It might seem strange to have retirement as the sixth and final pillar of the Six Pillars, but is included for a very important reason: when all else fails, when an athlete has suffered one or more concussions, and the risk of long-term injury simply becomes too high, the only step left to prevent further brain damage is to stop playing contact and collision sports (as one of the Newcastle High School players ends up doing).

Medicine has not yet figured out how many concussions is too many. The number that leads to permanent deficits in memory, concentration, and other cognitive processes, and/or that increases the risk of dementia and other problems later in life, is likely different for each athlete.

Factors

Several factors will likely influence a recommendation to an athlete to consider retiring from contact or collision sports (1-3), including:

• Number of concussions: Contrary to popular belief, there is no magic number of concussions that disqualifies an athlete from further participation in contact or collision sports. The number of concussions is a factor, but only one. (1-3)
• Concussions occurring with less force. For some athletes, as the number of concussions rises, the force required to produce a concussion seems to decrease. When an athlete reports developing concussion symptoms after a seemingly minor blow to the head (such as an accidental blow to the head by the arm of an opponent or friend), such a sign is concerning, and will prompt a sports concussion specialist to discuss retirement with the athlete. (1)
• Slower recovery. Most athletes recover from concussions quickly, in a matter of days to weeks. In high school-aged athletes, nearly 85 percent will be symptom-free within one week of their injury. For some athletes, however, the recovery time is much longer, lasting weeks to months. For others, they recover from their first few concussions quickly, but as they suffer more concussions, the recovery time increases, lasting weeks to months, or in some rare cases, longer than a year.
• More pronounced cognitive losses. After a concussion, many athletes lose some cognitive function, e.g. their ability to think, remember, concentrate, and reason, which they regain as they recover, and which is a prerequisite to return to play (Pillar Five). For some athletes, the cognitive losses they experience at the time of injury increase with the number of concussions, with their memory, reaction time, and the speed with which they process information (all of which can be measured through pen-and-pencil or computerized neurocognitive testing), becomes much worse. (2,3)

Even without the presence of these concerning factors, there remains some risk, of course, from continued participation in contact or collision sports after concussion, with increased risk of a second concussion.

For most athletes, retiring from contact or collision sports has a major impact on their lives. For elite high school and college athletes trying to make it to the pros, it means giving up their dream.

Even for athletes at the high school level and younger, much social activity, self-identity, and enjoyment comes from sports participation, which, studies show, have many benefits for both boys and girls. The importance of such participation is often underestimated by clinicians, parents, teachers and other adults.

Often, when an athlete stops playing contact and collision sports, they lose the friends they spend time with before practice, while dressing for sports, stretching, warming up, after practice, while changing and showering, and on the bus ride to games. Not being around during these times means they miss out on conversations, jokes, the latest gossip, and the discussions that make people friends. This can be quite devastating to the athlete.

The decision to retire should be made jointly, after long discussion between the athlete, the athlete’s family, other people important to the athlete (e.g. coach) and the team involved in the athlete’s care, including the physician, neuropsychologist, nurse practitioner, and other members of the care team, and takes place over a series of visits lasting weeks to months.

For those young athletes who do not seek to play professional sports, or who do not have a realistic chance of doing so, most will assume less risk, and will retire from high-risk sports after fewer concussions than prompt an athlete who earns their living by playing professional sports to retire.

Ultimately, athletes make the decisions themselves, and only in very rare cases will a doctor refuse to allow an athlete to return against his or her wishes, and, even then, they are encouraged to seek a second opinion.(3)

1. 1. McCrory P, et. al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013: 47:250-258.
2. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology2013;DOI:10.1212/WNL.0b013e31828d57dd (published online before print March 18, 2013)
3. Meehan WP, Kids, Sports and Concussion (Praeger 2011).