Sports Neurology—Beyond Concussions
Looking back, it may seem surprising that sports neurology is such a young discipline. But it’s only recently—perhaps as recently as 2008—that the field of sports neurology has become its own recognized discipline. That’s the approximate year when news stories began to inform the American public about the price being paid by professional athletes after a lifetime of head trauma. It’s also when the American Academy of Neurology’s Sports Neurology section was officially launched, after years of effort by a small but determined group of neurologists who had been noting the need for a more structured forum for their specialty.
At the head of that effort was Jeffrey Kutcher, MD, FAAN, now global director of The Sports Neurology Clinic in Brighton, MI, and the co-author of Back in the Game: Why Concussion Doesn’t Have to End Your Athletic Career (Oxford University Press, 2016). For most of the preceding decade, Kutcher had been engaged in completing his medical training, pursuing both his residency and stroke fellowship at the University of Michigan Medical Center in Ann Arbor. Although he had been a hockey player himself, sports weren’t part of his training focus. Until, that is, the university’s head athletic trainer buzzed his pager during one of his hospital shifts.
What began as a consult turned into a steady stream of patients and a dawning awareness of the special issues faced by athletes in terms of neurology. Not only were there concussion issues, which were to be expected, but there were specific concerns for the competitors who needed to manage their MS, epilepsy, and other neurologic disorders. Kutcher began to realize that a standard workup could miss important clues. As he started adjusting the process to include questions specific to athletes (“What sport are you training for? How many hours a day do you train?”), he started to move past a treatment of the symptoms to a more comprehensive look at how athletes could manage their conditions while still competing, and, in some cases, whether it was safe for them to compete at all.
When the New York Times broke a story on brain diseases in aging pro football players, it was as if the field that Kutcher and others had been shaping was suddenly born out of whole cloth. The AAN section, which had started with only a handful of members, grew quickly to 500; sports neurology fellowships sprang up, beginning with Kutcher’s program at the University of Michigan; and the annual AAN Sports Concussion Conference was created. There’s no question this is a specialty that needed to be recognized and formalized; the question now is how best neurologists can participate in this rapidly advancing field.
More than just concussions
To begin, Kutcher says, neurologists need to let go of myths that have sprung up around the concept of sports neurology. Not only does the specialty involve more than concussion treatment, but even that aspect of the field has been overrun with practices that could do more harm than good to the patient. As an example, Kutcher cites the common idea that three concussions in a sports career should mean the automatic withdrawal of the athlete, or the concept of simply waiting for concussion symptoms to disappear rather than evaluating which activities can still occur during the healing process.
Not only are those protocols based on shaky science, but they could actually harm the athlete. “Making those statements ignores things like the negative effect of removing that sport from a patient,” Kutcher says. “If you’re telling a 14-year-old lead soccer player, ‘Sorry, you’ll have to stop playing soccer,’ you’re essentially taking their identity and their social structure. Or if you tell a patient, ‘You can’t play sports until the symptoms are gone,’ that could be six months or two years. Their lives are absolutely turned upside down. Their college options diminish.”
As an alternative, Kutcher advocates evaluating the symptoms more critically, with a workup that includes physical activity in the athlete’s sports environment. From there, he says, the patient can be treated more accurately, often resulting in a return to play in only a few weeks.
But even with a better understanding of concussion treatment, Kutcher and his colleagues are quick to note that sports neurologists do so much more than manage brain trauma. Vernon B. Williams, MD, is the former chair of the AAN Sports Neurology section and the founding director of the Center for Sports Neurology and Pain Medicine for the Kerlan-Jobe Orthopaedic Clinic in Los Angeles. He began his connection to the field while working with a sports medicine clinic as a pain specialist, before creating a clinic for Kerlan-Jobe. “I always go to great lengths to explain that concussion is a part of sports neurology, but sports neurology is really so much more,” Williams explains. “That’s what I always try to reinforce to people who may be thinking about this as a career path.”
Four key areas of sports neurology—plus research
To that end, Williams identifies four subsections of the field, each of which he expects will expand. The first area is treatment of any injury to the brain or nervous system that occurs during the course of a sports activity. Moving past the question of concussion, he notes, allows the neurologist to be more attuned to other injuries. For example, Williams frequently sees players with elbow injuries in his practice, referred by orthopedic surgeons who recognize symptoms of damage to the ulnar nerve.
The second area Williams sees in sports neurology is counseling and consulting with individuals with a neurologic diagnosis about whether they should participate in their sports. “Should you be playing water polo with epilepsy?” or “How will your MS affect training for soccer?”
The third area, which Williams says gets less attention than it should, is the question of how participating in sports and exercise affects the nervous system. “There’s lots of evidence that the more a person exercises, the healthier their brains are,” he notes. “Or, if they have a neurological disorder, that exercise helps with the symptoms. The brain likes exercise; sports neurologists can apply the use of exercise and monitor a neurological disorder across a patient’s lifetime.”
The final area Williams identifies as a part of sports neurology is the emerging body of science relating to how the brain and the nervous system contribute to athletic performance. “This is a relatively new paradigm,” he says. “We’ve known about diet and sleep and physical training as contributors to peak performance. Now we know that we can train vision to improve performance. The same can be said for balance and proprioception. We can train the brain to recognize patterns, to improve cognitive endurance and reaction time.”
Francis X. Conidi, DO, FAAN, also sees an expansion of sports neurology in that fourth area, which he identifies as sports performance. “Biometrics, neurometrics, how fast the brain responds—that’s one of the untapped areas,” he says. “You try to quantitate how the brain performs and translates the information, using things like functional MRI and quantitative EEG with brain mapping, to show objectively what’s happening with athletes’ brains. That’s where sports is going. It’s getting very scientific.”
To that end, Conidi notes the role to be played by research in growing the field of sports neurology. As director of the Florida Center for Headache and Sports Neurology (FCHSN), and founding executive director of the Seeing Stars Foundation, Conidi is involved in sports neurology research on multiple levels. For example, FCHSN has seen about 600 National Football League players since 2008 as part of head trauma research. Meanwhile, Seeing Stars Foundation—which Conidi created as part of his Palatucci Advocacy Leadership Forum project—focuses on raising funds not only for research, but for community initiatives as well.
With so much going on in sports neurology, it might seem as if the sky’s the limit for new doctors entering the field. Maybe, but caution is still advised. For one thing, the leading service is still concussion management—which isn’t a very good money maker. Nor does sideline work—standing by at professional, college, or high school sporting events—pay very well, if at all. In many cases, that task can take an entire day but will only be billable if an athlete needs a consult. To make things even more difficult, hospitals and clinics are flooding the concussion market, using the service as a type of loss leader to attract patients who might graduate to more complex services later.
To overcome these issues, neurologists new to the field are advised by Conidi and others to integrate their practice with other disciplines, while using sideline work to establish credibility rather than as a direct income source.
Other growing pains for the field include the question of standardization of care, issues of ethics where doctors may shift from patient advocacy to representing the interests of a sports team, and the age-old problem of any new discipline where those hanging out a shingle may not be specifically trained for the practice.
Despite these and other potential problems, sports neurologists already in the field are optimistic that resolution will come with more structure. As an example, having an established AAN section provides a forum for conversation and debate over what aspects of the profession need more attention.
The next generation
Another example of the structure that comes with a maturing discipline is development of fellowship programs. To date, at least nine fellowships have been created, including that of Kutcher at the University of Michigan. Nicole Reams, MD, now associate director of the Sports Concussion Program at Chicago’s NorthShore University HealthSystem, was one of those fellows—but almost by accident. As she recalls, “On my first day of residency neurology orientation, I sat with Dr. Kutcher at lunch, just randomly, and talked with him about his work. He hadn’t started the sports fellowship yet; he was just doing the work and he described some of what that involved. I remember very distinctly going home and calling my mom and being so excited. I just couldn’t believe this was an option. When it got up and running, it was the only sports neurology fellowship in the country at the time and I was already right there. If that hadn’t happened, I wouldn’t be a sports neurologist today.”
Now that more fellowships are in place, employment is becoming easier to track. So far, Kutcher says, all of his fellows have gotten jobs in the field; Williams says the same of the fellows graduating from his program. For her part, Reams is enthusiastic about prospects for those entering the field, provided they keep realistic expectations. “It’s still a very new field, so you have to know what you’re getting into.” That said, she has advice for those who might be considering a fellowship. “It would be ideal for a resident to have their eye on this early, and try to do an away rotation, even in the 3rd or 4th year of medical school if it were allowed. That’s to try to find out if this is the career they think it is, but also to make a relationship with the fellowship director and the faculty where they think they want to match. And if they feel interested early on, they could improve their match by showing volunteer experience with sports medicine or other sports events. It’s not only enriching personally, but it also helps to establish the timeline of desire and show they know their way around an athletic training room.
”Reams believes the effort will be worth the prize for would-be fellows interested in sports neurology. “I think the coolest part is that Dr. Kutcher told me no two days are the same and he was right. I might be in clinic, then I sideline with the Bears game, then I could go do exertional testing or training in the PT gym, or see students on rotation, or give talks, or go see a player at the Bears’ Halas Hall. It’s a wonderful career to be in and I feel really lucky that I found out about it.”