Background



Management of children with disorders of cerebrospinal fluid (CSF) circulation is a common aspect of paediatric neurosurgical practice. Sport and physical activity play an integral role in the lives of patients in this age group. However, there is little evidence to support the dissemination of appropriate advice to children regarding such activities. The aim of this study was to evaluate the perspectives of clinicians across the UK regarding the participation of children with disorders of CSF circulation in sports.



Methods



Questionnaires were distributed to Consultant Paediatric Neurosurgeons practising across the UK via the Society of British Neurological Surgeons (SBNS). Five different patient scenarios were supplied, and participants were asked to choose whether they would advise participation in the following sports: Taekwondo, rugby, skiing, and football.



Results



An overall response rate of 66.7% (36 out of 54 paediatric neurosurgeons) was achieved. The following percentages of clinicians advocated football, rugby, Taekwondo, and skiing across all scenarios: 96%, 75%, 77%, and 97%, respectively. The majority of responders (91.2%) relied on personal experience when providing advice, whilst 50% used available literature and 19.4% used available guidelines.



Conclusions



There is a paucity of evidence in the literature to support the dissemination of appropriate advice to children with disorders of CSF circulation regarding participation in sports. Our findings demonstrate that the majority of clinicians rely on personal experience to make such decisions, emphasizing the necessity of larger scale studies to inform evidence-based guidelines

Bhatti, I.

Leach, P.

Manivannan, S.

Patel, C.

Petralia, C.

Zaben, M.

English

Online Research @ Cardiff

ORIGINAL ARTICLEPatient advice regarding participation in sport in childrenwith disorders of cerebrospinal fluid (CSF) circulation: a nationalsurvey of British paediatric neurosurgeonsM. Zaben1,2 & S. Manivannan1 & C. Petralia1 & I. Bhatti1 & C. Patel1 & P. Leach1Received: 5 January 2020 /Accepted: 8 February 2020# The Author(s) 2020AbstractBackground Management of children with disorders of cerebrospinal fluid (CSF) circulation is a common aspect ofpaediatric neurosurgical practice. Sport and physical activity play an integral role in the lives of patients in this agegroup. However, there is little evidence to support the dissemination of appropriate advice to children regarding suchactivities. The aim of this study was to evaluate the perspectives of clinicians across the UK regarding the participationof children with disorders of CSF circulation in sports.Methods Questionnaires were distributed to Consultant Paediatric Neurosurgeons practising across the UK via the Society ofBritish Neurological Surgeons (SBNS). Five different patient scenarios were supplied, and participants were asked to choosewhether they would advise participation in the following sports: Taekwondo, rugby, skiing, and football.Results An overall response rate of 66.7% (36 out of 54 paediatric neurosurgeons) was achieved. The following percentages ofclinicians advocated football, rugby, Taekwondo, and skiing across all scenarios: 96%, 75%, 77%, and 97%, respectively. Themajority of responders (91.2%) relied on personal experience when providing advice, whilst 50% used available literature and19.4% used available guidelines.Conclusions There is a paucity of evidence in the literature to support the dissemination of appropriate advice to childrenwith disordersof CSF circulation regarding participation in sports. Our findings demonstrate that themajority of clinicians rely on personal experienceto make such decisions, emphasizing the necessity of larger scale studies to inform evidence-based guidelines.Keywords Paediatric neurosurgery . Sports . Disorders of CSF circulation . Ventriculoperitoneal shunt . Chiari malformation .Arachnoid cystIntroductionManaging children with disorders of cerebrospinal fluid (CSF)circulation is common in paediatric neurosurgical practice. Theimportance of physical activity and sport for maintaining bothphysical and mental health are widely acknowledged [1, 2]. Itsrelevance to paediatric cohorts is highlighted by increasing ratesof childhood obesity and its potential to reduce the incidence ofdepression and anxiety in children [1, 2]. Given the issues thatchildren with disorders of CSF circulation must live with, it isvital that normality of life is achieved in every domain possible.Therefore, one of the most common questions arising from thesechildren and their parents relates towhether it is safe to participatein certain sporting activities. In the absence of level one evidenceand/or well-defined guidelines, giving appropriate advice re-mains a hit-and-miss exercise. Few studies have addressed thisissue, mainly focusing on singular sporting activities or specificpathologies [3–5]. Given the paucity of evidence to support thedissemination of appropriate advice to patients, we aimed toidentify perspectives of paediatric neurosurgeons across theUK. Therefore, in this study, we performed a nationwide surveyof paediatric neurosurgeons to elucidate current practice regard-ing recommendations being given to children with disorders ofCSF circulation who wish to participate in sport activities.* M. ZabenZabenM@cardiff.ac.uk1 Department of Paediatric Neurosurgery, University Hospital ofWales, Cardiff, UK2 Neuroscience and Mental Health Research Institute (NMHRI),School of Medicine, Cardiff University, Room 4FT 80E, 4th Floor,University Hospital Wales, Heath Park, Cardiff CF14 4XN, UKChild's Nervous Systemhttps://doi.org/10.1007/s00381-020-04536-3MethodsPractising paediatric neurosurgeons across the UK wereidentified via the Society of British Neurological Surgeons(SBNS) member’s database. A total of 54 paediatric neuro-surgeons were identified, and online questionnaires weredistributed to them between June 2018 and June 2019.The survey consisted of six questions (see Fig. 1). Fivebinary response questions involved different paediatric clin-ical scenarios and whether clinicians would advocate partic-ipation in four different contact sports (Taekwondo, rugby,skiing, and football). The final multiple-choice question ex-plored the rationale behind the decisions made in the previ-ous questions. A multi-database (PubMed, Ovid) literaturereview was performed to identify articles discussing sportparticipation in children with disorders of CSF circulationon 17th July 2019. Our search strategy involved varyingcombinations of the following search terms: “Chiari malfor-mation”, “arachnoid cyst”, “ventriculoperitoneal shunts”,“aqueductal stenosis”, “endoscopic third ventriculostomy”,“athletics,” “physical activities,” “limitations”, and “sport”.ResultsA total of 54 consultant paediatric neurosurgeons practising inthe UK were identified via the SBNS and asked to completean online survey. An overall response rate of 66.7% (36 out of54 neurosurgeons) was achieved (Fig. 1).Fig. 1 Summarizes strategy fornational survey of paediatricneurosurgeons in UKChilds Nerv SystCase scenario 1This scenario regarding a 14-year-old patient with aventriculoperitoneal (VP) shunt was answered by the ma-jority of responders (97.2%; 35/36) (Fig. 2a). All re-sponders agreed to allowing the patient to participate infootball and skiing. However, only 71.4% (25/35) and74.3% (26/35) advocated participation in rugby andTaekwondo, respectively.Case scenario 2The majority of responders (94.4%; 34/36) answered thisquestion regarding a 12-year-old patient with anFig. 2 Summarizes the results of the online questionnaire. Opinions of respondents regarding participation in four different sports based on clinicalscenarios (a–e), and the rationale behind their decision-making (f)Childs Nerv Systasymptomatic arachnoid cyst (Fig. 2b). Football was recom-mended by all responders, whilst 91.2% (31/34) advised par-ticipation in skiing. Only 55.9% (19/34) and 53.0% (18/34)however felt that participation in rugby and Taekwondo wasadvisable, respectively.Case scenario 3The question regarding this scenario regarding a 10-year-oldpatient with an asymptomatic Chiari I malformation and ton-sils down to the body of C2 was completed by 94.4% (34/36)of responders (Fig. 2c). In contrast, 97.1% (33/34) and 94.1%(32/34) advocated participation in skiing and football, respec-tively. However, participation in rugby was still supported by76.5% (26/34) and Taekwondo by 88.2% (30/34).Case scenario 4This scenario was identical to the previous scenario, exceptthe patient had undergone foramen magnum decompressiondue to symptoms (Fig. 2d). A lower response rate was ob-served, with 88.9% (32/36) responding. All responders sup-ported participation in skiing and 93.4% (30/32) for football.Both rugby and Taekwondowere advocated by 78.1% (25/32)of responders.Case scenario 5The majority of responders (97.2%; 35/36) answered this sce-nario regarding an 11-year-old patient that underwent an en-doscopic third ventriculostomy (ETV) for aqueductal stenosis(Fig. 2e). All responders supported participation in both foot-ball and skiing, whilst 97.1% (34/35) advocated both rugbyand Taekwondo.Decision-making rationaleThe final question explored the rationale behind decisions madeby responders, with the following options: personal experience,guidelines, and published literature (Fig. 2f). Responses werereceived by all participants, and the majority (91.2%; 33/36)reported basing decisions on their own experience. Half of re-sponders (50%; 18/36) also reported using available literature,and a minority (19.4%; 7/36) used known guidelines.DiscussionOur study demonstrates that paediatric neurosurgeons pre-dominantly rely on personal experience to issue advice regard-ing sport participation in children with disorders of CSF cir-culation, with little evidence for support. Current studies ex-amining sports-associated complications are either pathologyor sport-specific (Table 1).Only one study examined sport-related complications in chil-dren with ventriculoperitoneal shunts by performing a nationalsurvey of paediatric neurosurgeons in the USA [5]. Interestingly,77%of clinicians had never experienced sport-related shunt com-plications, and 90% did not restrict patients from participating innon-contact sports. On the other hand, one third of clinicians didnot advocate any form of contact sport, whilst another third onlyrestricted some contact sports. However, the applicability of thisstudy is limited by the fact that a response rate of only 55% wasachieved and does not reflect any potential changes in clinicianattitudes over the ensuing 15 years. Nonetheless, these findingslargely reflect our results, with all participating paediatric neuro-surgeons advocating football and skiing, and more than 70%supporting participation in rugby and Taekwondo (Fig. 2a).More recent studies have evaluated specific neurosurgical pathol-ogies and specific sporting activities. We have previously exam-ined the safety of VP shunts when scuba diving and identified noTable 1 Summary of studies reporting sports participation in patients with disorders of CSF circulationStudy Design Cohort FindingsBlount et al.2004Online national survey Clinician experience with sport-associatedcomplications in children with VP shunts77% of clinicians have not experiencedsports-associated complicationsMeehan et al.2015Single-centre retrospectivestudySport participation in patients withChiari malformationsNo serious neurological injuries(death, coma, or paralysis)Shastin et al.2016Literature review Scuba-diving in patients with VP shunts No associated complicationsStrahle et al.2016Single-centre prospectivestudySport participation in children with arachnoid cysts Two patients suffered subdural hygromas(no intervention required)Strahle et al.2016Multi-centre prospectivestudySport participation inpatients with Chiari type 1malformationNo serious injuriesSpencer et al.2017Literature review Sport/trauma associated injuries in patientswith Chiari type I malformationAnecdotal evidence of sudden death followinghead or neck injury but not in larger cohortstudiesChilds Nerv Systreports of associated complications in the literature [3]. However,this was not specific to the paediatric population and did notevaluate other sports.A recent single-centre prospective study in the USA exam-ined sports participation in children with arachnoid cysts [4].Patients were followed up over a 46-month period and of 112patients that participated in sports, only two patients sufferedsymptomatic subdural hygromas. Interestingly, our survey dem-onstrates that clinicians were most conservative with advocatingparticipation in sport in the case scenario involving an asymp-tomatic arachnoid cyst. Indeed, the lowest rates of clinician sup-port for all four sports were observed in this scenario (Fig. 2b).Three papers addressing sports participation in patients withChiarimalformationswere identified [6–8]. One literature reviewexamined the consequences of trauma or contact sports on pa-tients with asymptomatic Chiari type I malformations [6]. Otherthan anecdotal evidence of sudden death in patients followinghead or neck injury, severe neurological deterioration was notidentified in any studies of larger cohorts. A single centre retro-spective cohort study in the USA examined the incidence ofserious injuries in patients with Chiari malformations that partic-ipated in sports over a 3-year period [7]. Across 147 patients,there were no reports of death, coma, or paralysis with respect tosports participation. Another multi-centre prospective study inthe USA evaluated sport-related injuries in patients with Chiaritype I malformations [8]. Whilst only 65.2% (328 out of 503patients) participated in sports, there were no reports of seriousneurological injuries in these patients. Similar to our results withclinician opinions regarding arachnoid cysts, responders wererelatively conservative, with only 76.5% and 88.2% advocatingrugby and Taekwondo, respectively (Fig. 2c).Given that arachnoid cysts and Chiari type I malformation arethe only pathologies with clinical evidence indicating a positivesafety profile, it is interesting that paediatric neurosurgeons re-main relatively more restrictive in their attitudes towards sportsparticipation when compared with the remaining clinical scenar-ios. Follow-up studies to examine whether clinicians have per-sonal experience of sports-associated complications in patientswith these pathologies may provide invaluable insight. Therewere no studies exploring the safety of sport participation inpatients that underwent ETV or foramen magnum decompres-sion (FMD) for Chiari malformation. Our results show that pae-diatric neurosurgeons have similar opinions regarding sport par-ticipation in patients with Chiari type I malformations, whetherFMDwas performed or not (Fig. 2 c and d). However, the lowestoverall response rate (88.9%) was observed for the case scenarioexamining FMD. It is possible that this was a result of an absenceof tangible evidence in the literature to support the opinions ofclinicians. Importantly, we demonstrate that the majority of cli-nicians rely on personal experience to provide appropriate adviceto patients (Fig. 2f). Larger scale studies examining the safety ofsports participation in children with disorders of CSF circulationare required to develop evidence-based guidelines.ConclusionThere is a paucity of evidence in the literature to support thedissemination of appropriate advice to children with disordersof CSF circulation regarding participation in sports. Our findingsdemonstrate that themajority of paediatric neurosurgeons rely onpersonal experience to make such decisions, emphasizing thenecessity of larger scale studies to inform evidence-basedguidelines.Compliance with ethical standardsConflict of interest The authors declare that they have no conflicts ofinterest.Open Access This article is licensed under a Creative CommonsAttribution 4.0 International License, which permits use, sharing, adap-tation, distribution and reproduction in any medium or format, as long asyou give appropriate credit to the original author(s) and the source, pro-vide a link to the Creative Commons licence, and indicate if changes weremade. The images or other third party material in this article are includedin the article's Creative Commons licence, unless indicated otherwise in acredit line to the material. If material is not included in the article'sCreative Commons licence and your intended use is not permitted bystatutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/.References1. Eime RM, Young JA, Harvey JT, Charity MJ, Payne WR (2013) Asystematic review of the psychological and social benefits of partic-ipation in sport for children and adolescents: informing developmentof a conceptual model of health through sport. Int J Behav Nutr PhysAct 10:98–982. Services UDoHaH: (2008) Physical activity guidelines advisorycommittee report3. Shastin D, Zaben M, Leach P (2016) Can patients with a CSF shuntSCUBA dive? Acta Neurochir 158(7):1269–12724. Strahle J, Selzer BJ, Geh N, Srinivasan D, Strahle M, Martinez-SosaM, Muraszko KM, Garton HJL, Maher CO (2016) Sports participa-tion with arachnoid cysts. J Neurosurg Pediatr 17(4):410–4175. Blount JP, Severson M, Atkins V, Tubbs RS, Smyth MD, WellonsJC, Grabb PA, Oakes WJ (2004) Sports and pediatric cerebrospinalfluid shunts: who can play? Neurosurgery 54(5):1190–11986. Spencer R, Leach P (2017) Asymptomatic Chiari type I malforma-tion: should patients be advised against participation in contactsports? Br J Neurosurg 31(4):415–4217. Meehan WP 3rd, Jordaan M, Prabhu SP, Carew L, Mannix RC,Proctor MR (2015) Risk of athletes with Chiari malformations suf-fering catastrophic injuries during sports participation is low. Clin JSport Med 25(2):133–1378. Strahle J, Geh N, Selzer BJ, Bower R, Himedan M, Strahle M,Wetjen NM, Muraszko KM, Garton HJ, Maher CO (2016) Sportsparticipation with Chiari I malformation. J Neurosurg Pediatr 17(4):403–409Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Childs Nerv Syst

Patient advice regarding participation in sport in children with disorders of cerebrospinal fluid (CSF) circulation: a national survey of British paediatric neurosurgeons

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Patient advice regarding participation in sport in children with disorders of cerebrospinal fluid (CSF) circulation: a national survey of British paediatric neurosurgeons

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