To Play or Not to Play? That Is the Concussion Question

"Dr. Williams, would you let your son play football?" Over the course of a 20-year career as a sports neurologist, that question is one of the most frequently asked by patients, friends who are parents of young athletes and the public in general. Early in my career, the question was related to the risk of musculoskeletal and spine injury. Aware of the risk of fractures, bruises and other "nuisance" injuries as well as the very low risk of a catastrophic spine injury, it was always an easy answer: "Yes." I grew up playing football and have always been a fan of the sport. I usually reassured the person asking with a discussion of issues like "relative risk" and my personal and very positive experience playing football, emphasizing the benefits I had realized from the sport. More often than not, I was selling those benefits over the risks (relative and absolute) to a nervous mother who disagreed with the son and father about playing what she felt was "such a violent sport." I had, in fact, dealt with similar concerns from my own mom when I decided I wanted to play.

Over the last several years, the science of concussion has rapidly evolved, and concern over acute and chronic effects of concussion has become more frequently discussed and debated. As the major motivation for the "would you let your son play football?" question has evolved, so has my answer. Every child's circumstances must be evaluated on a case-by-case basis, and while there are numerous considerations and dynamics that contribute to my opinion, the answer is much more nuanced and conditional. "Yes, assuming..." depends on two important caveats:

1. Children with preexisting neurological impairment should probably avoid sports with elevated concussion risk. "Elevated concussion risk" deserves further explanation. We tend to think of the football player running full speed into an opponent, making helmet-to-helmet contact during a tackle. But it's clear that concussion can occur in almost any athletic or exercise-related activity. I've cared for cross-country athletes who concussed after stepping in a ditch and suffering a whiplash movement of the neck. I've cared for athletes who've concussed from hitting their head on the bus after the game. While tackle football has been studied to contain the highest risk for concussion among male youth athletes, it's worth noting that girls' soccer contains the highest concussion risk for female youth athletes and boys' soccer, and girls' basketball fall closely behind them. Equestrian sports and competitive cheer also have significant risk of concussion. I bring these points up for consideration during my answer because concussion is not just a football issue. Any sports or activities where athletes are moving at high velocity or where body contact is likely (be it with another person, a ball or the ground) may put a young athlete at high concussion risk. So, when I'm asked "Would you let your son play tackle football?" I carefully reframe the question to: "Would you let your child play a contact/collision sport or one with elevated concussion risk?"

The Child Neurology Foundation defines "neurologic disorder" as any condition that is caused by a dysfunction in part of the brain or nervous system, resulting in physical and/or psychological symptoms. Any condition that has already challenged my child with slower reaction times, reduced speed of mental processing or cognitive dysfunction – or otherwise predisposes him or her to neurological deficit before ever setting foot on a playing field where head and body contact is likely – would be a strong signal that I may want to help my kid explore a sport that doesn't contain an elevated concussion risk.

Deciding not to allow my child to play a contact sport is obviously much simpler if I know there is a preexisting neurological condition, but what if there was and I didn't know it? Or what about a child with certain so-called "modifying factors?" These are conditions and diagnoses that experts feel and research suggests may place individuals at increased risk of concussion or increased risk of worsened and prolonged symptoms and delayed recovery after concussion. Migraine headache, learning disability, sleep disorder, ADHD, mood disorder and previous concussions are examples of "modifying factors." In my opinion, these are not absolute contraindications for participation, but children with modifying factors should be evaluated more closely and benefit from more than the typical "baseline testing" frequently offered to the general team population as part of an organization's concussion program.

This is where the importance ofthepre-participation examination comes into play. While many are familiar with the "sports physical," the quality and scope of these pre-participation examinations can vary widely. Consultation from a sports neurologist or other physician skilled in the evaluation and treatment of concussion can be invaluable in these situations. More specific and detailed history, examination and testing can help identify a neurological disorder that was previously undiagnosed, can identify presence of modifying factors and can inform the best decision regarding safe participation. If the consulting doctor has concerns about an athlete's safety and/or readiness to compete in any sport, that concern must be considered and their recommendations should be heeded. Not doing so can put a young athlete's safety at further and truly unnecessary risk.

Of course, this is not to say that a child with a neurological impairment or certain modifying factors should not engage in sport. There are, in fact, innumerable benefits to sport and exercise that cannot be overstated. Exercise is one of the most important approaches to brain health across the lifespan. From learning self-discipline and elevating self-esteem to the preparation for adult life as a "team sport," there are countless benefits that athletic involvement brings to children. And while childhood (or life in general, for that matter) is not injury-proof, no sport can be, either. But there are many sports that don't contain as high a concussion risk. Participation in football or any other sport with elevated concussion risk should be carefully considered in certain circumstances and alternative options considered if indicated.

2. An intentional focus should be placed on concussion awareness and appropriate management by all stakeholders when children are playing contact sports or engaging in activities with high concussion risk. Many high school coaching staffs contain members who are solely dedicated to the sport they're coaching. This type of personnel is usually trained in a specific concussion protocol focused on awareness, education and early recognition of the signs and symptoms of a suspected concussion. In many cases, there are trained certified athletic trainers and other staff focused on concussion education, diagnosis and return to play protocols. But there are widely varying environments and resources available to athletes participating in high-risk sports activities.

For instance, in the case of youth football programs and often with sports activities unaffiliated with a school, the majority (if not all) coaching staff members are volunteers. There are typically no athletic trainers in these and many other environments. There may be no concussion-based education or documented concussion protocol. And even if these things are present, there may be a lack of respect for the injury without the kind of "buy-in" necessary to adequately protect athletes and encourage safe participation. Perpetuating a "gladiator mentality," under-reporting symptoms, focusing on winning rather than athletic and character development, encouraging early return to play and other negative attributes of sports culture can significantly increase an athlete's exposure to and risk of concussion as well as chronic neurologic impairment.

So I often answer the question with more questions. What kind of environment would the child be participating in? Have the coaches (who may change year-to-year depending on which level their own child is playing at) received extensive concussion training? What about the "team parent?" How about the referees? Is the concussion protocol being communicated openly with parents? Is there a certified athletic trainer? Does the coach respect the injury? Is there a process in place to reduce concussion risk by reducing exposure? Are the athletes removed from practice or play immediately if a concussion is suspected? Is the helmet and/or other equipment in good condition? Are rules appropriately enforced? Are techniques that reduce concussion risk actively taught? Are kids pressured to "shake it off," "be tough" or "walk it off" if there is a suspected head injury? Everyone involved should be on the same page with the concussion conversation.

The CDC, in collaboration with the National Football League, has a free, comprehensive and specific "Heads Up" training protocol for coaches, parents and athletes as well as sport officiants. The aim of this program is not only to educate those involved about concussions, but to also address the way the topic is talked about and responded to. The desire is for open, honest conversations about concussions so that everyone involved knows that concussion symptoms should not be hidden or "played through." Before I said "yes" to my child playing tackle football, I would need to be 100 percent confident that the organization and team being considered had created such an open culture and systematic approach to concussion conversation, prevention and evaluation.