Relapse of concussion symptoms in the context of premature return to learn and return to play

Abstract

Objective To determine whether the proportion of sport-related concussion (SRC) cases among student athletes that resulted in a relapse of their symptoms due to premature return to play (RTP) or premature return to learn (RTL) has changed compared with a prior (2006 to 2011) study. Design Retrospective cohort study of electronic medical record charts from a 5-year period (2011 to 2016) compared with previous data. Setting A sport and exercise medicine physician's office-based practice in Ontario. Participants Two-hundred forty-one students who had 258 distinct cases of SRC diagnosed. Main outcome measures Premature RTP and RTL were defined as chart records documenting the relapse, recurrence, or worsening of concussion symptoms that accompanied the patient's RTP or RTL. Results Between 2011 and 2016, premature RTP and RTL resulted in a relapse of symptoms in 26.7% and 42.6% of cases, respectively. When compared with data from the 2006 to 2011 chart review, the incidence of premature RTP decreased by 38.6%. However, the rate of the relapse of symptoms associated with premature RTL decreased by only 4.7%. There was a relapse of symptoms in 43.4% of the cases involving female students and 29.7% of the cases involving male students, indicating that female patients are more likely to experience a relapse of symptoms. Cases involving female athletes also resulted in much later RTP clearance compared with those involving male athletes, with a median duration that was almost double that of male athletes' cases (49 days vs 25 days). Conclusion An important decrease in the relapse of symptoms in the context of premature RTP occurred over the 2006 to 2016 period. However, this decrease was minimal for RTL. This may reflect the fact that efforts to implement structured RTP strategies arose earlier than those to implement RTL strategies. Efforts are needed to find the best method of implementing a coordinated plan for the postconcussion athlete who is returning to school. Editor's key points  In a chart review of an office-based practice over a 5-year period (2011 to 2016), 258 cases of sport-related concussion (SRC) were diagnosed among 241 student athletes. Premature return to play (RTP) and return to learn (RTL) resulted in a relapse of SRC symptoms in 26.7% and 42.6% of cases, respectively.  Compared with the results of a similar chart review conducted at the same practice for the preceding 5 years, the rate of premature RTP decreased by 38.6% in the 2011 to 2016 period. However, the rate of relapse was not significantly different for premature RTL for these periods, which reflects a need for greater awareness and implementation of RTL guidelines in this context.  Female athletes were more likely to experience a relapse of SRC symptoms (43.4% of cases) compared with male athletes (29.7%). On average, female athletes also experienced statistically significantly longer delays in RTP clearance than male athletes; more research is required to understand why female student athletes appear to struggle more with SRC recovery and how this can be addressed.