Role of the Neurologist in the Care of Athletes With Head Injuries

Abstract

Some American neurologists seem uncertain about their role in caring for head-injured athletes. My long neurologic career focusing on brain injury has taught me that neurologists have a unique clinical skill set and expertise that is invaluable to the medical care of patients with MTBI related to sports.

During a recent virtual meeting, a group of neurologists interested in sports neurology discussed the role of neurologists in treating head-injured athletes.¹ This set me to thinking about the issue. Based on my career experience of more than 40 years in treating patients and teaching young neurologists, I offer my opinions on what neurologists' strengths and roles are in treating athletes with MTBI. These opinions are my own and do not reflect those of any organization or institution. None of what I write is intended to denigrate or minimize the contributions of physicians of other specialties or other health care professionals who treat head-injured athletes. My goal is to point out the unique skill set that neurologists can bring to bear on the care and treatment of head-injured athletes.

Neurologists specialize in diagnosing, treating, and managing disorders of the brain and nervous system. We understand the clinical manifestations of brain dysfunction. We know what is normal and what is abnormal. We know how to take and interpret a comprehensive neurologic history and how to perform and interpret a comprehensive neurologic examination. In fact, our specialty is one of the last fields of medicine where clinical history and examination are still the foundation of all that we do. We are trained in the art of eliciting a thorough comprehensive neurologic history from the individual (including family members and other loved ones) sitting before us and just as importantly of listening, really listening to what they say. We are among the small group of physicians who continue to fully embrace Sir William Osler's call to: “Listen to your patient; he is telling you the diagnosis."² We are trained to use the results of clinical history and examination to formulate a differential diagnosis of the localization and etiology of a problem. We are trained to then order and evaluate the results of the appropriate ancillary testing necessary to further hone that differential diagnosis. We are trained, based on our diagnosis, to outline an appropriate course of therapy and then follow the clinical course and modify the therapy if necessary. We have the experience and training of caring for patients with a wide range of neurologic conditions, symptoms, and impairments; we stand ready to apply this knowledge to the continuing care that head-injured athletes require. The breadth and depth of our training and our clinical experience makes us uniquely qualified to treat head-injured athletes throughout their clinical course.

Neurology is known by physicians of all specialties as “the thinking man's/woman's specialty” for good reason. We are trained to approach the patient logically, coherently, and rationally and to “do what makes sense.” We pride ourselves on maintaining our composure under even the most trying of circumstances. By applying our time-honored clinical approach to every individual athlete presenting to us, we are uniquely situated to offer singular expertise in the care and management of these individuals. Sometimes, we will confirm the diagnosis that others have made. Sometimes, we will bring clarity to a heretofore muddled clinical picture. And sometimes, we will raise doubts and questions about what was previously believed to be a straightforward situation. In all these instances, our input will be of invaluable importance to the athlete and other health care professionals involved in their care.

All 50 US states legally require that student scholastic athletes who sustain a possible concussion be removed from play and not allowed to return to play until cleared by a “health-care provider.”³ These state laws differ regarding which health care providers can perform these evaluations and make the return to play decisions.³ We neurologists certainly possess the attributes necessary to play an integral role in this process and should make this well known to our fellow health care providers, local educators and parents, and legislators who make these rules. In addition, all the recent evidence-based and consensus guidelines regarding the evaluation of MTBI in athletes “assume or specifically recommend … completion of a thorough neurologic examination.”⁴ For example, the 2016 Berlin guideline states, “It is recommended that all athletes should have a clinical neurological assessment … as part of their overall management.”⁵ The AAN endorses the position that “the neurologic physical examination is a key part of the evaluation of a patient with concussion and is required in all clinical settings.”⁴ As a result of our training and experience, we neurologists are clearly the most qualified physicians to perform these services.

We do not need to replicate what other health care professionals do or compete with other specialties for access to these patients. We only need to continue to do what we are trained to do.

The specialty of neurology has come relatively late to the field of sports-related head trauma. Neurologists are confronted with a landscape where a myriad of other physician specialties (e.g., neurosurgery, orthopedics, sports medicine, ophthalmology, neuropathology, physiatry, psychiatry, epidemiology, and family medicine) and nonphysician specialties (e.g., neuropsychology, physical therapy, vestibular therapy, trainers, nurse practitioners, and nonphysician neuroscientists) have laid claim to the care of athletes with MTBI. In this environment, neurologists are confronted with the necessity of laying out the unique, special skill set and expertise that we can provide to the head-injured athlete. By doing what we do best, we can improve the care and treatment of these individuals and re-establish clinical neurology's critical role in the management of athletes who have sustained head trauma.

Appendix. Author

Study Funding

The authors report no targeted funding.

Disclosure

I. Casson has no financial relationships relevant to this article. Dr. Casson has no conflicts of interest. Dr. Casson was a member (1995–2009) and cochairman (2007–2009) of the NFL MTBI Committee. Over the course of his career, he has been the consulting neurologist for a number of professional and college sports teams. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.