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. 2014 Sep 1;1(4):158–165. doi: 10.1093/nop/npu020

Sports and childhood brain tumors: Can I play?

Sébastien Perreault (SP1) 1, Robert M Lober 1, Carissa Davis 1, Christopher Stave 1, Sonia Partap (SP2), 1, Paul G Fisher 1
PMCID: PMC4369718  PMID: 26034627

Abstract

Background

It is unknown whether children with brain tumors have a higher risk of complications while participating in sports. We sought to estimate the prevalence of such events by conducting a systematic review of the literature, and we surveyed providers involved with pediatric central nervous system (CNS) tumor patients.

Methods

A systematic review of the literature in the PubMed, Scopus, and Cochrane databases was conducted for original articles addressing sport-related complications in the brain-tumor population. An online questionnaire was created to survey providers involved with pediatric CNS tumor patients about their current recommendations and experience regarding sports and brain tumors.

Results

We retrieved 32 subjects, including 19 pediatric cases from the literature. Most lesions associated with sport complications were arachnoid cysts (n = 21), followed by glioma (n = 5). The sports in which symptom onset most commonly occurred were soccer (n = 7), football (n = 5), and running (n = 5). We surveyed 111 pediatric neuro-oncology providers. Sport restriction varied greatly from none to 14 sports. Time to return to play in sports with contact also varied considerably between providers. Rationales for limiting sports activities were partly related to subspecialty. Responders reported 9 sport-related adverse events in patients with brain tumor.

Conclusions

Sport-related complications are uncommon in children with brain tumors. Patients might not be at a significantly higher risk and should not need to be excluded from most sports activities.

Keywords: adverse event, brain tumor, neoplasm, pediatric, sports

It is now recognized that exercise and participation in sports during and after cancer treatment are feasible and safe.1,2 Exercise helps with rehabilitation interventions, leads to physiological improvements (muscle strength, immune and metabolic profiles, body composition, cardiorespiratory function), and is beneficial for cognition and psychological symptoms such as depression and anxiety.3–5 Animal studies suggest that exercise can abrogate memory decline and aid recovery of hippocampal plasticity after cranial irradiation.5 Thus, exercise might mitigate neurotoxicity associated with brain tumor treatments. Nevertheless, survivors of cancer are usually engaged in fewer physical activities than the general population.6

There is a general belief, along with a controversy, that children with brain tumors are at a much higher risk for complications with sport participation, particularly head trauma.7 However, there are presently no guidelines on sports, with or without contact, for children with a history of brain tumor. In our clinical experience, none of our patients have suffered complications related to sports during or after treatment. In order to estimate the risk of such events, we conducted a systematic review of the literature. We also surveyed providers involved with pediatric central nervous system (CNS) tumor patients to assess their current recommendations and experiences.

Materials and Methods

A systematic review of the literature in the PubMed, Scopus, and Cochrane databases was conducted for original articles addressing sport-related complications in the CNS tumor population. The search was performed on March 14, 2014, with the support of the librarian (C.S.) at Stanford University's Lane Medical Library (see Supplementary Data 1 for search terms). Articles grossly out of scope were rejected and were not included in the systematic review, as suggested by Cochrane guideline. Titles and abstracts from the remaining articles were reviewed by 2 authors (S.P.1 and R.M.L.). Relevant articles were then reviewed in detail and included if adverse events related to a brain tumor and sports were identified.

After the systematic review was deemed exempt by the institutional review board (Lucile Packard Children's Hospital at Stanford University), a questionnaire was created online using LimeSurvey (www.limesurvey.org). A total of 14 questions were included in the final version (Appendix 2). In order to reach the maximum number of responders involved in the pediatric neuro-oncology field, the survey was designed to be completed on 2 electronic tablets during the 15th International Symposium on Pediatric Neuro-Oncology (ISPNO) in Toronto, Canada, June 24–27, 2012. It was decided a priori to recruit a minimum of 100 responders, including at least 20 pediatric oncologists and 20 neurosurgeons. If this goal could not be achieved during the meeting, providers would be emailed an electronic version of the survey. Three authors (S.P.1, S.P.2, and P.G.F.) recruited providers for the questionnaire. Upon completion, providers received an electronic gift card in appreciation of their time. SPSS Statistics, version 20.0 (IBM) was used for all statistical analyses, which included Fisher exact test, chi-square test, and logistic regression with Bonferroni correction for multiple variables. Missing data were not included in final analyses.

Results

Systematic Literature Review

After a systematic literature search, 22 papers were selected and included in the results (Fig. 1). Six additional papers were retrieved by bibliography scanning.

Fig. 1.

Fig. 1.

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Search flow chart. (Search performed on March 14, 2014).

In those articles, a total of 32 cases were reported, including 19 patients who were aged ≤ 21 years (Table 1). All patients, except for one, presented with symptoms that led to diagnosis of a new CNS lesion (Table 1). Most tumors or lesions associated with sport complications were arachnoid cysts (n = 21) and glioma (n = 5). The majority of patients presented with headache (n = 18), nausea/vomiting (n = 10), or seizure (n = 4). The sports most commonly associated with symptom onset were soccer (n = 7), football (n = 5), and running (n = 5).

Table 1.

Description of patients reported in the literature with CNS tumors and sport-related complications

Authors Age (y) Sex Sport Clinical Presentation Diagnosis
Kertmen 201226 12 M Taekwondo N/A Subdural hematoma/arachnoid cyst
Işik 201127 13 M Soccer/heading the ball N/A Subdural hematoma/arachnoid cyst
Svahn 200928 N/A M Football Headache/lethargy Subdural hematoma/arachnoid cyst
Hopkin 200629 12 M Head-shaking contest Headache/Vomiting Subdural hematoma/arachnoid cyst
Robles 200630 20 M Boxing Headache/Vomiting Subdural hematoma/arachnoid cyst
Demetriades 200431 24 M Football Headache Subdural hematoma/arachnoid cyst
Tsuzuki 200332 16 F Basketball Headache Subdural hematoma/arachnoid cyst
Gelabert-González33 13 M Soccer/head injury Headache Subdural hygroma/arachnoid cyst
Prabhu 200234 16 M Soccer/heading the ball Headache/right facial numbness Subdural hematoma/arachnoid cyst
Heller 200135 18 F Vigorous exercise Exercitional legs tremor Occipital arachnoid cyst
Chillala 200136 21 M Soccer/heading the ball Headache Subdural hematoma/arachnoid cyst
Clear 200037 44 M Soccer/heading the ball Seizure Arachnoid cyst
Donaldson 200038 14 M Football/collision Headache/vomiting/lethargy Subdural hygroma/arachnoid cyst
5 M Bicycle/fall Headache/vomiting/blurry vision Subdural hygroma/arachnoid cyst
Hackett 200039 31 M High altitude hiking/climbing Diplopia and ataxia Arachnoid cyst
Kawanishi 199940 14 M Soccer/heading the ball Headache and nausea Subdural hematoma/arachnoid cyst
11 M Soccer/heading the ball Headache and nausea Subdural hematoma/arachnoid cyst
Vigil 199841 16 M Football Headache/vomiting/lethargy Subdural hygroma/arachnoid cyst
Alburquerque 199742 6 M Roller blading/fall Headache/vomiting/lethargy Subdural hygroma/arachnoid cyst
Kulali 198943 6 M Bicycle/fall Headache/vomiting Subdural hygroma/arachnoid cyst
Cullis 198344 11 M Swimming Headache Subdural hematoma/arachnoid cyst
Downey 198045 20 M Running Headache/vomiting/lethargy Intracerebral hemorrhage/glioblastoma
59 F Running Hemiparesis and hemisensory deficit Intracerebral hemorrhage/malignant lesion
Perin 200715 36 M Scuba diving Left hemibody dysesthesia/possible seizure Glioblastoma
Kashania 200646 14 M Running Exercitional diplopia Brainstem glioma
Büttner 199947 47 M Swimming Seizure/Death Known anaplastic astrocytoma
Shinton 198948 22 M Football/Physical training Exercitional diplopia Midline astrocytoma
Bakheit 198949 53 M Scuba diving Headache and brainstem dysfunction Pituitary carcinoma
Stechschulte 199450 25 M Skiing accident N/A Subdural hematoma/Primary meningeal extraosseus Ewing's sarcoma
Morales 200851 72 M Dancing Seizure/Left upper limb paresis Metastatic clear-cell renal carcinoma in a meningothelialmeniongioma
Chee 200252 37 M Running Exercitional vertigo Vestibular schwannoma
33 M Running Exercitional vertigo Vestibular schwannoma
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M: Male, F: Female, N/A: Not Available.

Survey

A total of 111 providers completed the survey, and 5 providers started the survey but did not finish. The majority of responders (n = 92 [83%]) completed the survey on the electronic tablet during the conference meeting at ISPNO. Two providers declined to answer the survey when approached. Because a minority of pediatric neurosurgeons attend the ISPNO, only 3 responders from this specialty had completed the survey by the end of the meeting. In order to achieve the targeted number of responders, an electronic version of the survey was emailed (after the meeting) to 78 pediatric neurosurgeons who were randomly identified through the American Society of Pediatric Neurosurgeons member directory. A total of 19 (24%) providers completed the survey sent via email.

Responders who completed the survey were 59 (55%) pediatric oncologists, 22 (21%) neurosurgeons, 13 (12%) child neurologists, 8 (8%) nurse practitioners, and 4 (4%) others. Sixty-three (60%) were male, and 42 (40%) were female. Most providers were associated with a university hospital (n = 95 [89%]), in contrast to a community hospital (n = 6 [5%]), private practice (n = 2[2%]), and other (n = 3[3%]). Clinicians were usually practicing in centers with large volumes of new brain tumor cases per year (>100 cases, n = 27 [25%]; 50–100 cases, n = 35 [33%]; 25–50 cases, n = 26 [25]; 10–25 cases, n = 17 [16%]; and 5–10 cases, n = 1 [1%]). Years of experience within the neuro-oncology field varied. Nine providers (8%) had been practicing for longer than 30 years, 38 (36%) between 10 and 30 years, and 59 (56%) between zero and 10 years. The majority of responders resided in North America (USA n = 79 [74%] and Canada n = 7 [7%]), followed by Europe (n = 14 [13%]), Asia (n = 4 [4%]), and South America (n = 2 [2%]).

Within the list of sports provided, 79 (75%) providers restricted participation in at least one sport. A total of 44 (41%) restricted 1–3 sports, 25 (23%) restricted 4–6 sports, and 10 (9%) restricted at least 7 sports. One provider restricted 14 sports. Boxing was the sport most frequently restricted (n = 64 [58%]), followed by football (n = 49 [46%]), rodeo (n = 42 [40%]), and hockey (n = 32 [30%]) (Fig. 2).

Fig. 2.

Fig. 2.

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Sports restricted in children with a history of brain tumor.

Thirteen (12%) responders reported that their threshold for restricting sport activities was even lower in patients with glioblastoma, nine (9%) in patients with supratentorial primitive neuroectodermal tumor, and eight (8%) in patients with medulloblastoma. Duration of restriction for sports after surgery varied among responders (Fig. 3).

Fig. 3.

Fig. 3.

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Duration of restriction for (A) sports without physical contact and (B) sports with physical contact.

The risks or rationales for limiting sports activities that were discussed most often with the family and patients were bleeding (n = 65[61%]), concussion (n = 56 [53%]), bone flap displacement (n = 47 [44%]), shunt dysfunction (n = 30[28%]), and seizures (n = 24 [23%]).

When asked about platelet levels during chemotherapy and clearance for sports, 31 (29%) providers reported their threshold for limiting activities was less than 100 x 109/L, compared with 51 (48%) providers with a threshold less than 50 x 109/L and 16 (15%) providers with a threshold less than 20 x 109/L.

Twenty (19%) responders restricted sports while patients were receiving bevacizumab, a vascular endothelial growth factor-specific antibody.

Eleven (10%) providers reported sport-related adverse events in children with brain tumors, for a total of 9 events. Three providers described the same incident for a single patient. After completing therapy, the patient suffered a traumatic brain injury in a go-kart crash. Two other patients suffered intracranial bleeding, one after body-to-body contact, and the other after a fall while cycling at a time when his platelets were less than 50 x 109/L. Two patients suffered fractures: one with known hemiplegia while skiing and the other (who was still receiving chemotherapy) while ice-skating. Two patients had seizures: one while playing soccer and the other during an unreported sport. One patient died after falling off her horse during a therapeutic-riding program. One patient with a brainstem tumor suffered a traumatic brain injury and progressed shortly after.

There were no differences in sport restrictions or duration of restrictions following surgery between subspecialty groups. However, neurosurgeons were more concerned about bone flap displacement (73%) as a possible complication compared with other specialists (36%) (P = .001). Oncologists were less inclined to limit activities when platelets were less than 100 × 109/L (20%) compared with other groups (42%). Most oncologists selected a threshold of 50 x 109/L, which was significantly different from other groups (59% vs 31%) (P < .003). There was no difference between male and female responders in terms of number of sports limited (3.3 vs 2.4 sports were restricted) (P = .24), nor was there any difference based on years of experience within the field (2.8 sports were restricted by providers with ≤10 years compared with 2.7 sports restricted by providers with > 10 years of experience; P = 1.0).

Discussion

Our study demonstrates that sport-related complications are rare in children with CNS tumors. Few cases were found in the literature, and only 9 cases were reported by survey responders. Our review shows great diversity in recommendations and restrictions between providers.

Despite an extensive review of the literature, few cases of sport-related adverse events involving patients with brain tumors were found. All but one case presented with manifestations of a yet-to-be diagnosed brain tumor or lesion. This population is different from a population with known brain tumor undergoing therapy or in follow-up. However, it is the closest comparison we could find in the literature. It does recapitulate the mass-effect phenomenon found in a child with an incomplete resection. Interestingly, 21 cases were subarachnoid cysts, which are nontumorous congenital sacs lined with an arachnoid-like membrane and filled with clear fluid. Because of it relatively high frequency but unknown real prevalence, the risk associated with arachnoid cyst and sports remains unlikely or unknown.8–10 Furthermore, since most patients with arachnoid cyst do not undergo surgery and do not receive adjuvant therapy, in contrast with children with brain tumor, the extrapolation of such events remains limited. We decided, however, to include patients with subarachnoid cysts in our analysis because of its space-occupying characteristics, instead of simply excluding them.

The overrepresentation of glioma could possibly be explained by its relatively high frequency in adults.11 Another possibility might be related to the actual nature of these tumors. High-grade glioma and, more specifically, glioblastoma are associated with vascular proliferation, hemorrhage, and necrosis.12 In patients with this type of tumor, strenuous exercise with change in oxygen, carbon dioxide and pH could, in theory, trigger symptoms.

Interestingly, 3 cases were associated with significant barometric change (one while hiking at high altitude and 2 while scuba diving). It is known that such activities demand a complex regulation of cerebrovascular distribution due to hypoxia and/or volume redistribution.13,14 Similarly, several cases of neurological symptoms associated with CNS tumors have been reported in transcontinental plane passengers.15 Due to mass effect, but also poor autoregulation within the vasculature of tumors, those patients may be more likely to become symptomatic in such conditions of physiologic stress.16

Only one adverse event related to brain tumors and sports has been reported during or after completion of therapy. This appears surprising because surgery, radiation therapy, and chemotherapy can alter the integrity of the brain and surrounding structures.

Even though the Pubmed, Scopus, and Cochrane databases were searched during our literature review, educational and sports literature might have been omitted; however, we believe that our search adequately demonstrated the rarity of sport-related injuries in patients with brain tumor. Of course, one cannot exclude that children presenting with an adverse event were simply not published. There is certainly a publication bias that underestimated the actual prevalence. One way to overcome this limitation would be to conduct a survey with providers involved with pediatric neuro-oncology patients.

Response rate for the survey sent by email was low but similar to a previous study using the same approach.17 Nevertheless, we were able to gather more than 100 responders from 3 main specialties involved in the care of children with CNS tumors. Our survey suggests that the actual incidence of sport-related complications is low.

Interesting recommendations were revealed by the survey. In general, providers will restrict noncontact sports activities for 1–3 months after surgery (82%). The responses varied, however, for contact sports and were almost equally distributed between 3 months, 6 months, and 1 year. Neurosurgeons were generally more concerned about bone flap displacement than other providers, despite a lack of reported cases involving sport or head trauma. Several professional athletes, including a professional boxer, have undergone craniotomy and eventually returned to play.10 The best timing for reintegrating sports with and without contact remains unknown, and no guidelines have been suggested. Some investigators have suggested performing an x-ray to assess partial or complete healing of the bone flap before an athlete can return to play.18 This healing usually occurs within a year.10

Shunt-related complications were a concern for 28% of responders. Blount et al did not find a case report of shunt dysfunction following sport participation after an extensive review of the literature and legal documents.19 In their survey, cases reported by providers mainly included catheter disconnections and shunt rupture after wrestling and soccer. Presumed events involved heading the ball, football, cartwheeling, rapid somersaulting, sledding/tobogganing, and a fall directly onto the shunt.

Slightly less than a quarter of responders recommended that sport activities should be restricted if the child had seizures. However, no data support this restriction, even for patients with active epilepsy. Some studies actually suggest that exercise suppresses temporal epileptic activity and that patients are less likely to seize.20 Except for swimming, there is no evidence that children or adults with epilepsy have significantly more risk than the general population while participating in sports.21,22 Because risks are low, different groups such as the American Medical Association's Committee on Medical Aspects of Sports and the American Academy of Pediatrics have lifted restrictions related to sports and epilepsy.23,24 Obviously, activities that present higher risk for the patient or his companions, such as scuba diving or hang gliding, should be thoroughly discussed with patients and their families.

In general, providers were limiting activities for platelet counts less than 50 × 109/L. Oncologists, however seemed to be more liberal, and few chose 100 × 109/L as their threshold in contrast to other specialists. One explanation might result from their experience treating patients with various cancers (such as leukemia and lymphoma) and confidence dealing with deeply thrombocytopenic patients. Anecdotally, neurosurgeons or child neurologists are reluctant to perform lumbar punctures in children with platelets less than 50 × 109/L, whereas oncologists will sometimes perform the procedure on patients with platelets slightly above 10 × 109/L. This practice has been supported by studies that have shown the rarity of serious complications from lumbar puncture in patients with platelets >10 × 109/L.25

Overall, 27 responders did not restrict any sports, whereas 35 responders restricted more than 4 sports from the provided list. This discrepancy was not associated with specialty, experience within the field, or previous sport-related complications. This brings forth an intriguing question: why are some providers more restrictive, while others are more liberal? Because there are no guidelines and the literature is scant, those recommendations possibly depend on individual beliefs, fears, and anecdotes.

Our survey assessed general opinions and was not designed to evaluate every specific individual situation. The sport-related limitations recommended to an adolescent with no residual tumor versus those recommended for a younger child on chemotherapy with a complication such as ataxia would likely be different, even if the two shared the same diagnosis. A survey with specific clinical scenarios would have made it lengthy, and analysis would not have been possible. Recall bias is another limitation of our survey. When completing the survey, some providers might have forgotten sport-related injuries that occurred several years previously. Despite this limitation, our study produced interesting observations and showed great diversity in recommendations between providers. In a future study, it would be interesting to survey patients and their families to investigate the perceptions of sports and restrictions.

Our extensive review of the literature and our survey demonstrated that sport-related complications are generally rare in children with CNS tumors. A formal restriction is sometimes advisable but, in the majority of cases, brain tumor patients should be able to participate in sports. Each patient needs to be individually assessed, and factors such as age, type of tumor and surgery, associated complications, cognitive dysfunction, and coordination should be considered when making specific recommendations. Patients and families should be aware that some activities present theoretically more risks, but the physician should also be aware that such complications are rare.

Based on literature review and our survey:

  • - Sport-related complications are rare in children with CNS tumors.

  • - There is no guideline on sport restriction for patients with brain tumor.

  • - Recommendations vary greatly between providers.

Recommendations:

  • - Each patient needs to be individually assessed before considering restrictions.

  • - In general, the emotional, social, psychological, and physical benefits from sports probably outweigh the risks.

  • - Physical activities should be promoted rather than restricted.

Future steps:

  • - A similar survey specifically designed for physical therapists should be conducted.

  • - The impact of sport participation and restriction on patients and families should be investigated.

  • - Prospective studies should be conducted to assess risks and benefits of sports in patients with CNS tumors

Conclusion

According to a systematic review of the literature and survey of current practitioners, sport-related brain tumor injuries are rare. Children with known brain tumors might not be at a significantly higher risk and should not be excluded from most sport activities. Sports with contact are not necessarily safe, but neither is there evidence that they should be systematically restricted. In general, emotional, social, psychological, and physical benefits of sports outweigh the risks, and physical activities should be promoted rather than restricted.

Funding

This work was supported by Fonds de Recherche en Santé du Québec” (23353 to SP1); Beirne Endowment for Brain Tumor Research; and Justine Lacoste Fundation.

Conflict of interest statement. None declared.

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