By Vernon B. Williams, MD
Neurologists have historically participated in evaluation and management of injured athletes when the injury has affected the nervous system. Neurologists had been consulted in other instances to evaluate the function of nerves in conjunction with a primary musculoskeletal injury. But lately, Neurologists have played an even larger role in sports medicine, expanding from pure post-injury involvement into roles associated with injury prevention and peak athletic performance.
Sports Neurology is an emerging area of sub-specialty. It is proving to be extremely valuable on a number of levels. Sports Neurologists have primary training in expert evaluation and management of the nervous system. This includes expertise related to the brain, spinal cord, peripheral nerves, and neuro-muscular structures.
Increasingly, the role of the nervous system is being recognized as a critical aspect of athletic performance. Approaching sports medicine using a “Biomechanical paradigm” has yielded impressive results in developing a fund of knowledge concerned with athletic performance. Many of the principles and lessons learned have been translated beyond sports medicine to benefit larger segments of the population and society as a whole.
The same is occurring in Sports Neurology. An emerging and complimentary “Neurological paradigm” in sports medicine is yielding fascinating results. Appreciation of the importance of the brain and peripheral nervous system in sports is rapidly evolving. Reaction times are neurologic in nature and critical to peak performance. The science of sleep is being applied to athletic populations. Proprioceptive training after knee and shoulder injuries significantly improves stability, balance, and strength/power. The neurologic aspects of flow state or being “in the zone” relative to performance is being studied with electrodiagnostic and functional imaging techniques applied to the brain. Neuro-endocrine, and Neuro-myofascial sciences are evolving to further enhance and maximize peak performance.
The most obvious neurological injury in sport is concussion. Sports Concussion is a topic of increasing interest in medicine, the lay press, and at every level of athletic competition in recent years. Spinal cord injury is a potentially catastrophic athletic injury associated with high velocity and collision sports. Brachial plexus lesions (stingers and other neurovascular injuries related to stretch or compressive forces of the neck and shoulder girdle) are commonly encountered in contact sports as well as cycling (resulting from falls), and overhead/throwing sports. Peripheral nerve injuries (acute/traumatic as well as chronic/micro-traumatic) associated with high velocity extremity motion, repetitive motion, and biomechanical forces on neural structures from surrounding bones, tendons, and ligaments are well described and common neurological disorders related to sport. Skeletal muscle is at risk for contusion, hematoma, cramping, and may be a source of complaints and findings in athletes with metabolic myopathies. Every component of the neuromuscular system, central and peripheral, is subject to injury and symptom generation that rightly falls in the purview of the Sports Neurologist.
Neurologists are obviously well trained in the performance of a physical examination of the nervous system. The ability to collect accurate and meaningful information related to neurologic symptoms is another skill well developed through years of training specific to Neurologic diagnoses. In addition to these clinical skills, a number of diagnostic tools are available and commonly used by Sports Neurologists in evaluation and management of injuries as well as in consultation regarding maximizing performance. Electrodiagnostic tests (EMG/NCV, SSEP, EEG, QEEG, and Event Related Potentials) provide critical information regarding nervous system function. Diagnostic musculoskeletal ultrasound can be effectively utilized to identify soft tissue abnormalities including those involving peripheral nerves. Neural compression, neural edema, scarring/fibrosis, and other anatomic abnormalities can be appreciated under ultrasound guidance. The advantage of evaluating structures with dynamic movement of a joint or extremity under ultrasound, further increases diagnostic capabilities. In addition to the diagnostic advantages, the technology is inexpensive, does not involve exposure to radiation, and can add to patient education by allowing real-time visualization and explanation. Patient insight improves dramatically. Ultrasound-guided injections of peripheral nerves also have significant diagnostic and therapeutic value. Fluoroscopic guidance can enhance specificity of diagnostic and therapeutic injections as well as radiofrequency and other electrical procedures aimed at spinal and peripheral nerve neuromodulation. Other emerging diagnostic technologies such as fMRI, Diffusion Tensor Imaging, Brain Network Activation, and Transcranial Magnetic Stimulation are improving the Sports Neurologist’s ability to identify abnormal anatomy and/or function in cases where traditional examination and testing fall short.
Sports Neurology will continue to contribute greatly to evaluation and management of injuries and performance medicine. The developing fund of knowledge will improve the neurologic health and function across the lifespan, and will not be limited to athletic populations.
About the Author: Vernon B. Williams, MD is a Sports Neurologist and Pain Medicine Physician. He is the Founding Director, Center for Sports Neurology at the Kerlan-Jobe Orthopedic Clinic in Los Angeles, California, the Director of Pain Medicine at the Kerlan-Jobe Orthopedic Clinic, the Founding Director of the Sports Neurology Fellowship at the Kerlan-Jobe Center for Sports Neurology and the Chief Medical Officer of the Sports Concussion Institute. Dr. Williams serves as consultant to the Los Angeles Lakers, Los Angeles Dodgers, Los Angeles Kings, Los Angeles Sparks, Anaheim Ducks, Loyola University, Fullerton College, and numerous high schools. He completed his Pain Medicine Fellowship at Johns Hopkins. He is a frequent speaker on sports neurology, concussion, and pain. Dr. Williams is an experienced expert witness and independent medical examiner.