Head Injury Assessment for Sport
Head injuries in sport, especially rugby, are very much a hot topic at the moment. The Rugby world cup has further focused the spotlight on the subject.
We all agree that sport can play an integral part in promoting physical and mental wellbeing but that the safety of participants is paramount.
Many sports have adopted head injury protocols to protect participants and Wessex LMCs fully supports the sentiment around these initiatives. Unfortunately, an unintended consequence of some of these head injury protocols is that GPs can be put in a difficult position, with patients being instructed to get authorisation from a doctor before resuming contact sport. We are particularly seeing examples of schools instructing parents to get a letter of authorisation stating that a child can resume contact sport after a head injury.
We have a duty to see or assess patients who are ill or believe themselves to be ill as part of our GMS contract. We are also required to work within our competences as per GMC guidelines.
We would suggest that GPs can reasonably be expected to assess and advise around minor head injuries and concussion but that the majority of GPs are not experts in sports medicine and are not familiar with the Return To Play Program that has been agreed across sports and reproduced as national guidelines for the Education sector endorsed by the Department of Health and the Department for Education.
With this in mind you should assess the patient in the way that you would assess anyone with a head injury to decide if they have sustained a significant injury and require onward referral for specialist assessment. For a minor head injury not requiring onward referral you would give the standard head injury advice that we give all patients.
Formally clearing players to return to sport is not the role of the GP and you could reasonably decline to give an opinion on this as it is out with your GMS obligations and the expertise of most GPs. If you do decide to issue a letter clearing someone to return to playing you should contact your MDO to ensure that you are covered to do this as it is unlikely to be covered by the NHS Clinical Negligence Scheme for GPs.
England Rugby have produced very useful management guidelines for concussion in Under 19s. https://www.englandrugby.com//dxdam/c0/c0424163-9a4d-4bb1-ad3d-228b157dfb66/PRINTER%20-%20HEADCASE%20U19%20Concussion%20Management%20Guidelines.pdf.
Their guidance states:
‘Following a concussion or suspected concussion it is recommended that children and young people should be reviewed/assessed by a doctor ( typically a GP) before returning to sport and other activities with a predictable risk of head injury.
Some doctors are happy to clear a player to return to play, but formally clearing players to return to sport is not their role. It is however considered by most experts in concussion that good routine clinical management should include a review by a doctor at an appropriate time to confirm recovery and satisfy themselves that there are no other underlying conditions.
This review should be undertaken having completed 14 days of relative rest and up to stage 5 of the Graduated Return To Play. This fits with the GRTP at around 23 days for children.
The doctor does not need to provide a letter as verbal confirmation by a parent/guardian for U18s is acceptable. Clubs are advised to make a record of this verbal confirmation. GPs may charge a fee for providing a letter.’
For U18s: there should be a minimum interval of 23 days from injury before return to sport that carries a predictable risk of head injury, unless their recovery is closely supervised by a doctor with expertise in concussion management.
Referral criteria for specialist neurological assessment and management
- Concussion symptoms persisting beyond 10 days after injury
- Difficulties in returning to work or study
- In sports players, persistent failure to progress through a protocol for returning to sport
- Repeated concussions, especially if the causative trauma seems innocuous
- Children and young people sustaining =2 concussions in 12 months