Neurologic disorders associated with behavioral symptoms
May. 10, 2023
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In this installment of our Featured Contributor series, we’re delighted to spotlight Francis X Conidi DO MS FAAN FAHS, Director of the Florida Center for Headache and Sports Neurology and MedLink Neurology author of Minor closed head injury. Dr. Conidi has spent much of his career working to develop the field of sports neurology and is a founding member and Vice Chair of the American Academy of Neurology (AAN) Sports Neurology Section and coauthor of the AAN’s position statement on concussion in sports. He is the team neurologist for the NHL’s Florida Panthers and has served as a consulting neurologist for the NFL, US Tennis Association, NCAA, and MLB players.
Tell us about your early background.
I am a first-generation Italian American (my father was from Italy) who grew up in Braintree, Massachusetts, a middle-class suburb 15 miles south of Boston that is rich in history (birthplace of presidents John Adams and John Quincy Adams as well as John Hancock and General S. Thayer, who founded West Point) and, for those of you who grew up, trained, or lived in the Boston area, the last stop on the T. It is also the hometown of Dr. Priscilla Chan, ie, Mark Zuckerberg's wife.
I attended public schools up until college. I was an average to slightly above-average student despite having ADHD. However, as my report cards always stated (my mother saved all of them) "seems distracted and never fully applies himself" and "appears bored." In fact, up until college, I cannot remember a time when I actually studied for a test. That was because my first love was sports. I wanted to be a professional hockey player up until my junior year in high school when the realization that unlike some of my teammates, NHL scouts were not looking at me (three of them actually made it to the NHL). In fact, I was involved in sports for as long as I can remember and started playing ice hockey at age 5 when our next-door neighbor and former Boston Bruins player Don McKenny suggested that I try the sport. Most of my life through high school and freshman year in college involved playing sports, ie, baseball in the spring, golf in the summer, football in the fall, and ice hockey and skiing in the winter (I was a pretty good ski racer as well). My parents said they had to keep me involved in sports to" help get rid of all the energy I had."
My grades and SAT scores were apparently good enough to get me into Boston University as a pre-med major. It was during the first semester of my freshman year that I essentially grew up and realized that I needed to buckle down and start to apply myself. This was the first time I was in an environment where academics were emphasized over sports. I actually did quite well in my first two years and was well on my way to med school.
Then early in the second semester of my Junior year tragedy struck. I came home one day and found my 56-year-old father, who prior to that was in excellent health, on the couch, he was breathing but unresponsive. He was rushed to a local hospital. It was also at this moment that I got my first exposure to the field of neurology. I'll never forget the on-call neurologist, Dr. Paul Blachman, coming in and speaking with my mother and me. He informed us that my father had suffered a significant brainstem stroke. It was not clear if he was going to survive. I also remember telling him I was studying to be a doctor and him taking me into the radiology room and showing me the evolving stroke on the MRI. My dad ended up surviving the stroke, however, was never the same. The next 4 months involved intense rehab at Spaulding Rehab Hospital in Boston. My mother did not drive, and I would get out of school, pick her up at work, and then drive her to the rehab hospital where we would spend the evening with my dad and get home around 10 pm. He eventually returned home, however, had a significant disability (turns out it was a top of the basilar stroke with thalamic involvement). He required 24-hour care, and we were fortunate to have home health for almost a year (cannot see that happening today), which allowed me to finish college. However having to work and take care of my dad significantly affected my grades, and med school was not in the cards.
I took a year off and worked the third shift at a local toxicology lab, which allowed me to take care of my dad during the day and my mom to continue to work. I was able to get into a newly developed Master’s program in medical science at Boston University School of Medicine, which promoted itself as a bridge year into medical school. After a bit of a transition getting back into academics, I did pretty well, however, did not have time to study for the MCATs, so I ended up spending another year doing research in neuropsychology at the Boston VA and studying for the MCATs and did well enough to get accepted to medical school at Southeastern University in Miami. At this point, my mother had stopped working, and my parents would come down and spend the winters with me. I also met my future wife Svea (who is from Berlin) during my junior year; I was actually working as a bartender on South Beach at the time.
After medical school, I returned to Boston and completed my internship at Tuft's St. Elizabeth's hospital where I was actually born and which was featured in the book "The House of God", and then my residency back at BU at Boston City Hospital and University Hospital. I also spent a few months at Mass General and Brigham and Women's Hospitals obtaining additional training in headache medicine.
What or who motivated you to pursue a clinical or scientific career? How did you get interested in neurology and your subspecialty?
I am really not sure who or what motivated me to pursue a career in medicine. I asked my mother, and she thought it was her. However, I think she just wanted to have a son who was a doctor. I was, however, always good in math and science, and they say people tend to gravitate to their strengths. Having a father who suffered a stroke at a young age got me interested in neurology. I can recall going over to the medical school campus as an undergrad and reading everything I could about brain structure and function and stroke.
Did you have any mentors who guided or inspired you?
First and foremost, my parents. They both worked full time from the time I was 2 years old, my dad for a local utility and my mom in the banking industry. They taught me early on the value of hard work. I had a paper route from when I was 8 until age 13 and then worked for Lord and Taylor till I was 22. After college, I worked in a toxicology lab, and during grad school and med school, I worked as a bartender. Even today, I still work 12-hour days seeing patients.
I would also say my father’s neurologist, Dr. Paul Blachman, inspired me through his caring and thoughtful approach to patients and their families. He never rushed a visit and always took the time to ask how I was doing, told me to keep pursuing my goal to be a neurologist, and gave me advice along the way. I try to incorporate his approach in dealing with my patients today.
Then during residency, there was our chairman, Dr. Robert Feldman, who actually knew me from the time I was 10 years old as one of my best friends was his next-door neighbor. He would actually tell stories about me when I was a little kid during grand rounds (Uggh). Dr. Feldman was one of the few people who recognized that I had ADHD, and I can recall sitting in his office during my first year and him telling me the following, "you are very bright, and I can see your potential to do great things in neurology, especially as a clinical neurologist, but you don't have a governor; you must learn how to play the game; don't always say what you think; you know your right, there are ways to prove your point and teach the other clinician; if you want to be successful, be affable and available." Affable and available are two words I live by today.
I was also fortunate to spend some time with some of the legends in the field of neurology. I spent a month on Raymond Adams’ service at MGH as a medical student. He was tough but fair; you could never get away with not being prepared during rounds, even as a med student. He taught me to always be prepared for the unexpected. Dr. Flavio Romanov, a neuropathologist who came up with Dr. Adams and was mentored by the legendary Denny Brown, was one of my mentors at BU during my residency. He loved to teach and was an amazing diagnostician, especially as it related to structure and function. Finally, during my internship year at St. Elizabeth's Medical Center, I was fortunate to spend time with Alan Ropper, who is a brilliant neurologist; there was not one subspecialty of neurology that he did not excel in. He was also an outstanding teacher and passionate about the field of neurology.
What do you consider your most significant career achievement to date?
Having one of my studies being roasted on SNL's weekend update!! Just kidding. It actually may be the job I turned down. I was a finalist for Chief Medical Officer of the NFL and withdrew my application as I felt I would be better able to make a difference in sports-related head trauma by continuing my research on head injuries in current and retired NFL players and continuing to treat athletes and other individuals with concussion and headache. The two studies I am most proud of are: the ongoing study on head trauma in NFL players and the 2016 study on football helmets published in Neurosurgery, which changed the way football helmets are tested and resulted in improvement in football helmets in protecting against brain injury.
How has the field of sports neurology evolved in the last 15 years?
The field of sports neurology has evolved significantly since we started the AAN Sports Neurology section about 15 years ago. I can recall sitting in an empty lecture hall at the AAN annual meeting with Jeff Kutcher, Tony Alessi, Vern Williams, Barry Jordan, Brian Haline, and Kevin Crutchfield in an attempt to outline a vision for the field. We were essentially working with a blank slate, which was unprecedented at the time as most subspecialties in neurology had been around for years. We initially were able to get a program approved for the following year (which was very well attended) and set up the structure of the section and mission of the section; Dr. Kutcher, Dr. Alessi, and I published a position statement on sports concussion, which was well received in the sports medicine community and gained media attention as well.
It was also around this time that concussions in the NFL started to gain widespread media attention with the release of the studies on CTE and subsequent concussion movie a few years later. Concussion had become the hottest topic in neurology; it was sexy, and everyone wanted to be a part of the concussion world, which had both good and bad ramifications. Membership in the section increased and is now above 600 members. Perhaps the biggest development was that neurologists started “gaining seats at the sports concussion table,” ie, appointments on amateur and professional committees on sports concussion management. Prior to this, sports concussion was managed by primary care sports medicine physicians, neurosurgeons, and PMR docs. More recently, we have seen neurologists continue to assume leadership roles, with Dr. Kutcher as head of NBA concussions, Dr. Haline as medical director of the NCAA, and many others on various NFL, NCAA, and state and local committees. The NHL and the soccer world could use more neurological involvement.
From an education and training perspective, we have seen the development of the AAN Sports Concussion conference and a number of fellowship programs. Perhaps, the biggest development throughout the years has been with respect to the research of sports concussion and head trauma in general. If one were to have conducted a Pub Med or related search in 2007, they would have found a handful of articles relating to sports concussion and sports neurology. Today that search would yield hundreds of articles from pathophysiology to management. It has slowed/plateaued a bit over the past could of years due to COVID, lack of funding, and the fact that a number of topics that were lacking research have now been addressed. With that said, sports neurology continues to evolve (be it at a much slower pace), and we are starting to see the next generation of sports neurologists assume a more active role. There are still issues with sports concussion management at the NFL level, ie, the Tua Tag fiasco, which itself opens an opportunity for sports neurologists to assume a greater role on the sidelines and in office management and clearance. The field also needs increased funding to develop evidenced-based return-to-play guidelines (they are still based on consensus opinion), biomarkers, imaging studies, and treatment, especially as it relates to posttraumatic headache, and there is still limited evidence for nonconcussion sports neurology topics, ie, peripheral nerve injuries, participation with underlying neurological disorders, and the effects of sport and exercise on chronic neurological conditions. I see a bright future for the field with continued ascension of neurologists into leadership roles in sports concussion and new fields, such as directly exploring the brain and its role in sports performance.
What has been your experience treating professional athletes?
They are some of the nicest and most down-to-earth people I have ever met. Many get a stigma of being stuck-up and self-centered, even prima donnas. As is the case with people in general, you have your occasional individual who has their issues; however, most will go out of their way to help you or other individuals in their community. For example, my mother recently had to have a cardiac procedure, and I was up in Boston to be with her before and after the procedure. I had a tele-visit with one of the players I was treating who actually lives in S. Florida. He asked me what I was doing in Boston, and I told him "I was here with my mom who is having a cardiac procedure." He actually texted me the day after and once a week for a couple of weeks after to ask how she was doing. This kind, good-natured attitude tends to resonate among all types of athletes.
When it comes to treating professional athletes, it's "a tale of two cities with a splash of Jekyll and Hyde." I see both active and retired players. Most of the visits are related to head trauma.
When a player is in the midst of their career and comes to see me, it is usually for clearance for return to play, and in rare cases, they are pondering early retirement due to head injuries. For those seeking clearance on return to play, their goal is to get back into the game asap. Some have concerns about the long-term effects, and I always make an effort to discuss the potential long-term effects and for them to "be your own trainer; if you feel you have suffered a head trauma, take yourself out… The same goes for your teammates, you are a second set of eyes on the field and on the ice." The one thing I never do is preach; I tell them that it is their decision to play, and my job is to give them as much information as possible to make informed decisions on their health and future well-being. However, many want to forego or wait on advanced diagnostic testing as they are concerned that it could result in their current team using it against them, ie, as a potential cut or voiding of a current contract.
The retired players have a much different attitude. Many fear they have or are at risk for CTE (see below as to that misconception) and are really looking for help with a multitude of neurological issues. They can include cognitive issues, chronic headaches or other forms of chronic pain (or both), or sleep issues, and many have significant psychological issues, especially depression and psychosocial issues. As one player who actually modifies high-end vehicles said, "I want the Bentley workup," and that is what we attempt to give them. Many players will fly in and spend 4 or 5 days with us, and depending on their insurance the workup includes: conventional and DTI MRI brain imaging (the latter is compared to one of the largest normative databases in the country and is one of the most sensitive tests for detecting TBI), FDG and beta-amyloid PET imaging (with tau imaging to come in the next year under a research protocol), along with neuropsychological testing and mental and occupational health evaluation. The other thing we do is start to treat their medical problems, and, surprisingly, most have limited to no access or guidance to continued care once their playing days are over. In addition, and with the help of telemedicine, we can continue to follow the players while we transition them to neurologists and sports neurologists in their area, a kind of spoke-and-wheel approach.
Finally, there are differences based on the sport played, the nature of the sport, and the player’s background. NFL players tend to be more unprepared for life after professional sports. A major contributing factor is the business of the NFL. Unlike a number of other sports, NFL players rarely have a chance to leave the game on their own terms. I cannot say how many times a player, with memory issues, has been able to tell me in detail about the day they were cut, ie, where they were, the time, who called them, and what was said. This creates significant animosity towards the league. All of the above factors, in addition to the chronic pain that many suffer from, can create issues including depression and anxiety. In fact when it comes to the NFL, where the average career is only just over 3 years, many have only the money from their rookie contracts, which is not going to sustain them for very long. Conversely an NHL or MLB player or other professional athlete has a much longer career, they usually go out on their own terms, and you don't see the negative views about their former employers.
What is your opinion of the NFL retired players’ settlement?
First a needed disclosure. I am the retained expert on the players who opted out of the settlement. Given the above and my work with professional athletes, I was not considered to be involved in evaluating players for the lawsuit. However, our practice did employ two neurologists as subcontractors who were BAP and MAF doctors. It appears that both were removed by the claims administrator after it was found out they were referring the players to my ongoing research study on TBI in NFL players.
The settlement is wrought with issues. It starts with the name itself. The term “Concussion Lawsuit” is misleading. A concussion is a transient process that by all definitions and research does not result in permanent impairment. This is really a traumatic brain injury lawsuit. Unfortunately, the NFL refuses to formally acknowledge that its sport can result in permanent brain injury.
Many of the retired players will not receive a true medical diagnosis, and no organized follow-up and treatments are currently being offered. This is more ethical than legal. Neurologists have an obligation to their patients to make the most accurate and specific diagnosis possible and to treat or refer the patient for proper treatment whenever possible. A good portion of the diagnoses outlined in the settlement are fictional in nature (ie, Level 1, Level 1.5, Level 2 neurocognitive impairment) leaving the player confused about the cause of their symptoms. The fact is many players likely have traumatic brain injury.
The evaluation process does not follow standard of care for the diagnosis of dementia in the young. A majority of the retired players are under 65 and, therefore, would be classified as early dementia. Recommendations from numerous organizations outline standard workup for the diagnosis of dementia and other causes of neurocognitive impairment. This workup should include basic neuroimaging to screen for MID, VAD, NPH, and TBI to name a few, and routine blood work for possible reversible causes of dementia, ie, B12 and vitamin D deficiency, hypothyroidism, and in some cases, neurosyphilis. In addition, FDG PET has been available for a number of years and is quite useful in distinguishing between dementia and TBI. The latter of which is the most likely etiology of the patient’s symptoms given my research and others on retired NFL players. Finally, beta-amyloid PET has the ability to rule out the diagnosis of Alzheimer disease and would be extremely helpful to the neurologist in these cases. Although some would argue the technology should still be used for research purposes, it is showing promise and being widely used in older patients through the CMS-sponsored IDEAS trial.
Up until last year, the neuropsychological testing was using racial bias. The settlement was applying a binary standard--known as "race norming." It assumes the average black player has a lower level of baseline cognitive functioning than the average white player and adjusts their cognitive test scores accordingly. As a result of the race norming methodology, black players were required to demonstrate greater levels of cognitive decline in order to be eligible for a payout.
The potential for malpractice lawsuits for “failure to diagnose Alzheimer disease” (MAF and BAP physicians) and “failure to diagnose Parkinson disease and ALS (BAP physicians). In reviewing the WHO and DSM-5 criteria as well as guidelines from the AAN, National Institute of Neurological and Communicative Disorders and Stroke (NINCDS), and the Alzheimer’s Disease and Related Disorders Association (ADRDA) and current consensus statements, it is clear that all call for Alzheimer disease to be diagnosed early. And then applying the above to the criteria outlined in the concussion lawsuit, any player receiving a Level 1, Level 1.5, or Level 2 could easily be classified as having any of the various stages of Alzheimer disease. More specifically, possible, and in most cases probable, Alzheimer disease would apply to every individual. Given the difference in awards for the various diagnoses, one could easily see how malpractice attorneys would be interested in pursuing a failure-to-diagnose suit. There was an apparent reason for the requirement of 1 million and 3 million malpractice coverage!!
Reimbursement for the BAP exams is not fair and reasonable and does not properly reimburse for the scope of work, level of expertise, legal requirements, and assumed risk required for evaluation of the players. The neurologist is paid between $300 and $500 for what is in essence a complex IME with extensive record review. In Florida, the average reimbursement for such an evaluation is $1,500.00 and up. In addition, the neurologist is required to make the final diagnosis (the neuropsychologist can only act as a consultant) and assumes all of the risk in the player’s diagnosis. Yet the neuropsychologist is paid five times the amount of the neurologist.
In addition to the above, in order for a neurologist to be accepted as a diagnosing physician, he or she cannot be a physician who is considered to be a thought leader in the field of sports concussion or have extensive experience as a plaintiff expert witness--or have worked with professional athletes in the past or acted as a consultant in the lawsuit. As the program unfolded, a number of excellent neurologists were removed from the program based on their award diagnosis rate, ie, those with a higher rate of level 1.5 or higher diagnosis. In addition, the claims administrator has attempted to disqualify a good number of the MAF physicians who are chosen by the players and their representatives.
You practice in South Florida, and one of the biggest headlines during the past NFL season was the Tua Tagovailoa situation, ie, multiple concussions. In fact, concussions were significantly up this year. Do you think the NFL is doing enough to protect its players against concussion and potential long-term effects of head trauma including CTE? Do you think that Tua Tagovailoa should continue to play football?
I tell anyone who will listen, especially young athletes, that football is a collision and not a contact sport. As a result, there are inherent risks to playing, including death and TBI. There is eventually going to be a limit as to how much the scientific community can do to protect players against injury. The NFL has actually made strides in improving safety when it comes to brain injuries (unlike the NHL, which has chosen to deny the problem or even acknowledge it exists). However, more can certainly be done, and Tua Tagovailoa suffering multiple concussions in a season has again brought the issue out into the open, which is a good thing. The NFL Players Association and the NFL added the criteria of postural instability as a condition for immediate removal from play. However, one of the major issues with Tua was that he was cleared to return to play (RTP) by the head team physician who is an orthopedic surgeon (whom I have worked with in the past, ie, Florida Panthers). A simple solution is that all players see an independent sports neurologist prior to final RTP. In stating the obvious, a neurologist is going be much more likely to pick up subtle findings, ie, postural or eye movement on the neurological examination. The other issue is that the sideline “neurotrauma specialist” does not need to be a neurologist or neurosurgeon. Again, having a specialist evaluate a player in the specialty that the injury falls under is going to provide the highest level of care. I am hopeful that the NFLPA and the NFL Head and Neck workgroup will get together in the spring and address these issues further. I would also recommend Tua come to our facility (which is in S. Florida) and get evaluated to see if he may already have TBI; there are also blood biomarkers, ie, APO-E promoter that we could check to see if he is more susceptible to concussion, permanent injury, and a longer recovery time.
As far as CTE is concerned, this is the classic case of putting the cart before the horse. At this time, CTE remains a pathological diagnosis. It is a tauopathy, and one can safely say that the pathological presentation and neurodegenerative mechanism are different from Alzheimer disease. Furthermore, until longitudinal and genetic studies are complete, we cannot define specific symptoms, etiology, risk, or prognosis, despite what has been put out by the consensus CTE workgroup. Unfortunately, and as is often the case, the media has perpetuated the notion that anyone who has multiple head traumas and has cognitive issues has CTE (ie, a progressive neurodegenerative condition) and is doomed to die a death that includes progressive dementia and behavioral issues. It has become such a commonly used term that the NFL players who come in all think they have it. It has been long known that a small portion (ie, between 10% and 30%, and the studies are not good) of individuals with TBI will go on to develop earlier dementia, and there appears to be a genetic predisposition--this is likely what CTE is. However, most will stay the same, and some will get better. Individuals with TBI suffer from cognitive issues as one of their three major symptoms; headache and vestibular issues are the other two. These individuals also experience behavioral issues likely due to frontal lobe involvement. All of the above symptoms have been hypothesized to occur in CTE. Furthermore, our research has shown that approximately 60% to 70% of retired high-impact sports players that we see (most are NFL) have radiological evidence of TBI and correlative neuropsychological testing. However, this population, like the population who has been shown to have pathological evidence of CTE, is skewed as they have generally sought out evaluation or were having symptoms prior to death, and their representatives sent their brains for analysis. It is not a random sampling, which is really what needs to be done. With that, we (ie, the medical community and the media) need to stop using the term CTE for any individual who has cognitive and other issues after playing high-impact sports. A better term would be traumatic brain injury or just plain brain injury.