Article Link: Neurologists on the Sidelines: The Sports Neurotrauma Consul... : Neurology Today (lww.com)
Neurologists who work as consultants to sports teams discuss the training they receive, their challenges in obtaining liability insurance, and the pressures that come with having to make treatment decisions on the sidelines under high-pressure conditions.
When Miami Dolphins quarterback Tua Tagovailoa's head slammed into the turf after a tackle during the second quarter of a Sept. 25 game against the Buffalo Bills, he appeared disoriented as he stumbled to his feet, took a few steps, then collapsed to his knees. But he cleared the team's concussion protocol and returned to the game.
Four days later, he took a similar hit in a game against the Cincinnati Bengals. This time, he didn't get up, and he was ultimately taken off the field on a stretcher and sent to a hospital. On Oct. 2, the Dolphins announced that the unaffiliated neurotrauma consultant who evaluated Tagovailoa had been fired over “several mistakes.”
A week later, the National Football League (NFL) and the NFL Players Association (NFLPA) issued a joint statement announcing that the league's concussion protocol had been modified.
“Specifically, the term ‘ataxia’ has been added to the mandatory ‘no-go’ symptoms. ‘Ataxia’ is defined as an abnormality of balance/stability, motor coordination or dysfunctional speech caused by a neurological issue,” the statement read. “In other words, if a player is diagnosed with ‘ataxia’ by any club or neutral physician involved in the application of the Concussion Protocol, he will be prohibited from returning to the game, and will receive the follow-up care required by the Protocol.”
Under the terms of the agreement between the NFL and the NFLPA, three unaffiliated neurotrauma consultants (UNC) must be present at each US professional football game; protocol dictates that two UNCs are positioned on the sidelines, and one is in a booth above the field. They are jointly selected by the NFL's Head, Neck, and Spine Committee and the players' association to work with team physicians to identify, screen for, and diagnose concussions. The NFL and NFLPA pay these UNCs to be at the games.
Who Are These Neurotrauma Consultants?
What are the qualifications for neurotrauma consultants, and what roles
do they play? Although the current chair of the Head, Neck, and Spine
Committee is a neurosurgeon—Nicholas Theodore, MD, the Donlin Long
Professor of Neurosurgery, Orthopaedics, and Biomedical Engineering at
Johns Hopkins University School of Medicine—and its vice chair is
a neurologist—Javier Cardenas, MD, FAAN, director of the Barrow
Concussion and Brain Injury Center—not all the UNCs selected are
neurologists or neurosurgeons.
The concussion protocol specifies that UNCs should be “board certified in neurology, emergency medicine, physical medicine and rehabilitation, or any primary care CAQ [certificate of added qualification] sports medicine certified physician or board eligible or board certified in neurological surgery.” The UNC also must have documented competence and experience in the treatment of acute head injuries.
“While I know of five to six neurology colleagues who work as UNCs, at least half of them are from other specialties, such as sports medicine,” said Francis Conidi, MD, director of the Florida Center for Headache and Sports Neurology, a founding member and vice chair of the AAN's Sports Neurology Section, and the team neurologist for the National Hockey League's Florida Panthers. Dr. Conidi has also served as a consulting neurologist for the NFL.
“They do have to have specialized training through the players' association,” he said. “Unfortunately, neurology had washed its hands of sports like football and boxing for many years, and it's taken us a while to develop these programs within neurology.”
Other physicians with concussion training and experience, such as sports medicine practitioners, can certainly be qualified UNCs, said Joel Morgenlander, MD, FAAN, professor of neurology at Duke University and director of the Duke Neurology Concussion and Sports Neurology Clinic.
“There are people other than neurologists who are trained in the way we would examine people with concussion; that's not unique to neurology,” he said. “And just because you're a neurologist, that doesn't necessarily mean you're comfortable evaluating patients with concussion. When we formed the sports neurology section of the AAN, one of the first things we worked on as a group was to get concussion and mild TBI included in the residency review committee core competencies for neurology, because at the time there was no general requirement to teach neurologists about concussion.”
While non-neurologists can be good UNCs, a neurologist with the right concussion training and experience is particularly well qualified, said Vernon Williams, MD, FAAN, director of the Center for Sports Neurology & Pain Management at Cedars-Sinai Kerlan Jobe Institute in Los Angeles. Dr. Williams also is a consultant for several professional sports organizations, including the Los Angeles Rams and the NFLPA.
“I'm of the opinion that these professionals should be individuals who have specific expertise, training, qualifications, and experience in evaluating and managing concussive injury and head injury,” he said.
“You can be a neurologist and not have any experience acutely evaluating concussive injury, and you can be trained in a different medical specialty and have that appropriate education and experience. But for neurologists, our medical heritage is related to the development of keen observational skills, identifying even subtle changes that non-neurologists might not. Once you have a basic level of qualification, I think neurologists and neurosurgeons offer additional skill and value in these roles.”
Dr. Conidi agreed. “The sideline concussion evaluation tests are based on algorithms, but there is an art to neurology, to recognizing when something doesn't look right,” he said. “Players with concussion can show very subtle signs that aren't in the algorithm, that I as a sports neurologist would pick up. Your eye movements don't look quite right, or you stumbled when I did your eye exam, or you looked like it made you uncomfortable when I checked your eye movements—as opposed to a simple yes or no to a question like whether someone has nystagmus. And I think after the work we've done over the past decade in advancing sports neurology, we do have enough trained and qualified neurologists who could staff the NFL sidelines.”
The Essential Skills Needed
In addition to specific professional expertise, experience, and training,
what else makes a good sports neurotrauma consultant for the NFL or other
high-impact sports?
For one, they need strong observational skills while facing a ticking clock. “You need to be a careful observer, which is what makes neurologists uniquely qualified for this role,” said Anthony Alessi, MD, FAAN, associate clinical professor of neurology and orthopedics and director of the University of Connecticut NeuroSport Program.
“Much of what we do in sideline sports is based on observation, when we may not be able to put our hands on the athlete. But we also have to make these observations quickly. I do a lot of work in combat sports, and in boxing, for example, you have 60 seconds in the corner to decide whether you're going to let the person go back out or end the fight. You can't sit there for an hour mulling over how to localize things; you have to be able to get information quickly that is usable to make a decision.”
The UNC must also be able to stand firm in a diagnosis under pressure. “To be a neurotrauma sideline physician, you can't be influenced by the coach or the athlete who's wanting to get back out and play,” said Stephanie Alessi-LaRosa, MD, director of the sports neurology program at the Hartford HealthCare Ayer Neuroscience Institute in Connecticut. “You have to have authority and confidence in your decision and be ready to say, ‘I'm going to take your helmet and what I say is the final word,’ because they need someone objective who can do what is safest.”
The UNC needs to have Intense focus. “I often say that the sports neurologist is the one on the sideline watching every play of every game,” said Dr. Alessi-La Rosa. “We're not hanging in the background, not looking at our phones, not having side conversations. We have to be up front and focused at all times because our observation is the first exam.”
Dr. Williams agreed, noting that “it's very different from watching as a fan where you follow the ball.”
“You have to observe what's going on behind the play, in front of the play, and in between the action,” he said. “Key moments are when people are getting up, sometimes in those first few seconds, when they might be stumbling or shaking their head.”
It also is important to be able to work as a multidisciplinary team player. “Neurologists are relatively new to being on the field as members of the sports medicine team,” Dr. Williams said. “It's helpful to understand how to be a good teammate [and] how to work with orthopedic specialists and primary care sports medicine specialists, who often have a lot of experience in sideline coverage, sometimes more than the neurologist does. But neurologists should also be aware that they have something to contribute and make sure there's mutual respect with the other team physicians and athletic trainers.”