EXPERT Q&A

As the Super Bowl puts player safety under a microscope, neuroscientist Jonathan Lifshitz of the University of Michigan Concussion Center will watch with the perspective of both a researcher and a football father.

Lifshitz, professor of physical medicine and rehabilitation and of kinesiology, leads an internationally known neurotrauma research team at Michigan Medicine and the VA Ann Arbor focused on head injuries across the spectrum. His vast knowledge of traumatic brain injury hasn’t tempered his enthusiasm for competition on the gridiron; in fact, he brings his expertise to teams and the game—specifically his sons’ teams.

Fresh off his middle son’s NCAA Division 3 Football National Championship victory in early January as a player on the University of Wisconsin-River Falls team, Lifshitz explains why he never sidelined his children’s athletic ambitions on the football field, discussing why their family has always valued the developmental benefits of physical activity and teamwork, which always come with risk, in football, competitive sport and even recreation.

What was the conversation like when your son came to you and said he wanted to play football?

Our three sons grew up cheering for the Pittsburgh Steelers. After three years of flag football, our middle son was frustrated that flag football did not have offensive and defensive lines. He asked to play Pop Warner in 8th grade. My reaction was one of initial surprise, because our sons generally were not athletes; they were not the three-or-four-sport athletes like some youth. After identifying a team for him to possibly join, we looked into the coaching staff. After learning that coaches came from an associated high school and that the state mandated concussion (among other health) training, we were less opposed.

The conversation with our son continued as with anything. First, there is protective gear designed for a purpose (helmet, mouth guard) and it will be worn in practice and games, always. Second, we engaged with the team, talking by phone with the coaches, sharing expertise in concussion, should it be needed. Third, the family discussion was clear that everyone had equal responsibility to identify, communicate and decide about any injuries. Everyone could raise an alert, proceed with an evaluation and discuss decisions. The last point was critical for our son to know that he had a role in his own health.

You have an appointment at the Michigan Concussion Center. How do other parents who know your family react when they learn what you do for a living?

There is always an array of reactions, first depending on their own lived-experience with concussion/head injury or one associated with someone in their life. Most have questions about the potential long-term effects. Overall, they value the access to expertise, much as one would ask a mechanic about their car. Very quickly, however, there is a stark realization that my sons play football. Having built a sense of trusted expertise, they are objectively curious about the reasons for condoning football and approaches we take to keep our sons as safe as possible. Being on the sideline and in the bleachers brings a sense of objectivity and evidence to an otherwise fearful misunderstanding.

If a parent comes to you and says, “My child wants to play football but I’m terrified of the brain risk,” what do you tell them?

First, I reinforce the reality that football has an inherent risk of concussion and head injury. I also share that the likelihood that their child sustains a concussion is low, but not absent. I share that our family speaks openly about concussion and its symptoms, so that any indication can be identified and included in future health care decisions. I also reinforce that preparation is key, which includes strength, flexibility, knowledge of the game, nutrition and sleep. Then, I share the benefits of exercise, athletics, teamwork and commitment. Every coach, every athlete, every sport psychologist can and has shared the well-known benefits of sport on physical, mental and social health. The benefits put the risk—and the measured response to risk—against the benefits.

What recent research can you point to that supports the idea that football is getting safer?

This is not my area of expertise and as a football father, I am the beneficiary of the more recent changes. My exposure comes from watching practice, working the sidelines on the chain gang, attending team meetings and talking with players and coaches. First off, helmets are designed to reduce or disperse impacts over a larger area, thereby distributing the forces rather than concentrating them. Second, practice makes perfect and reinforcement of approved tackling methods and play style protect all aspects of the athletes. Many of these are reinforced by rule changes, such as those protecting a defenseless player.

There is a growing movement to ban tackle football for children under 14. Given your research on the developing brain, where do you stand on this?

From a brain injury perspective, there is never a good age or time in one’s life to sustain a concussion. The developing brain is neither better or worse at enduring or recovering from a concussion, and all concussions must be taken seriously. My argument in this discussion relates to identifying a minimum standard for youth to transition to higher levels of sport engagement rather than an arbitrary age assigned to everyone. Football is a complicated sport with the opportunity to work toward more advanced levels, similar to the belt standards in martial arts. At the same time, the athlete must be prepared for tackle football—a novice older than 14 could be placing themselves at risk, before understanding basic elements of the game.

What is the most misunderstood fact about concussion?

There is one misunderstood fact at the front end and one at the back end of concussion. At the front end, a concussion is a traumatic brain injury. No evidence suggests that “just a concussion” exists, because every head injury can have downstream, longer lasting effects. Individuals and their families fear brain injury and therefore delude themselves that a concussion is somehow better. At the back end, concussions can be treated. Our biggest advances in the field have come from a change in perspective about courses of action—primarily a graduated return to activity—that allow the brain to heal. Additionally, graduated levels of expertise are available to help educate and rehabilitate concussion symptoms.

You were instrumental in getting the “fencing response” into the NFL concussion protocol. When you’re watching a game, what are the “red flag” physical responses that you look for that signal something is wrong on the field?

My team and I conducted the initial studies on the fencing response and brought the translational data into the field. Our goal was to publicize an immediate, objective sign of concussion that could be valuable in underresourced areas—practices and games without a medical staff on-site. The public awareness of the fencing response led the NFL to incorporate it as a sign of concussion, warranting immediate removal from competition. Because the response is mediated by the brainstem, our subsequent study pointed to crying, vomiting, snoring and motor seizure as additional, but less frequent, signs of concussion. Beyond these immediate signs, one can observe unsteady walking, poor balance or voluntary avoidance of light and sound.

If you could change one rule in football to make it 50% safer without changing its essence, what would it be?

Regarding NFL rules, I am fortunate to know a couple of members of the health and safety committee. We are in excellent hands at the elite level. At the lower levels, where the vast majority of athletes play football, the best change to protect a player’s whole health relates to the roster size. When athletes play the full 60 minutes, sometimes on both sides of the ball, fatigue and risk can increase. A mindset change to limit the number of consecutive plays—similar to a baseball pitch count—could expand the game to more players and change the risk profile. However, practice distributed over more players may not prepare athletes for the game.