Laird Harrison

October 28, 2016

SAN FRANCISCO — Thirty-eight percent of children surveyed at a Texas clinic told researchers that they returned to sports the same day they incurred a concussion.

Those who returned to sport in the first day reported worse symptoms.

The finding suggests that many children, parents, and coaches are not following sports concussion guidelines or even state law, according to Meagan Sabatino, from the Texas Scottish Rite Hospital in Dallas.

"It comes back to education," Sabatino told Medscape Medical News. She presented the finding here at the American Academy of Pediatrics (AAP) 2016 National Conference.

Attention to concussions has grown in the United States, with reports of professional football players experiencing disabling symptoms from chronic traumatic encephalopathy.

Children under 18 years have between 1.1 and 1.9 million concussions per year in the United States, Sabatino said, citing a recent estimate (Pediatrics. 2016;138:e20154635).

While concussions occur most often in football, with a rate of 0.47 per 1000 games or practices, they are also very common in women's soccer (0.36), men's soccer (0.22), women's basketball (0.21), and wrestling (0.18), she added, citing a study from Clinical Sports Medicine (2011;30:1-17).

Concern about the problem has led to laws limiting concussed players' return to play. For example, Natasha's Law, passed in Texas in 2011, prohibits return to play until the athlete is free of symptoms and cleared by a medical professional.

The AAP guidelines and those of many other professional associations recommend similar restrictions.

Recent research has supported these rules, showing that athletes who continue to play are 8.8 times more likely to need more than 21 days of recovery, said Sabatino, according to a recent study (Pediatrics. 2016;138:e20160910).

To get an idea of how often children return to sports within a day of a concussion, Sabatino and her colleagues retrospectively reviewed 187 consecutive patients aged 19 years or younger with initial clinic visits from April 2015 to February 2015, disqualifying 2 because of missing information.

Of the patients, 133 were male and 52 were female, with a mean age of 14.1 years.

Football concussions made up the largest proportion, accounting for more than double the number of concussions from soccer, which were the second most frequent.

In order of frequency, basketball, hockey, volleyball, wrestling, cheerleading, baseball, softball, rugby, gymnastics, swimming, rodeo, martial arts, and lacrosse accounted for the other concussions.

The researchers used the Sport Concussion Assessment Tool 3 (SCAT-3) questionnaire, with answers confirmed by a physician during the clinic visit, to tally the incidence of return to play within 24 hours and to rate symptoms.

Among girls, 37% returned to play the same day as the concussion. Among boys, 39% returned to play the same day.

Symptoms Worsen After Same-Day Return to Sport

At the time of the clinic visit, patients who returned to play on the same day reported more severe and frequent dizziness, balance problems, nausea, sensitivity to light, sensitivity to noise, trouble concentrating, pressure in the head, feeling "slowed down," confusion, and trouble falling asleep. The differences between them and those who returned after the first day were statistically significant (P < .05).

And looking back on the day of the concussion, patients who returned to play recalled more severe dizziness (P = .04) and balance problems (P = .01).

The researchers did not find any differences by age, sex, or sport.

It's difficult to determine why so many players are returning to sport prematurely, Sabatino said. "Are people telling them to push through the pain and tough it out? Or is it a lack of education — the coaches and players and families don't know what to look at" to identify a possible concussion.

After Sabatino's presentation, one person in the audience asked how the players knew they were concussed before they returned to play.

Sabatino said sports physician Shane Miller, MD, tried to confirm the diagnosis by carefully interviewing patients about the events.

I was shocked, I couldn't believe it. This type of study is important because it highlights the need for more education out in the field. Dr Jennifer Shu

The study hit home for Jennifer Shu, MD, from Children's Medical Group of Atlanta, Georgia. Recently she treated a cheerleader who fell during practice, blacked out, and was told by her coaches that she wouldn't be able to compete in an upcoming tournament unless she returned to practice immediately.

"I was shocked," Dr Shu told Medscape Medical News. "I couldn't believe it. This type of study is important because it highlights the need for more education out in the field."

Meagan Sabatino, Dr Chung, and Dr Shu have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2016 National Conference: Abstract 319134. Presented October 22, 2016.

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