
4 (9.1%)
35 (79.5%)
2 (4.5%)
1 (2.0%)
9 (18.4%)
32 (65.3%)
7 (14.3%)
4 (3.9%)
13 (14.7%)
67 (70.6%)
9 (10.8%)
36 (81.9%)
5 (11.4%)
3 (6.8%)
23 (46.9%)
12 (24.3%)
14 (28.6%)
59 (63.4%)
17 (18.3%)
17 (18.3%)
40 (90.9%)
1 (2.3%)
0
3 (6.8%)
22 (44.9%)
4 (8.2%)
8 (16.3%)
17 (34.7%)
62 (66.7%)
5 (5.4%)
8 (8.6%)
18 (19.4%)
31 (70.5%)
4 (9.1%)
6 (13.6%)
3 (6.8%)
11 (22.4%)
6 (12.2%)
11 (22.4%)
21 (42.9%)
42 (45.2%)
10 (10.8%)
17 (18.3%)
24 (25.8%)
3 (6.8%)
4 (9.1%)
21 (47.7%)
16 (36.4%)
13 (26.5%)
9 (18.4%)
14 (28.6%)
13 (26.5%)
16 (17.2%)
13 (14.0%)
35 (37.6%)
29 (31.2%)
17 (38.6%)
18 (40.9%)
9 (20.5%)
15 (34.1%)
25 (56.9%)
1 (2.3%)
1 (2.3%)
21 (42.9%)
15(30.6%)
12 (24.5%)
13 (26.5%)
31 (63.2%)
1 (2.0%)
4 (8.2%)
38 (40.9%)
33 (35.5%)
21 (22.6%)
28 (30.1%)
56 (60.2%)
2 (2.2%)
5 (5.4%)
30 (68.2%)
11 (25.0%)
3 (6.8%)
21 (42.9%)
17 (34.7%)
11 (22.4%)
51 (54.8%)
28 (30.1%)
14 (15.1%)
Other levels of competition included; state, regional, rural and age group levels.
NA = not applicable.
When compliance with on-field management practices was
defined as performing all tasks recommended by the CISG
statement, 32/76 (42%; 95% CI 31–54%) children involved in
organised-sports were not managed appropriately. This included
14/76 (19%; 95% CI 10–31%) not removed immediately from play;
21/76 (27%; 95% CI 17–40%) not assessed by qualified personnel;
and 22/76 (29%; 95% CI 18–41%) allowed to return to play same
day, with 6/76 (7.9%; 95% CI 3.0–16.4%) allowed to return to play
after less than 30 min.
Follow-up calls were completed for 85 children. Of these 85
children, 42 (49.4%) played AF. Overall 65 children (76.5%; 95% CI
66.0–85.0%) experienced post-concussive symptoms.
The most frequent post concussive symptoms reported in follow
up were fatigue (57.6%), headache (56.5%), neck pain (25.9%),
difficulty concentrating (17.6%), difficulty remembering (15.3%),
irritability (15.3%), sensitivity to light (14.1%), being more emotional (12.9%), dizziness (11.8%), sensitivity to noise (11.8%), nausea
and vomiting (10.6%). Forty-nine of 85 children (57.6%; 95% CI
46.4–68.3%) experienced symptoms for fewer than 7 days, and
16/85 (18.8%; 95% CI 11.2–28.8%) experienced symptoms for 10
days or more after their injury. Compliance rates with components
of RCH return-to-play guidelines are shown in Table 3.
None of the 85 patients followed the CISG based step-wise process exactly as set out in terms of a 6 step staged process or with
progression to the next step every 24 h. However, as set out in
methods, we defined compliance with RTP guidelines in a modification of the 2008 CISG guidelines.15 Seventy children (82.4%;
95% CI 72.6–89.8%) (57 organised, 13 non-organised) followed at
least two steps of the step-wise RTP process. One of these children playing organised AF did not complete each step for at least
24 h, and 12/85 (14.1%; 95% CI 7.5–23.4%) children, all playing organised sports, returned to play whilst still experiencing symptoms. A
further two children who had followed a step-wise RTP, both playing organised AF, experienced symptoms during their RTP process
but did not rest for at least 24 h until asymptomatic, as prescribed
by the CISG protocol. Fifty-five percent of children had followed a
RTP and returned to sport and six were still symptomatic and had
not yet returned to sport. Therefore, overall 61/85 (71.8%; 95% CI
61.0–81.0%) were broadly compliant with our RTP guidelines. In
organised sports, 47/70 (67.1%; 95% CI 54.9–77.9%) were compliant with our RTP guidelines. In most measures of compliance there
was little difference between the different organised sports or unorganised sport. However more children who played organised AF
received medical clearance before returning to play.
Prior to presentation for this injury, 45/93 (48.4%; 95% CI
37.9–59.0%) of parents were aware of some HI information. However, 71/76 (93.4%; 95% CI 85.3–97.8%) of parents and 73/76 (96.1%;
95% CI 88.9–99.2%) of children involved in organised sports were
unaware of head injury information from their own organisation.
Of the 17 children with a previous sport-related HI in organised
H.P. Haran et al. / Journal of Science and Medicine in Sport 19 (2016) 194–199
197
Table 2
On field management of concussive injuries.
Organised sports (n = 76)
AF (n = 41)
Personnel attending injury
1 (2.4%)
No
Yes
36 (87.8%)
Coach
21
Medical staff
33
Other
5
Did not report head injury
4 (9.8.%)
Personnel assessing injury
4 (9.8%)
No
Yes
32 (78.0%)
16
Coach
24
Medical staff
2
Other
1 (2.4%)
Unknown
4 (9.8%)
Did not report head injury
Field-side assessment using symptom checklist
10 (24.4%)
No
Yes
15 (36.6%)
12 (29.3%)
Unknown
Did not report head injury
4 (9.8%)
0
NA, non-organised
Stoppage of play
18 (43.9%)
No
18 (43.9%)
Yes
NA
5 (12.2%)
4
Did not report head injury
End of game
1
0
Non-team sports
Immediate removal from play
No
4 (9.8%)
33 (80.5%)
Yes
Did not report head injury
4 (9.8%)
Stand down time
<15 min
2 (4.9%)
2 (4.9%)
15–30 min
0
Unknown
NA
37 (90.2%)
7
Kept playing
Did not return to play
30
Same day return to play since head injury
29 (70.7%)
No
12 (29.3%)
Yes
8
Kept playing
Same game
4
0
Unknown
Management between field and emergency department
9 (22.0%)
No
32 (78.0%)
Yes
22
Paramedic
10
Other Doctor/Hospital
3
Other
Transport to emergency department
17 (41.5%)
Personal car
23 (56.1%)
Ambulance
1 (2.4%)
Air transport
Non-organised sports (n = 17)
Total (n = 93)
3 (8.6%)
29 (82.9%)
21
15
4
4 (11.4%)
5 (29.4%)
9 (52.9%)
0
5
2
3 (17.6%)
9 (9.7%)
74 (79.6%)
42
53
11
11 (11.8%)
9 (25.7%)
21 (60.0%)
11
15
6
1 (2.9%)
4 (11.4%)
6 (35.3%)
8 (47.1%)
0
6
1
0
3 (17.6%)
19 (20.4%)
61 (65.6%)
27
45
9
2 (2.2%)
11 (11.8%)
17 (48.6%)
7 (20.0%)
7 (20.0%)
4 (11.4%)
0
NA
NA
NA
NA
17
27 (29.0%)
22 (23.7%)
19 (20.4%)
8 (8.6%)
17 (18.3%)
7 (20.0%)
22 (62.9%)
6 (17.1%)
3
1
2
NA
NA
NA
NA
NA
NA
25 (32.9%)
40 (52.7%)
11 (14.5%)
7
2
2
3 (8.6%)
29 (82.9%)
3 (8.6%)
NA
NA
NA
7 (9.2%)
62 (81.6%)
7 (9.2%)
1 (2.9%)
1 (2.9%)
1 (2.9%)
31 (88.6%)
6
25
NA
NA
NA
NA
NA
NA
3 (3.9%)
3 (3.9%)
1 (1.3%)
68 (89.5%)
13
55
25 (71.4%)
10 (28.6%)
6
2
0
12 (70.1%)
4 (23.5%)
3
0
1 (5.9%)
66 (71.0%)
26 (28.0%)
15
6
1 (1.1%)
14 (40.0%)
21 (60.0%)
15
4
4
4 (23.5%)
13 (76.5%)
9
6
1
27 (29.0%)
66 (71.0%)
46
20
8
20 (57.1%
15 (42.9%)
0
8 (47.1%)
9 (52.9%)
0
45 (48.4%)
47 (50.5%)
1 (1.1%)
Non-AF (n = 35)
AF – Australian Football.
sports, only 1 child and parent were aware of HI information from
their organisation.
At follow-up, all parents (100%) were aware of the hospital provided RTP guidelines as provided in the HI handout they received.
However, 74.3% (95% CI 62.4–84.0%) of all parents with completed
follow-up calls who participated in organised sports were unaware
of any RTP guidelines from their organisation. Of those participating in club sports, 15/54 (27.8%, 95% CI 16.5–41.6%) were aware
of RTP information from their club and of those participating in
school sports, 3/16 (18.8%; 95% CI 4.0–45.6%) were aware of RTP
information from their school. 1 child and 1 parent was aware of
both school and club guidelines.
4. Discussion
It is widely accepted that same day return to play in concussed athletes can cause prolonged symptoms, and increase the
risk of both complications and recurrent HI.7,17 CISG consensus recommendations5 have been adopted by Australian sporting
codes such as AFL8,18 and NRL.9 They mandate the use of an
approved sideline assessment tool (SAT) and trained personnel to
assess concussive injury. This study was designed to assess the
implementation of these guidelines in children’s sport, the participants’ knowledge of these guidelines, and concussed patient
compliance with return to play guidelines. The underlying sports
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H.P. Haran et al. / Journal of Science and Medicine in Sport 19 (2016) 194–199
Table 3
Return to play (RTP) protocol followed in children with concussive injury in organised Australian Football (AF), organised non-AF sports and non-organised sports, including
second head injury.
Organised Sports (n = 70)
Attempted any RTP
No
Yes
First full gameplay RTP attempt
Not yet full RTP
<7days post-concussion
≥7days post-concussion
Attempted step-wise RTP
No
Yes
NA, not yet RTP
Contact RTP with medical clearance
No
Yes
NA, not yet returned to contact sports
RTP whilst symptomatic
No
Yes
NA
Symptoms during RTP and action taken:
No symptoms
Experienced symptoms
Continued RTP without rest
Rested until asymptomatic for ≥24 h
NA
Non-organised sports (n = 15)
Total (n = 85)
3 (9.7%)
28 (90.3%)
1 (6.7%)
14 (93.3%)
6 (7.1%)
79 (92.9%)
4 (10.3%)
0
35 (89.7%)
10 (32.3%)
1 (3.2%)
20 (64.5%)
4 (26.7%)
1 (6.7%)
10 (66.7%)
18 (21.2%)
2 (2.4%)
65 (76.5%)
4 (10.3%)
33 (84.6%)
2 (5.1%)
4 (12.9%)
24 (77.4%)
3 (9.7%)
1 (6.7%)
13 (86.7%)
1 (6.7%)
9 (10.6%)
70 (82.4%)
6 (7.1%)
21 (53.8%)
14 (35.9%)
4 (10.3%)
22 (71.0%)
3 (9.7%)
6 (19.4%)
8 (53.3%)
4 (26.7%)
3 (20.0%)
51 (60.0%)
21 (24.7%)
13 (15.3%)
31 (79.5%)
6 (15.4%)
2 (5.1%)
22 (71.0%)
6 (19.4%)
3 (9.7%)
13 (86.7%)
1 (6.7%)
1 (6.7%)
66 (77.6%)
13 (15.3%)
6 (7.1%)
28 (71.8%)
9 (23.1%)
5
4
2 (5.1%)
21 (67.7%)
7 (22.6%)
3
4
3 (9.7%)
13 (86.7%)
1 (6.7%)
1
NA
1 (6.7%)
62 (81.2%)
17 (11.8%)
9
8
6 (7.1%)
AF (n = 39)
Non-AF (n = 31)
2 (5.1%)
37 (94.9%)
NA – not applicable.
activities in this study were dominated by AF, a sport mainly played
in the southern hemisphere winter months when the study was
conducted.
This study highlights that while these international sports
related concussion guidelines have been adopted by sporting
organisations they have not necessarily been implemented at many
sporting fields with 40% of children who sustained a concussion
playing sport not receiving on field management consistent with
CISG recommendations.5 Deficiencies in management were evident at all points of the guideline – players were not immediately
removed from play, were allowed to return to play on the same day,
or were not assessed by qualified personnel. International studies
have been conducted assessing youth sporting staff awareness and
knowledge of concussion management guidelines,12,13,19 and have
identified gaps in coach and trainer sports related concussion management. This study indicates that these knowledge gaps translate
into inappropriate on-field management and premature return to
play in youth athletes.
Despite the largest sporting codes adopting best practice concussion management guidelines, only 7% of parents or children in
this study were aware of any pre-injury concussion instructions
or RTP guidelines from their sporting organisation, suggesting current implementation of the guidelines is inadequate. We also found
that a number of children did not report their head injury during
the game. The problem of underreporting of HI by youth athletes
has been previously identified, with higher rates of underreporting in studies in the US and New Zealand compared to the present
study.20,21 Although we did not prospectively ascertain reasons for
not reporting concussion at the time of injury, the lack of awareness
of concussion guidelines, and the presumed lack of knowledge of
the significance of a sports related concussion may be contributing
factors.
Most children recovered within 7 days with 81% reporting
no postconcussive symptoms 7 days from their injury. Previous studies have demonstrated higher rates of post concussive
problems.22–24 However, these studies used detailed neuropsychological testing to assess cognitive recovery whilst the present
study used a researcher administered symptom checklist only.
While over two thirds complied to some degree with the CISG5
based RTP information provided at hospital discharge, only 8.2%
complied with all 6 steps of the protocol. Of particular concern,
17.6% of children either returned to play whilst symptomatic
or did not follow appropriate remedial action after experiencing
symptoms during their RTP process. Possible explanations for this
inadequate response include poor parental understanding, lack of
medical supervision during the step-wise programme and the difficulty of using a process primarily designed for adult athletes in
a non-professional paediatric sports setting. Generally, the literature shows poor compliance rates with RTP guidelines among
youth athletes.12,13,25 A US study of concussed high school athletes found that at least 40% were non-compliant, however it was
unclear whether all athletes were aware of RTP guidelines.12 A
recent Australian study of mostly adult athletes found a rate of
non-compliance of 87%.25
Despite the poor compliance with the RTP steps the majority
of children in this study waited until they were asymptomatic for
at least 6 days before returning to full gameplay and followed the
appropriate sections of RTP recommendation if they experienced
symptoms during any stage of RTP. These rates are higher than
those previously reported.12,13,25 Previous studies, however, have
examined all sports related head injuries and concussion, whilst
our cohort tended to the more severe end of the spectrum as we
included only children presenting to a major paediatric hospital
after a head injury. The non-compliance with RTP guidelines in
youth athletes is often explained by the sporting culture of ‘not
letting the team down’. Thirty-two percent of New Zealand high
school rugby players believed a concussed player on their team
had been under pressure to return to play.13 At follow-up no parent in our study reported that their child had been under any such
pressure.
Our findings demonstrate the lack of universal adherence to
appropriate on-field management of sports related HI, and RTP
guidelines are not being adequately implemented or supervised
by clubs or medical personnel. These practices potentially expose
H.P. Haran et al. / Journal of Science and Medicine in Sport 19 (2016) 194–199
children to a greater risk of complications from concussion. Considering the focus of a number of sporting organisations on improving
care for possible concussion through their websites and freely provided materials26 there appears to be a problem with both the
transfer of information from the sporting organisation to the individual clubs, coaches, parents and players, and the implementation
of the recommendations. In the US state laws mandate compliance with concussion education and return to play rules.26 Similar
laws do not exist in Australia nor in many other countries. Before
considering legislative changes the community, sporting clubs, and
sporting organisations need to accept the problem and address the
knowledge and implementation deficits in managing sports related
concussion.
Findings are limited in their generalisability due to a focus
on a single, paediatric tertiary referral hospital. The results were
dominated by AF injuries as there was a weekend and winter seasonal focus which is the main season for football playing in the
southern hemisphere. This may have resulted in a study population dominated by AF. Selection bias may have been introduced
as recruitment was based on researcher availability. Although very
few sideline assessment tools appeared to have been used on-field
information on the use of these tools may be better collected by
targeting coaches and team staff rather than parents and child athletes, who may not be aware of the tools being used. The population
studied was hospital based and findings cannot be generalised to
all field-side concussions, particularly those not transferred to hospital.
5. Conclusions
On-field concussion management and return to play practices
are often suboptimal and awareness and education of coaches,
teachers, parents and children and actual practice on the sports
fields need to be improved. Many children with sports related
concussion are not being appropriately assessed on-field and continue to play despite signs or symptoms of concussion, potentially
increasing the risks of complications and further head injury.
Practical implications
• Sports associations need to improve the transfer of information
about best practice of on-field concussion management to the
individual clubs, coaches, parents and players, and ensure the
implementation of the recommendations.
• Acute care settings should routinely provide information on
return to play and school in children with concussion.
• Return to play recommendations for children and adolescents
will need to be modified from existing adult focused guidelines
to be more practicable.
Acknowledgements
The authors declare that there are no competing interests
and no grants associated with the research contained within this
manuscript. We acknowledge the support of the families involved
in the study, the assistance of medical and nursing staff and Ms.
Amanda Williams, emergency research coordinator, Murdoch Children’s Research Institute, Melbourne, Australia. This study was
supported by the Victorian Government Infrastructure Support
programme and the Royal Children’s Hospital Foundation (2014400), Melbourne, Australia.
Contributor statement: FEB conceived the study. All authors
developed the design of the study. HH undertook the data collection
and analysed the data. HH drafted the manuscript with significant
contributions from all authors.
199
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at doi:10.1016/j.jsams.2015.02.009.
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