Sports Neurology: Then and Now
Dr. Jeffrey Kutcher is an associate professor of neurology at the University of Michigan, and the director of Michigan NeuroSport which is the M.U. sports neurology program. But to tell the full story starts over eight years ago when he was only at the beginning of his fellowship and working with the athletes in the university clinic.
Shortly after he became faculty, one of his professors and mentors in the department, Dr. Jim Albers, was retiring. He had been the “go to” person that the university trainers in athletics would call with a patient they wanted him to see.
In that era (2000 -2001), the only reason an athletics department would call in a neurologist would be to support their decision to have an athlete retire. The neurologist didn’t want anyone with a potential for more severe injury to participate in any risky sports at all. Neurology at that time was very risk-adverse and extremely conservative.
Dr. Albers said to Kutcher, “You play sports and love athletics, and you’ve had concussions yourself. I’m going to give them your number so they can call you in now when they have these cases. But, they’ll only call you maybe twice a year.”
Kutcher accepted, but he was called the following week with a wrestler who had experienced his fifth concussion in a two year time frame. The team physician was recommending retirement. The athlete and his parents were fighting it. But, they wanted a full neurological opinion, so they sent him to Kutcher.
“Actually, the first thing I had to do was brush up on my knowledge of concussion. We never had to learn that for the board certification for residency. It just was not part of the system,” said Kutcher. “I found that there was not much data pertaining to concussion and neurological risk available. So, when faced with any evaluation of a condition that does not have a lot of supporting evidence, in neurology you fall back to comprehensive critical thinking and applying what my chair had taught me about how to evaluate a patient.”
After all the testing was done, Kutcher found no reason for the athlete to retire. He had no negative symptoms between his injuries. He had no sense that he was getting injured more frequently or easier between injuries.
“He had a history of migraine headaches which to my training said that he would be prone to injuries easier than someone who did not get migraine headaches, but the more I thought about it, then and even today, when you analyze a concussion you are diagnosing the brain’s ability to produce symptoms. That ability is different in everybody. That statement is not taken to heart enough. Because in essence, there are people who can be injured and produce not one single symptom or finding. Then there are others who can sustain the same injury and be out for two weeks.”
If that’s the case Kutcher thought, how do you make any reasonable conclusion or statement about things like concussions – three and you retire? Even the concept that one concussion leads to another: “All those are a complete assumptions. There is no research or confirming data. Nothing supports rules like that. This one case was what got me interested in finding the answers to neurological sports trauma and how to diagnose it. I saw a huge need. I went to the athletic board and told them. This particular patient had two more good years of wrestling. And it got me going down this path.”
Taking the reins, Kutcher approached the American Academy of Neurology and told them that the association should have a sports neurology section. He received a lukewarm response that basically was, “Why treat athletes different than anyone else?”
He told that board that their argument did not stand up because a athletes are experiencing different injuries in different scenarios and it is a wholly different practice of neurology. So, he began a sport neurology section at the clinic that was only himself and one other colleague. They had to see athletes at lunch time and after clinic time along with keeping up with normal clinical duties.
Suddenly everything changed in late 2008 when the first national level news stories started surfacing about the potential long term effects of playing sports, specifically NFL football. Then congress got involved and government started paying attention. That changed the whole conversation. Suddenly the Academy of Neurology was listening.
“As soon as they began understanding the scope of this area, they started supporting us and have been a fantastic partner in developing a sports neurology section and sport specific concussion conferences, trying to raise the level of neurologists’ involvement in sports, both in clinical care and in research. There has been a fantastic growth in that area,” said Kutcher.
Today, he helped set up a stand-alone conference in sports concussion July 2014 in Chicago. The National Neurology meeting had two solid days of educational programming just on sports neurology. The tide had changed significantly.
“You must realize that on the other side of the equation, trainers have been taking care of neurological injuries in athletes for decades. I have always felt that their experience is invaluable and we can’t underestimate the value of that experience,” Kutcher said, adding, “Neurologist train regarding injury and brain disease. You need to marry those two. That’s what my career has really been all about; bringing the world of neurology and the world of sports medicine together for the common purpose of increasing the neurological care of athletes at all levels. We founded the first sports neurology fellowship in the country. This is our third year in that area. I am happy to say there are others around the country coming on line with this. There is a swell of interest in this area.”
Brain Network Activity (BNA)
One of the things Kutcher has been teaching for years is concussion as a network injury. “When we talk of localizing things in the brain one of the first things we do is try to describe whether it is a focal process like a stroke, a multi-focal process like MS, or is it a diffused process; something that affects the neurons or blood vessels in the brain in a very general way. Concussion did not fit any of those. Brain function that controls memory, balance, eye function, mood, sleep patterns. The networks are very complicated. In concussion, we don’t see any focal or space occupying lesion or anything on routine imaging. But we see a fib logical state, a state of inefficient function. This creates inefficient networks.”
A good analogy is the difference between traffic on a Sunday morning and Monday at rush hour. The networks themselves are simply slow. There is no specific issue; a bridge didn’t fall down on the roadway. There wasn’t a massive traffic collision. The information can still get through, but it is just very, very slow. Now, the question then becomes, if a concussion caused the traffic to be slowed, will that make it late for work? At the end of the day, will there be a detrimental clinical result?
Also, the idea that other neurological diagnosis which have a strong network component to them, were producing different clinical syndromes in concussion came into play. Dr. Kutcher gave ADHD as a great example: “ADHD is basically a network dysfunction state. People with ADHD already have slow brain traffic, so it would take less trauma to produce an effect in them and longer to recover from that effect. We see this clinically all the time. The same with depression, sleep disorders, and other things.”
He reported that there were all types of computer tests, for things like eye movement and many other things that were not only completely being misused, but misrepresented themselves. “Companies were saying our test can diagnose concussion. It was marketing going overboard. Also, was and is, dangerous,” he said. “The FDA was being bombarded with certification requests for such devices to be cleared for concussion diagnosis, but they didn’t know anything about the area. So they decided to hold a workshop that I helped format and run. This was about three years ago in June.”
This workshop addressed what is the nature of the injury and what kind of evidence is needed to be able to say that any device can help diagnose concussion. At this conference Dr. Kutcher was approached by Uri Antman from ElMinda, with what he believed was a device that could do what Kutcher – and the FDA – were looking for.
The company was already applying their technology to people with ADHD and could produce a measurement that would clinically establish whether the person actually had ADHD or not. They were measuring brain network functions, which is exactly what Kutcher wanted to do.
“I studied the technology and saw it analyzed bulk capability, where someone was asked to do the same task over and over again while hooked up to EEG. This ran through ElMinda algorithms to produce a physical and temporal representation of the network it took to do that task. It is not measuring a clinical effect. It’s not measuring balance or eye movement or memory. It is not just an extension of a physical examination. It produced data that described an injury much like an MRI would describe an internal injury. It is actually producing direct evidence of the clinical effect,” said Kutcher.
It took several months of talking and getting comfortable with the technology to make sure it was a stable tool over time. A series of experiments was conducted and Kutcher also looked at whether the tool could demonstrate a change in a concussion situation vs. a non-concussed control subject. Then, through multiple sites along with his, all data was pooled to provide enough to satisfy the FDA. The tool was FDA cleared only in August 2014. Kutcher notes that is was not cleared for concussion because that requires a lot more work, but it is now cleared for monitoring brain networking activity.
“At the end of the day, this is only the first step in understanding this technology. What I want to know next is how does this look in people with depression? People who have ADHD and concussion? How does it perform in different scenarios? Right now it is an incredible step forward because it does give me a way to measure brain network activity accurately; the network function or traffic, if you will. But I still need to put all the pieces together in clinical trials to see if the results I am seeing are truly from concussion and not from something else,” he said.
“The brain is incredibly complex. This gives us a beginning tool that we didn’t have before and we need to do all the work involved to make sure it becomes as valuable as ultrasound as a common tool because while this tool is set up to be used to track concussion, it is actually able to track a whole range of conditions; early onset Alzheimer’s disease, Parkinson’s disease, Asperger’s, Depression – any brain function abnormality.”
But, Kutcher admits that much more work needs to be done before this BNA tool could be out in all doctors’ offices as a common diagnostic tool; “It needs to be studied in controlled situations first and eventually, I see different physicians branching out with this as a tool for a variety of very specific studies and conditions. One way to put it is that we have come to the end of the beginning. Now we are entering the next phase of accelerated discovery. It will be an ongoing process. The full potential of the tool will take at least ten years to establish. But along the way, we will start getting more experience with concussion, more experience with ADHD and other things. As it grows, we will see growing use of the tool, but for full acceptance on a wide scale, such as ultrasound, I say it is about 10 years away.”
Today, Kutcher has five faculty in the sports neurology clinic, seeing somewhere between 1,500 and 1,600 sports concussions a year. He is using the newly FDA approved BNA tool in his work and also in his continuing research and ongoing educational efforts.
Kutcher notes that as an example, he has medical students from other medical schools around the country asking to come just to spend time in the clinic. He has neurology residents from other institutions and even actually board certified neurology practitioners coming to spend time learning with him. “It is an honor being on the cutting edge of this aspect of neurology,” he concluded.