When the Philadelphia Eagles face off against the Kansas City Chiefs in Super Bowl LVII this Sunday, players and coaches won’t be the only people on the sidelines. Neurotrauma consultants will also be there, keeping a watchful eye on the game and being ready to move when any player appears to be injured.
When that happens, these experts—including neurologists and physicians certified in emergency medicine and sports medicine— must make important health care decisions fast. “You can't sit there for an hour mulling over how to localize things [identify a region of the brain affected by injury or a lesion]; you have to be able to get information quickly that can be used to make a decision,” Anthony Alessi, MD, FAAN, associate clinical professor of neurology and orthopedics and director of the University of Connecticut NeuroSport Program, told Neurology Today, the official news source of the American Academy of Neurology.
Three unaffiliated neurotrauma consultants attend every NFL game—two are on the sidelines and one is in a booth above the field—as part of an agreement between the NFL and the NFL Players Association (NFLPA). The NFLPA and the NFL's Head, Neck, and Spine Committee select the consultants, who work with team physicians to identify, screen for, and diagnose concussions.
“We're not hanging in the background, not looking at our phones, not having side conversations,” Stephanie Alessi-LaRosa, MD, director of the sports neurology program at the Hartford HealthCare Ayer Neuroscience Institute in Connecticut, explained to Neurology Today. “We have to be focused because our observations are the first exam.”
Sports neurologists and certified athletic trainer spotters watch every play. The spotters have a private booth above the field to monitor the game for potential head or neck injuries and can call a medical timeout if they believe a player on the field may have a concussion or other head injury, according to the NFL. The neurologists look for signs such as abnormal eye movements, stumbling, and disorientation. Both the consultants and the spotters use the Injury Video Review System, developed specifically to review on-field injuries.
The system gives medical experts access to every camera angle in the stadium, which allows them to review plays from multiple vantage points. The consultants and team physicians are required to review video as part of their evaluations of a potential player injury.
If a player is hit on the head but doesn’t appear to have a concussion, medical staff will evaluate him on the sideline, according to the NFLPA. He can re-enter the game if he continues to show no concussion symptoms. If, however, he displays at least one of the four “no-go” symptoms of concussion after being hit on the head—loss of consciousness, ataxia (poor muscle control that causes clumsy movements), confusion, and/or amnesia—he cannot return to the game, the NFLPA says. He then undergoes further evaluation in the locker room.
The consultants sometimes must withstand on-field pressures when making their decisions about whether players can return to the game. “They can't be influenced by the coach or the athlete who's wanting to get back out and play,” Dr. Alessi-LaRosa says. “They have to have authority and confidence in their decisions and be ready to say, ‘I'm going to take your helmet and what I say is the final word,’ because the players need someone objective who can do what is safest.”
Concern for how concussion and repetitive head injuries affect football players’ health rose over the last two decades, in part because of the work of Bennet Omalu, MD, MBA, MPH, a Nigerian-born forensic pathologist and neuropathologist. When examining the brain of the late Mike Webster, a former Pittsburgh Steelers player, Dr. Omalu noticed abnormal, tangled accumulations of a protein called tau that had damaged many brain cells, which he called chronic traumatic encephalopathy (CTE), a term introduced by MacDonald Critchley, MD, a British neurologist, in 1949. Dr. Omalu’s research and that of other scientists suggested a link between CTE and repetitive head injuries with symptoms such as mood and behavioral changes, short-term memory loss, and confusion.
The NFL initially dismissed these findings—the drama between Dr. Omalu and the league was adapted into the 2015 film Concussion, starring Will Smith—but it now takes a more proactive approach to protecting players’ brains. In 2011, the league set new standards for caring for players with concussion symptoms. At the start of the 2014-2015 season, the NFL added the unaffiliated neurotrauma consultants to the sidelines. This season, the NFL and NFLPA added ataxia as one of the mandatory “no-go” symptoms that prevents injured players from returning to the game.
