Late in the Game: Concussion, CTE, and the Role of the Neurologist

A sports neurology expert shares insights on the science of concussion, common misperceptions about CTE, and the dire need for more education and research funding.

 

Last month, roughly 100 million people watched the Super Bowl, easily making it the most viewed television event in the world and further cementing football’s legacy as America’s most popular sport. That popularity has persisted (and arguably grown) in spite of increased public scrutiny of the National Football League (NFL) over its response to compelling findings pointing to significant health risks associated with repeated head trauma. In fact, the league’s inaction and active resistance to mounting scientific evidence has prompted a rash of criticism and accusations that it has prioritized business over the safety of its players.

The continued media exposure of the concussion controversy in recent months suggests that the issue has penetrated the public consciousness. Last September, findings from a study revealing that 87 of 91 deceased players tested positive for chronic traumatic encephalopathy (CTE) made big headlines in mainstream news circuits. Around the same time, renowned NFL columnist Peter King conducted an interview with one of the NFL’s sideline neurotrauma specialists (available on www.si.com). Then, in December, Sony Pictures released the film Concussion, which chronicles Dr. Bennet Omalu’s discovery of CTE in the brains of deceased NFL players. The film is based on a 2009 expose in GQ magazine detailing the NFL’s suppression of research conducted by Dr. Omalu, who is played in the film by Will Smith.

ARTICLE AT A GLANCE

As the spectrum of concussion research expands, physi- cians and researchers are rapidly uncovering new chal- lenges to meet. Despite increased attention in concussion and CTE, a significant gap remains between goals and results in both research and practice. Neurology as a spe- cialty should take the lead when it comes to increasing awareness, executing proper protocols, and instituting management.

However, despite Sony’s hefty marketing campaign (including regular promos airing during NFL games), the film grossed a modest $40 million at the box office during the holiday season, the rough equivalent of nine 30-second TV advertisements during the Super Bowl. Thus, while the increased awareness and significant media attention regarding concussion has forced the NFL into taking steps to address player safety and reduce concussions, it remains to be seen whether the swelling interest in this issue will result in real change. Compounding matters is the fact that CTE and concussions in general remain poorly understood by general public and the news media. Even within the specialty of neurology, much work remains to better understand, manage, and prevent serious brain injury.

According to Frank Conidi, DO, Director of the Florida Center for Headache and Sports Neurology, Assistant Professor of Neurology at Florida State University, Team Neurologist for the NHL’s Florida Panthers, and a founding member of the American Academy of Neurology’s sports neurology section, the issues surrounding concussions and CTE require not only more attention but clarification.

Ahead, Dr. Conidi reflects on the science of CTE, the state of research and education, the NFL’s steps to address and reduce concussions, and developing best practices for identifying and managing TBI.

Concussions and the Role of the Neurologist

Although little can be done to control media representations of concussion, neurologists should play a significant role in the clinical realm in not only managing these conditions but also spreading awareness, according to Dr. Conidi. “Concussion is a neurological disorder—there is no question about it,” he states. “Neurologists need to be at the forefront when it comes to concussion research, education, and commentary, because we are the thought leaders.” Given the complicated picture of concussions, Dr. Conidi believes that neurologists are best trained and equipped to manage and address prolonged and complicated cases as well as the long-term sequela, such as dementia, ALS, Parkinson’s disease, and others that have been hypothesized to be associated with repetitive head traumas.

To better understand the role of neurology in modern sports medicine, a dose of history would be helpful. While neurology research may have impacted boxing many decades ago, the trajectory of sports medicine has trended in another direction since then. “Years ago, the American Academy of Neurology issued a position statement on the risk of repetitive head trauma associated with the sport of boxing, but since then sports medicine has taken over—physical therapy, orthopedics, neurosurgery, neuropsychology.” Recently, however, the tide has swung back in favor of neurology, thanks in part to the groundbreaking research on concussion at Boston University, where Dr. Conidi received his training.

Since that time, a media tidal wave has has engulfed the NFL and its actions regarding player safety on concussions. Dr. Conidi feels that the increased awareness that this coverage engendered has been beneficial to neurology, specifically in that the role of the specialty is gradually increasing within the field of sports medicine. But despite the newly invigorated presence of neurology in this arena, Dr. Conidi sums up the current state by invoking a common phrase usesd in sports: “We are late in the game.”

The impact of a movie like Concussion cannot be measured tangibly, but Dr. Conidi suggests that increased awareness in both the public sphere and in medicine, “can keep the issue at the forefront and potentially help generate research and funding opportunities.” Momentum is badly needed in concussion research, an area that Dr. Conidi says is grossly underfunded. “The field of concussion is so far behind any other neurological disease state,” he observes. “The NFL contributed $30 million to Harvard University for concussion research, but we really need close to $1 billion to really make headway and get to where we need to be.” In addition to the NFL’s contributions falling well below the needed total funds, Dr. Conidi believes research dollars are being misallocated. “The money should be unrestricted: it should either go to the National Institutes of Health or be used to set up a truly independent organization to investigation these issues.”

Economics, Training, and Education. Another reflection of the lack of progress in the concussion field is the confusing economic picture of research and practice, according to Dr. Conidi. “A majority of neurologists are not in academics and don’t have support, but we do have patients and access, whereas universities often do not,” he explains. The academic setting also comes with other responsibilities, such as teaching, which may account for why some physicians interested in treating concussion have moved out of academics and into private practice, Dr. Conidi observes. “I see 30 to 35-some patients per day, and a majority are for concussion,” he says. “We develop research protocols and learn how to treat these people through experience.”

Beyond the issue of private versus academic practice, complexities abound. For instance, within the specialty of neurology, a consensus has not been achieved regarding training and education on concussion. With more public awareness, a more consistent level of education will be needed to ensure that general neurologists can accommodate increasing demand. “As awareness gets higher, neurologists are going to be called on to see refractory patients, including those with chronic headache and memory problems.” In addition, once the NFL lawsuit regarding concussion is finally settled, Dr. Conidi notes that the baseline assessment program will entail neurologists to evaluate NFL players. “These players are going to be coming through neurology practices across the country, and we will be looking at possible dementia, Parkinson’s disease, ALS, and other conditions that appear to be linked to CTE.”

While a reliable framework for continued education has proven elusive, Dr. Conidi expects much progress to be made in the coming years, resulting in increased opportunities for education. “Sports concussion is a top priority of the AAN,” says Dr. Conidi. “There are a number of venues at the Annual Meeting, a sports concussion meeting in July, as well as various online Continuing Medical Education courses.” Dr. Conidi also suggests that annual concussion training courses to certify neurologists and other specialists are also being explored.

In the mean time, while the demand for further education is high, there is not a lot of real evidence regarding successful interventions beyond basic assessment for return to play. Dr. Conidi stresses that the clinical picture of concussion is ever evolving, which is why neurologists should maintain a strong focus when it comes to their own education. Ultimately, though, neurologists’ knowledge and experience in dealing with all manners of disease states will make the difference on understanding and managing concussion. “We need to draw on our skills when it comes to evaluating these patients because it’s what we do every day with patients with other disease states. Evaluating an NFL player may not be that different from an Alzheimer’s patient or an individual with post-traumatic headache,” says Dr. Conidi. “The basic understanding is there, so to properly manage concussion patients is not a far reach from what we are already doing.”

CTE: Clearing Misconceptions and Future Directions

One of the negative effects of a greater spotlight on concussion is increased public misperception, specifically regarding CTE. “The history of CTE goes back to the 1920s, with research continuing through the 50s, 60s, and 70s, when researchers tried to classify it as a clinical disorder,” Dr. Conidi explains. Then, Dr. Omalu’s research in the early 2000s on the brains of NFL players brought the issue back to the forefront. However, since the discovery of CTE in NFL players, the media has fostered the false perception that CTE is a clinical syndrome, which it is not. Table 1 offers an overview of the “history” of CTE.

“CTE is a pathological diagnosis—no clinical syndrome has ever been shown with prospective studies,” he says. “The only longitudinal testing that has been conducted has been post-mortem evaluations of the brain.” While a clinical syndrome has been proposed based on interviews with retired athletes who have donated their brains for study, Dr. Conidi points out that these surveys are not rooted in evidence-based science.

PRACTICAL POINTER

The knowledge and experience of neurologists in dealing with all manners of disease states will make the difference in understanding and managing concussion. Therefore, maintaining a strong focus on continued education regarding concussion is critically important.

Dr. Conidi has seen many NFL players and has observed that each individual represents a distinct clinical presentation; for example, some have memory loss but may not appear to exhibits symptoms of Parkinson’s disease. Dr. Conidi also points out that he has not witnessed a propensity of behavioral issues among the patients he has seen. “Behavioral issues can be affected by other variables, such as boredom, unemployment—there could be many potential alternative explanations.”

Researchers have much to learn about CTE and what causes it. “Nobody has shown cause and effect; nor do we know why some people get it and some people don’t,” Dr. Conidi explains. Many possibilities have been suggested—such as genetic predisposition—but each requires deeper inquiry. Additionally, he says, “There is some evidence older patients appear to have a much higher presence of amyloid, leading to questions of whether these patients may have a form of post-traumatic dementia, or more of an Alzheimer’s dementia, or possibility a separate entity altogether.”

Still, more questions surround the issue of neurocognitive symptoms. “We’re seeing that these athletes have traumatic brain injury, so that explains the number of neurocognitive symptoms, and we’ve correlated that with neuropsychological testing,” says Dr. Conidi.

Although there is no shortage of questions that need answering concerning the science of CTE, Dr. Conidi notes that two current tests—specifically a PET biomarker and a CSF biomarker for tau—give some sign that someday CTE may be diagnosed in the living. “Perhaps in 10 years we’ll have a better grasp on at least who will develop CTE, and then maybe we can make more definitive statements about clinical symptoms.”

Management Strategies and Future Research. To achieve best practices on concussion management, Dr. Conidi notes that neurologists and the medical community at large must first acknowledge what concussions really are. “A concussion is a brain injury. Nobody is ever the same after a concussion. They lose brain cells, and there is a good science to support that,” he says. Thus, one of the top clinical and research priorities going forward will be to build solid strategies for stopping the progression of concussions to prevent further injury. “In the future, management will start from the time of concussion, addressing the cascade of concussion causes a protease release that damages cells,” says Dr. Conidi. “With the initial protease activation, there is a whole cascade of issues that cause the abnormality to continue that eventually leads to CTE, so the goal of future research and best practices will be to target the abnormality at the time of the issue.”

EDUCATIONAL OPPORTUNITIES AT THE UPCOMING AAN MEETING

The upcoming Annual Meeting of the American Academy of Neurology in Vancouver offers a host of opportunities for physicians seeking continued education on concussion and CTE. Here is a snapshot of relevant sessions:

Sports Concussion Skills Workshop (registration required)

• Part I: Saturday, April 16—6:30am to 8:30am

• Part II: Saturday, April 16—3:30pm to 5:30pm

Sports Concussion and Other Mild Concussive Injuries

• Part I: Wednesday, April 20—1:00pm to 3:00pm

• Part II: Wednesday, April 20—3:30pm to 5:30pm

Sports-related Concussion: Vision and Vestibular Insights

• Thursday, April 21: 1:00pm to 5:30pm

For more information, visit www.aan.com

In terms of preventing further damage for individuals with multiple concussions, Dr. Conidi points out that further research into the disorder will lead to the development of medications. For example, some research points to lithium as a possible treatment for behavioral issues stemming from CTE, while there are several medicines already available for addressing emotional components, according to Dr. Conidi.

Beyond the realm of management, many studies are ongoing with the goal of understanding the long-term effects of concussion. Testing is also a major area of emphasis and industry support. “New types of baseline tests are being developed that may offer better or more validated results,” says Dr. Conidi. Additionally, biomarkers and neuroimaging remain central components in concussion research. “The Holy Grail in concussion research is a saliva test that could be used on the sideline that turns blue when a player has a concussion,” he says. A PET study and amyloid test also represent areas of promise that could be developed further over the next several years.

Catching Up to Do

As the spectrum of concussion research and care expands, physicians and researchers are rapidly uncovering new challenges. Nearly every new advance comes with the further realization that science and medicine have so far to go with respect to understanding, treating, and preventing concussion and CTE. “The challenge facing us all is global, especially for neurology,” says Dr. Conidi. While funding remains a challenge, particularly given the vast number of proposed studies that have yet to launch due to lack of support, Dr. Conidi is confident that increased interest may yield more support for research.

On the clinical front, Dr. Conidi points to new fellowship and the development of sub-specialty certification as signs of progress that may shape the future of concussion treatment.

Yet, a significant gap remains between goals and results, which is true of both research and practice. “We need more objective, longitudinal tests and biomarkers for concussion, and for that we need more funding,” says Dr. Conidi. With CTE and concussion now at the surface public thought, both financial support and clinical progress will gradually follow. In the interim, neurologists must be diligent in raising awareness and continuing their own educational efforts. Legislation has been proposed at state levels for mandating CME on concussion, but Dr. Conidi feels that those within the specialty should hold themselves responsible for keeping up the momentum that’s been building these past several years. “We don’t need legislation—we need to start it ourselves,” he says. “Neurology needs to take the lead. The programs are in place, we just need to keep at it.” n

Frank Conidi, DO is Director of the Florida Center for Headache and Sports Neurology, Assistant Professor of Neurology at Florida State University, Team Neurologist for the NHL’s Florida Panthers, and a founding member of the American Academy of Neurology’s sports neurology section.

SPOTLIGHT ON: NFL CONCUSSION PROTOCOLS

Is the league doing enough?

In recent years, the NFL has taken several steps to reduce head traumas in football, from changing the placement of kickoffs to penalizing helmet-to-helmet contact more harshly with increased penalties and player fines. But the most controversial modification the league has made to the game is the addition of in-game concussion protocols. As part of the protocols, “neurotrauma” specialists are standing by on the sideline at each game to assess any players exhibiting symptoms of concussion. However, according to Dr. Conidi, these specialists are not necessarily neurologists. “Sideline physicians are either emergency room doctors or neurosurgeons, but they should all be neurologists,” he notes. While players require clearance from a neurologist to return from a concussion, Dr. Conidi believes that the NFL needs to boost the presence and role of neurologists in all of their neurotrauma committees. “Neurosurgery dominates the NFL, but neurology tends to have a stronger role within the NFL Player’s Association.”

Additionally, Dr. Conidi believes that the NFL could be doing more in terms of both diagnostic testing as well as its protocols throughout the process to ensure that players are fully able to return to play. While there is always more the league can do, Dr. Conidi notes that it is moving in the right direction.

Where the issue becomes more complicated is in the economics, specifically regarding player motivations. “The players often don’t want to think about concussions while they are playing, because they feel it could be used against them when they’re playing in terms of their playing time and more broadly when it comes to contract negotiations,” says Dr. Conidi. “This is how they make their living. If a player was found to have early signs of CTE or dementia or ALS, that’s going to affect their ability to make a living, so they don’t want to know,” he says. “Players often play injured because they are feel they could lose their job if they don’t, so that’s the dynamic we have. There may not be much more that the league can do,” he says.

Changing the mentality and the culture is not easy and it may never happen. “Football is a violent sport. People know the risks going in and they choose to take those risks. They are trying to change the way they tackle and teach proper tackling techniques, while internally the league and the player’s association have agreed to reducing the amount of contact in practice at an early age,” he says. “Without killing the game or making it flag football, there probably isn’t a whole lot more that can be done.”

 

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Launched in January 2002, Practical Neurology strives to enhance quality of care and improve the daily operation of neurology practices. Each month, our experts explain the real-world significance of recent advances in neurologic science and offer step-by-step advice on how to overcome the clinical and business challenges neurologists face. Our straightforward, how-to articles give neurologists tools they can put into practice right away.

 
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