Neuro Athletes,

Good Morning, Good Afternoon or Good Evening, wherever you are in the world. This is a post about the absolutely insane, crushing and misguided protocols imposed on athletes by those governing bodies that deem to protect them (mainly FIFA and NFL). This email might be shocking to you at first but I assure you, once I prove my thesis, you will be just as outraged as I am. Let me start with some basics:

When it comes to an on field concussion there really is only three things we need to know:

1. You cannot properly assess a players neurologic status in three minutes

2. A concussion protocol should be an individualised approach, therefore a cookie cutter on-field diagnosis is not the way to go

3. If the concussion is overlooked it can have deleterious effects in the future

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What goes into these three categories?

Category 1 (diagnosis): This is easy. The number one thing medical officials will do when they run to the player who’s been concussed is checking if they’re awake and conscious. Then they’ll assess for things like the airway, breathing and circulation before even worrying about the neurologic status.

If the player can see two fingers and clearly state that he sees the number ‘2’ then he is cleared to go back on the field.

Category 2 (cookie cutter approach)

Grade 1, Mild: Symptoms that last less than 15 minutes and entail no loss of consciousness.

Grade 2, Moderate: Symptoms that last for longer than 15 minutes and involve no loss of consciousness.

Grade 3, Severe: The person loses consciousness.

Depending on where the concussion took place, all come with different consequences.

And knowing this, I have to ask, why are we treating every athlete the same and putting through a cookie cutter approach?

Category 3 (evaluation over points):

As seen with Patrick Mahomes of the Kansas City Chiefs who suffered a scary head injury and concussion, displaying posturing, the fencing response, and wobbling on the field. He was unable to get up by himself and therefore was taken off the field, this is clearly a concussion.

However, what we are seeing more of now is return to play if the player isn’t wobbling back and forth.

It seems we would rather get the player back on the field playing then caring for his long-term health. Timely identification of Sports-Related Concussion (SRC) is of critical importance to SRC management, to avoid adverse neurological implications. Appropriate SRC management ensures participants do not return to play (RTP) prematurely as this can lead to a secondary brain injury.

Parents, coaches and even athletes themselves need to know what a concussion is, and how to diagnose the signs and symptoms of a concussion. There’s 30 different types of knee injuries, why do we think there's one type of concussion?

Why Football Has to take Head Injuries Seriously

Do you remember the 2020 Euro’s? Let me take you back for a moment. It was the game where France vs. Germany and Benjamin Pavard collided with Robin Gosens' knee. The defender hit the ground without his arms protecting him from the fall and later admitted he was "a little knocked out for 10, 15 seconds".

Despite this, the player was allowed to continue after receiving on-pitch medical attention for less than three minutes. 

This scene was like a scene from a horror movie. Clearly, this is an example of football authorities failing to protect the short and long-term health of a player and focusing more on the game.

What We Overlook in the NFL

The posthumous brain examination of Phillip Adams, a 32-year-old retired journeyman N.F.L. player who shot and killed six people before dying by suicide in April, revealed that he had an “unusually severe” form of C.T.E., a degenerative brain disease found in athletes and others with a history of repeated hits to the head.

Dr. Ann McKee, director of the C.T.E. Center at Boston University, said an examination of Adams’s brain showed significantly dense lesions in both frontal lobes, an abnormally severe diagnosis for a person in his 30s that most nearly resembled that of Aaron Hernandez, a former New England Patriots tight end who was 27 years old when he died by suicide after being convicted of a 2013 murder.

New Research in Treatment of Concussion

1. “Metformin Reduces Repeat Mild Concussive Injury Pathophysiology” (link)

Who can resist the allure of a magic pill especially when it promises to age you slower?

Metformin does a lot of interesting things.

For example, it affects the 5′‐AMP-activated protein kinase (AMPK). This an enzyme that — what’s in a name? — plays an important part in the AMPK signaling pathway that regulates cellular energy homeostasis. This jumble of fancy words means that metformin stimulates fatty acid oxidation and glucose uptake to give our cells more energy. As we age, the activity of that pathway declines.

Metformin also increases the levels of glucagon-like peptide 1, a hormone that promotes satiety and, as a result, it tends to lower caloric intake.

I have been reviewing a study that was published on December 3rd, 2021 that shows the results of Metformin reducing concussion injury pathophysiology.

Interestingly, there are some hints that metformin might be protective against cognitive decline and — interestingly — depression. But not every study supports this observation. There is actually a study that finds a link between metformin use and an increased risk for cognitive decline.

Nutrition and Concussions. What is the best diet for athletes who are at risk for getting a concussion? (link)

I have referenced a wonderful article from 2020 many times that outlines how poor dietary intake would be expected to exacerbate the secondary damage in TBI. By impacting similar molecular pathways as TBI, a Western Diet can dramatically worsen post-injury outcomes by exacerbating neuroinflammation.

Several potential pathways appear to contribute to the increased vulnerability of the brain to traumatic injury in individuals on a Western Diet. These pathways include gut dysbiosis, epigenetic modulation, induction of inflammatory pathways, alteration of autophagic/oxidative flux, and alteration of the adipokine profile, and ultimately culminate in an augmented neuronal injury.

So Neuro Athletes, why am I writing this? Well, I have many NFL players who go through the Neuro Athletics program and my job is to protect and train their brain. Unfortunately, medicine and science is at the forefront of politics and policy, some of which I don’t fully understand and my hope here is to educate on the neuroscience of a concussion and what it means to a player (and their families).

I hope you enjoyed this, I will do my best to write a follow up on the pathophysiology of a concussion but if you enjoyed this, then you will want to check out my conversation with Dr. Stephanie Alessi-LaRosa, MD, a sports neurologist with the Hartford Healthcare Ayer Neuroscience Institute.

This episode not only lays the foundation to understanding the necessity of a sports neurologist but it also introduces to the various neurological conditions that athletes from all different sports posses.