Should My Kid Play Football? Jim Messerly DO

Nothing to Declare

Dr. Bennet Omalu, Forensic Pathologist “There is no such thing as a safe blow to the head. And then when you have repeated blows to your head, it increases the risk of permanent brain damage.”

Dr Omalu- Sports to Avoid Until Age 18 The Big 6- High-Impact, High-Contact Sports Football Boxing Ice Hockey Wrestling Mixed Martial Arts Rugby and: Lacrosse Heading in Soccer

Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football JAMA July 25, 2017; 318(4):360-370 Results: Among 202 deceased former football players (median age at death, 66 years), CTE was neuropathologically diagnosed in 177 players including: 0 of 2 pre-high school players 3 of 14 high school players (21%) All mild CTE 48 of 53 college players (91%), 56% Severe CTE 110 of 111 NFL players (99%), 86% Severe CTE

JAMA CTE Article Continued Among the 84 participants with severe CTE pathology, 75 (89%) had behavioral or mood symptoms, 80 (95%) had cognitive symptoms and 71 (85%) had signs of dementia. Conclusions and Relevance: In a convenience sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of CTE, suggesting that CTE may be related to prior participation in football.

CTE Pathology

Editorial Response to CTE Article JAMA July 25, 2017. Dr. Rabinovici U of Cal. “The cohort represents a convenience sample of former players whose brains were donated for research (usually by the next of kin). As investigators acknowledge, such a sample is likely to be biased to include more impaired individuals who experienced significant neuropsychiatric decline during life, thus prompting their family members to pursue brain donation.”

CTE Unresolved Questions- Dr. Rabinovici, Memory and Aging Center What is the incidence and prevalence of CTE in population-based samples? What is the magnitude of risk associated with participating (and allowing children to participate) in various contact sports? Are there individual susceptibility and resilience factors that modify the risk or expression of the disease? What are the mechanisms that link acute TBI to a latent neurodegenerative process, and what is the best way to intervene?

Journal Orthopaedics and Related Research April 25, 2016 Editorial: Orthopaedic Surgeons Should Recommend That Children and Young Adults Not Play Tackle Football. Seth Leopold MD and Matthew Dobbs MD. “Football has properly come to attention because as a public-health problem, it causes vastly more concussions than do other sports…Exposing millions of children to an activity that may permanently alter the structure of their developing brains in the interest of “fitness” as some have suggested is short-sighted and wrong…Orthopaedic surgeons should look for ways to guide families and their children away from tackle football.”

Journal Clinical Orthopaedics and Related Research Sept 5, 2017 Editorial: Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games? Seth Leopold MD, et al. “To restate the obvious, football is only a game. Our first responsibility is the health and safety of our patients. Is it right for us to support a game through our presence on the sidelines… that causes grave harm to at least 9% of those who play it professionally? In light of the known risks, we suggest that surgeons evaluate whether continuing to support this sport is consonant with the best values of our profession. We believe it is not.”

Cumulative Head Impact Burden in High School Football J Neurotrauma Oct 28, 2011. Broglio et al 95 high school football players over 4 seasons (190 practices and 50 games) used Head Impact Telemetry System (HITS) with 15 g threshold. 652 Average number of impacts per season 868 Average number of impacts/season, linemen 619 Average number of impacts/season TE,RB,LB 467 Average number of impacts/season QB “The adolescent athlete in this study clearly sustained a large number of impacts to the head, with an impressive associated acceleration burden as a direct result of football participation.”

High School Football and Late-Life Risk of Neurodegenerative Syndromes, 1956-1970 Mayo Clinic Proceedings, Jan 2017. Janssen PH, et al. Results: We identified 296 varsity football players and 190 athletes engaging in other sports. Football players had an increased risk of medically documented head trauma, especially if they played football for more than 1 year. Compared with non-football athletes, football players did not have an increased risk of neurodegenerative disease overall or of the individual conditions of dementia, parkinsonism and amyotrophic lateral sclerosis.

Association of Playing High School Football with Cognition and Mental Health Later in Life JAMA Neurology, July 3, 2017, Deshpande SK, et al Objective: To estimate the association of playing high school football with cognitive impairment and depression at 65 years of age, graduates in Wi in 1957. Results: Among the 3904 men (mean age 64.4), after matching and model-based covariate adjustment, compared with each control condition, there was no statistically significant harmful association of playing football with a reduced composite cognition score or an increased modified Depression Scale depression score vs controls.

Multiple Past Concussions in High School Football Players: Are There Differences in Cognitive Functioning..? Am J Sports Med Dec 2016, Brooks BL, et al Conclusions: In the largest study to date (5232 male adolescent football players), high school football players with multiple past concussions performed the same on cognitive testing as those with no prior concussions. Concussion history was independently related to symptom reporting.

Consensus Statement on Concussion in Sport- Berlin October 2016 Br J Sportsmed, McCrory P, et al. April 27,2017 “The literature on neurobehavioral sequelae and long-term consequences of exposure to recurrent head trauma is inconsistent. Clinicians need to be mindful of the potential for long-term problems such as cognitive impairment, depression, etc.” “As the ability to treat or reduce the effects of concussive injury after the event is an evolving science, education of athletes, colleagues and the general public is a mainstay of progress in this field.”

Case Study #1 High School football playoff game- WR, punter states he took a hit covering a punt and has a HA. Total Symptom Score is 2 for HA which persists. SAC is 28 with repeat 29, 10 min later. VOMS- neg. Neuro exam- neg. Is this a concussion? Return to play?

Case Study #2 HS RB reports to LAT on Monday after Friday game that he took a hard hit in that game and was “a little off” for the remainder of the game, but did not report his symptoms. Over the weekend, his father (a medial provider), noticed balance concerns in his son and went on-line for some balance tests which were performed and seemed abnormal. The father called the AD Monday am reporting the weekend events requesting further concussion evaluation.

Case #2 Continued When evaluated by the LAT, the player reported a SS of 12. ImPACT testing was performed and was at baseline. Neuro exam was nl. The player was informed that because of symptoms on Monday, he would be unable to start the Stepwise Return to Play Protocol and therefore, would not be able to play in Friday’s game. Tuesday’s SS was 0. Mom voiced significant frustration about her son being withheld from play and Dad then questioned the Return to Play Protocol stating that it encouraged players to lie on symptom reporting. Withhold or play on Friday?

WIAA Concussion Management form

WIAA Parent & Athlete Agreement As a Parent and as an Athlete it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form you are stating that you understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury. Parent Agreement: I _________________________________ have read the Parent Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a concussion is suspected. I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me. I understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach.I understand the possible consequences of my child returning to practice/play too soon. Parent/Guardian Signature_________________________________________Date__________________ Athlete Agreement: I_______________________________ have read the Athlete Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I understand the importance of reporting a suspected concussion to my coaches and my parents/guardian. I understand that I must be removed from practice/play if a concussion is suspected. I understand that I must provide written clearance from an appropriate health care provider to my coach before returning to practice/play. I understand the possible consequence of returning to practice/play too soon and that my brain needs time to heal. Athlete Signature_________________________________________Date___________________ 125 South Webster Street, PO Box 7841, Madison, WI 53707-7841 PHONE 608-266-3390 TOLL FREE 800-441-4563 WEB SITE http://www.dpi.wi.gov

Tackling in Youth Football- AAP October 25, 2015 There are approximately 250,000 youth football players 5-15 years of age in Pop Warner leagues alone. Conclusions and Recommendations: Officials and coaches must ensure proper enforcement of the rules of the game. Removal of tackling from football would lead to a fundamental change in the way the game is played. Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling.

Tackling in Youth Football- AAP Continued The expansion of non-tackling leagues for young athletes who enjoy the game of football and want to be physically active… should be considered by football leagues and organizations. Although the effect of subconcussive blows on long-term cognitive function, incidence of CTE, and other health outcomes remains unclear, repetitive trauma to the head is of no clear benefit to the game of football or the health of football players.

Tackling in Youth Football- AAP Continued Delaying the age at which tackling is introduced to the game would likely decrease the risk of these injuries…, however athletes who have no previous experience with tackling would be exposed to collisions for the first time at an age at which speeds are faster, collision forces are greater, and injury risk is higher. Although definitive scientific evidence is lacking, strengthening of the cervical musculature will likely reduce the risk of concussions in football by limiting the acceleration of the head after impact.

Final Thoughts According to recent medical literature high school football does not seem to cause long term neurologic sequelae from concussions. College and pro football are probably different. Though research to date has been complicated by a variety of methodological issues We just don’t know yet A heightened awareness of concussion injury is critical in the management of concussion. Participation in Youth Football would need close scrutiny.

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