Return to play guidelines [Neurosurgery Wiki]

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=====Return to play guidelines=====
No system of return to play (RTP) guidelines has been rigorously tested and proven to be scientifically sound. Regardless of the system used, one universal recommdation of experts is:

a symptomatic player should not return to competition.

Selected studies show evidence that, although a previously concussed athlete may be symptom-free and returned to a neuropsychological baseline, the athlete may continue to have prolonged neurological abnormalities that could disqualify them from being ready to return to play
((Porcher NJ, Solecki TJ. A narrative review of sports-related concussion and
return-to-play testing with asymptomatic athletes. J Chiropr Med. 2013
Dec;12(4):260-8. doi: 10.1016/j.jcm.2013.08.002. PubMed PMID: 24396328; PubMed
Central PMCID: PMC3838723.
)).

====Contraindications====

Persistent postconcussion symptoms

Permanent CNS sequalae from head injury

Hydrocephalus

Spontaneous SAH from any cause

Symptomatic (neurologic or pain producing) abnormalities about the foreman magnum (e.g. Chlari malformation).

====American Medical Society for Sports Medicine position statement====

Concussion symptoms should be resolved before returning to exercise. ▸ A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact. ▸ If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step. ▸ RTP after concussion should occur only with medical clearance from a licenced healthcare provider trained in the evaluation and management of concussions. SHORT-TERM RISKS OF PREMATURE RTP: ▸ The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms. LONG-TERM EFFECTS: ▸ There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae. ▸ Some studies have suggested an association between prior concussions and chronic cognitive dysfunction. Large-scale epidemiological studies are needed to more clearly define risk factors and causation of any long-term neurological impairment
((Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA,
Kutcher JS, Pana A, Putukian M, Roberts WO. American Medical Society for Sports
Medicine position statement: concussion in sport. Br J Sports Med. 2013
Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941. Review. Erratum in: Br J
Sports Med. 2013 Feb;47(3):184. PubMed PMID: 23243113.
)).

===== Cervical cord injury =====
see [[Return to play in cervical cord injury]].

====Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation====
Lumbar disc herniation has a prevalence of up to 58% in the athletic population. Lumbar discectomy is a common surgical procedure to alleviate pain and disability in athletes. We systematically reviewed the current clinical evidence regarding athlete return to sport (RTS) following lumbar discectomy compared to conservative treatment.
METHODS:
A computer-assisted literature search of MEDLINE, CINAHL, Web of Science, PEDro, OVID and PubMed databases (from inception to August 2015) was utilised using keywords related to lumbar disc herniation and surgery. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodological quality of individual studies was assessed using the Downs and Black scale (0-16 points).
RESULTS:
The search strategy revealed 14 articles. Downs and Black quality scores were generally low with no articles in this review earning a high-quality rating, only 5 articles earning a moderate quality rating and 9 of the 14 articles earning a low-quality rating. The pooled RTS for surgical intervention of all included studies was 81% (95% CI 76% to 86%) with significant heterogeneity (I2=63.4%, p<0.001) although pooled estimates report only 59% RTS at same level. Pooled analysis showed no difference in RTS rate between surgical (84% (95% CI 77% to 90%)) and conservative intervention (76% (95% CI 56% to 92%); p=0.33).
CONCLUSIONS:
Studies comparing surgical versus conservative treatment found no significant difference between groups regarding RTS. Not all athletes that RTS return at the level of participation they performed at prior to surgery. Owing to the heterogeneity and low methodological quality of included studies, rates of RTS cannot be accurately determined
((Reiman MP, Sylvain J, Loudon JK, Goode A. Return to sport after open and
microdiscectomy surgery versus conservative treatment for lumbar disc herniation:
a systematic review with meta-analysis. Br J Sports Med. 2015 Oct 21. pii:
bjsports-2015-094691. doi: 10.1136/bjsports-2015-094691. [Epub ahead of print]
PubMed PMID: 26491033.
)).