Dr Gregory W Stewart On Tua Tagovailoas Head Injury The Evolution Of The Concussion Protocol And How

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If you tell me all the healthcare professionals on the sidelines and no one saw Tua get up and shake his head and stumble, I'm not going to believe it.

What's up you guys? I'm Rachel DeVita and welcome to the Courtside Club.

Today we have a special episode for you.

As you've likely seen, headlines across sports media this week have been highlighting the very scary injury of Miami Dolphins quarterback Tua Tungavailoa,

enforcing discussion around the NFL's current concussion protocols, who was to blame for allowing Tua to play on Thursday night,

and how do teams and the league do better to keep their players safe?

So today, Dr. Gregory Stewart is joining us to help us look deeper into these topics and give us the insight from a medical professional who specializes in sports.

Dr. Stewart is Chief of the Section of Physical Medicine and Rehabilitation and the W. Kennan McWilliams Professor in Sports Medicine at Tulane University in Louisiana.

So Dr. Stewart, welcome to the Courtside Club. Thank you so much for joining us.

Thank you for having me.

So before we dive into this topic, I know that you've been reading the headlines.

You've been keeping up on the news. You're a big sports fan yourself.

You work with the football team at Tulane.

But could you give us a little bit of background?

Give our Courtside Club viewers just your background and what you do specialize in.

So my specialty is physical medicine and rehabilitation and have done sports-related concussion for 30-plus years.

I have taken care of Tulane athletes for 35, 36 years.

Concussion management has changed during that time.

And then...

I also take care of a number of former professional athletes as well.

So kind of that perspective of both sides.

And then here at Tulane, we also have started a brain bank to be able to look a little more in detail at these very topics.

Oh, amazing.

So obviously, the hot topic of the NFL lately is what's been happening with TUA.

I want to take it back to...

Sunday night.

Because a lot of people are going back to the hit that he took on Sunday.

And why was he allowed to be back in the game and play then?

And then obviously, we saw what happened on Thursday.

But what was your initial reaction when you saw the playback of what happened on Sunday?

When you first see that Sunday play and he gets up, kind of grabs his helmet, shakes his head, stumbles a little bit,

from just standing...

sideline or watching it on TV, certainly at that time felt like that it was a concussion,

that this was his head. I'm not an NFL physician, not on the sidelines, but at least what you saw

was that Miami indicated that he was going in to be evaluated for his head.

We're going to fast forward now to Thursday. And you were actually, you said, in Houston

with the Tulane football team on Thursday, and you were getting text messages like,

did you see what just happened? And obviously from an outsider who doesn't know the intricacies

of what happens during a concussion, but when you see somebody fall and you see their arms kind of

lock up the way that they did, I think everybody viewing can see, oh, this was serious. So from

what you saw then, how could you take what happened Sunday? Does it correlate to what

happened Thursday?

In your opinion, or was this just a harder hit?

First off, when you see what happened on Thursday night and the hands, that's called posturing.

And so at that point, you know that this is brain that you're dealing with on Thursday.

And you can see being in the position that they were probably in, in the locker room on Sunday.

Does it correlate to what happens on Thursday?

Well, it's really important to be able to tell if a person is able to take a successful

decision during the day or might be able to retake a concrete decision during the day.

But always keeping in mind that the focus is really還是 affected.

So actually if now there was anything that happened that was considered Mendel's most

effective, I feel like immediately and that has really left a real feeling of, oh wow,

this is going to work out.

When you're fighting your opponents, how you're thinking about your offense procedurally,

things that make you believe you're going to win over them.

No, I think if that happened.

it's not my head. We go into the locker room, you've got the athletic trainer, you've got the

team physician, and at the NFL level, you have the UNC, the unaffiliated neurotrauma consultant,

who's going to be in the room as well, just watching what's going on. So my guess is you

go through the protocol, and there's a whole host of things that you do, all the way from a symptom

checklist to balance and memory and a whole bunch of different things that you go through.

And he tests out, well, his balance is everything else tests very similar to his baseline. And at

that point, the team folks probably look at each other and go, gosh, you know, it certainly looked

like it was his head out on the field. He's been fine since he came off the sideline. He's tested

normal.

He's back to his baseline. What do we do? And so you kind of are in a spot where the player is

saying, that's not my head. You test and you do everything, and everything's normal. So you're

kind of in a hard spot to come out and say, well, you know, he says it's his back, his tests are all

normal, and I'm not going to let him back in. Now, that's what probably is going to happen.

That's what probably should have happened watching the video. But that's also then the role of the

UNC, the unaffiliated neurotrauma consultant, to then step in and potentially say, yeah, you know

what? I saw the video. I hear what y'all are saying. I don't think he should go back in because

the video certainly looked like it was his head. And Tua had a breakout game on Thursday, not had

an injury.

We'd not go back and talk about Sunday anymore either. I mean, we wouldn't be here having this

conversation. The Thursday injury is a significant injury, even if Sunday doesn't happen. I mean,

he gets whipped around, slammed to the ground, and his head hits the ground. Probably would have

caused that same injury even had Sunday not happened, or if we go and find out that Sunday

really was his back.

I have multiple questions.

Yes.

You talk about the test. That has been something that a lot of former NFL players who are now in

the media have come out and talked about. We know what the baseline needs to be, that even if we

have a concussion, we can test lower than it needs to be so that we can still get out there and play.

And myself, being a lifelong athlete, I understand that when you're in the heat of the moment,

the last thing you want to do is come out of the game no matter what.

And so, is it a test that is easy to pass, or if you understand it, you can get through it just

enough to, I guess, fool your doctors into letting you back out there?

Well, so let's start with, let's go back to Alex Smith. When he was with the 49ers and had his

concussion, and he came out and said, I'm not ready to go back, look what happened to him.

So, it's next man up. So, he ends up not playing the next game,

ended up getting replaced and getting cut. So, these guys all understand that, that this is

a business at the NFL level. And so, it's next man up. So, given that understanding and that

this is their livelihood, and this is what they want to do, they want to play football. That's

their job. They enjoy it. That's what they want to do. So, having said all of that, yes, the testing

that we do now, we're going to be able to do it. We're going to be able to do it. We're going to be

able to do it. We're going to be able to do it. We're going to be able to do it. We're going to

be able to do it. We're going to be able to do it. We're going to be able to do it. We're

not completely subjective, but we don't have any good, absolute testing for concussion.

You know, I tell people, you know, we're no longer in the infancy of concussion management

and understanding it, but we're still at the toddler stage. I mean, there's still a lot we

do not understand. And we don't have really good tests. So, we do the best we can, even in the

world of traumatic brain injury. So, we do the best we can. And we do the best we can,

concussion is on the mild end of mild traumatic brain injury. And even that has its own range

of what's going on. So, and if you've seen and treated one concussion, you've seen and treated

one concussion. It's not like an ACL where, okay, you see an ACL, you know what's going on. All

right. It's Sunday. You tear your ACL. We're doing x-rays and MRI tomorrow morning.

Oh, we're waiting this period of time to do the surgery. This is the kind of surgery that's done.

That's not how this is. Some people are going to have light sensitivity. Some people are going to

have headaches. Some people are going to have dizziness. Some people are going to have eye

problems as far as tracking and not every person has the same symptoms. So it's really all based

on the exam, the honesty of the athlete and trying to

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call or text 1-800-522-4700. How careful do you have to be with diagnosing it kind of on a scale

and letting somebody get back in with the risk of another head injury happening?

Great questions. And I guess the real answer at the beginning is going to be,

we don't know. And that's just the honest answer, is that those are the things we're

still trying to understand and figure out. We know that different areas of the brain

are affected at different times. So the memory portion, some of the headache portion,

and things like that is a different area of the brain than when you actually get knocked out.

So you don't have to be knocked out to have had a concussion. And that's important to know about

this as well. You know, one of the things that we think that's kind of the last thing to leave

in a concussion is that exertional headache. So you have the headache, you go out and you

start practicing, or you go out and you start reading or doing something like that, and the

headache starts getting worse, then those are the symptoms that we know, okay, you're not

ready to go back and do anything. Why do some people have prolonged symptoms and others don't?

Why do some people develop CTE and others clearly not? Why do some people who have some of the

changes that we see in the brain with CTE end up with symptoms and other people with similar

changes don't have symptoms? And that's some of the stuff that we're really studying and trying

to understand. I mean, I think there's a strong genetic component that we don't understand.

You know, you hear out in the media that, oh, you know, you hit your head, you're going to develop

CTE. And then the conventional thought is, oh, if you have CTE, you're going to go crazy and

kill yourself. Well, if that's the case, we should have an epidemic of former high school football

players committing suicide. And we don't. So there's something that we don't understand.

There's something else going on. And we don't understand what that something else is.

We're just not there yet. And I think that's where, you know, a lot of the study goes,

a lot of the understanding of concussion goes as well. That's so interesting, because obviously,

from a fan perspective, or somebody who's just listening to the media, you hear when any NFL

player or former NFL player acts out or gets into trouble, or you see kind of this personality

change, and you're like, oh, I'm going to die. And then you hear, oh, I'm going to die. And then you

change. Everybody's screaming CTE. And everybody knows that that's very serious and bad, but we

don't know much else about it. So it's interesting that you talk about you as a doctor and people in

your field are also still trying to understand what CTE means, how some players get it and others

don't. I think somebody who's been in the news the most, obviously, is Antonio Brown, because we've

seen a character arc of his.

That is confusing for some. When you see him in the media and see what he's been getting into

lately, do you see that as being a cut and dry CTE case?

No, no, absolutely not. And one of the interesting things is that we see a number of former

professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

former professional football players. And as we go through early on in that program, we see a number of

concussion. And what we found is that this is transition in mental health. You have these guys

who are paid to run in and hit someone, get up, 15, 30 seconds later, do it all over again.

And they go and they hit someone. And if they're disrespected during the week or someone gives

them a hard time or something like that, they've got practice and they've got the game that's

coming up to be able to take out some of these emotions that they have. And now all of a sudden,

they're out. They're no longer playing the game. They have, you know, generally, you know,

you don't leave the NFL. The NFL leaves you. So most of these people don't retire on their own.

They just are cut and they don't make a team. And now they're having to transition

into...

To a world that they really haven't prepared for because they've been playing football since

high school. So now they have to figure out how to do these things. So their whole world

changes in a moment often. They've got a life. They've got a family. They have everything else.

So all of that comes into play with how they react. And these guys have potentially had

problems before they got into football. So, you know, you've got your childhood,

experiences that you're bringing in. So we're all unique individuals. And I don't think that

you can go and say, oh, someone's acting up. They said something ugly. They got mad. Oh,

it's because they hit their head all the time. It could be. But I don't think you can jump to

that conclusion as an automatic. So how do we decipher between it being,

you know, something that has to do with mental health or past experiences?

I guess, again, the reality is we don't know. But what we do know about CTE is that this is

generally something that occurs more distant to football. You know, this is more than, you know,

oh, I played high school, college, five years professionally. I've been fine. I stopped.

Three months later, I'm acting out. Probably not CTE that's that's causing the problems.

You know, if this is someone who 20 years ago, 25 years ago and now really starting to have some problems.

OK, then let's start talking about that. The in-between part, we don't know.

And don't hear me be a CTE denier either. A hundred percent. Believe it. Seen it.

You know, we have a brain bank here at Tulane. We've we've we've seen this in individuals,

but we've had individuals who have had significant memory problems,

significant other changes, have passed away, have honored us with the donation of their their brain.

And they've had Alzheimer's. You know that the the the changes that we've seen in the brain were not CTE like they were Alzheimer's.

Like and it's a very different pattern from from what we see.

So, you know, I think from our standpoint, when we're seeing former players, we meet them where they are.

So let's figure out what's going on. You know, is this some cognitive decline?

Is this mental health? Is this, you know, transition issues?

And let's treat what we see in one of the programs we have is we've looked there's an increased incidence.

Of high blood pressure, prediabetes and diabetes, elevated cholesterol, sleep problems in former professional athletes.

So they have separate risk factors for cognitive decline that you have to treat and you have to make them aware of.

So they don't just sit back and say, oh, I played football. I hit my head.

You know, we've had guys that have come through who feel like,

oh, I'm having whatever problems, so I may as well kill myself now because I know eventually I'm going to kill myself.

And it's like, no, no, no, no, no, no. Wait, wait a minute.

Let's sit back and let's talk about what's going on.

And you find out that they have low testosterone, they have depression,

they have something that's not football related, that they have post-traumatic stress from.

And it's like, why don't we start taking care of some of these things?

Things that we can manage and then let's see where you are.

And you start managing those things and all of a sudden they're better.

And so it's very multifactorial.

And I think to say playing football causes CTE, therefore you're going to have all sorts of psychiatric problems and commit suicide is a huge disservice to this population.

Wow.

It's so interesting because that's that just goes against kind of what we hear.

You know what I mean?

So it's a very complicated issue and you've really got to take a very holistic approach to look at these guys,

because if you just say it's their brain or you just say it's their low back or you just say it's whatever, you miss the picture.

And you really have to to dive deep into medical and orthopedic and neurologic and mental health.

And there's.

Spiritual health and everything altogether.

And what you're saying, we should take a step back and holistically look at the picture.

Is there anything I would say just to tie it up with the concussion protocol that could be better, or is this just going to take more time in research from a medical perspective?

I think some of this is a learning experience.

I mean, you go back and you look in the media, you know that the players association, the league are happy to point fingers at each other.

And and barbs at each other.

And they're not, which says that this is a very important topic that they really want to get to the bottom line on and that they're working together behind the scenes to try and figure this out and understand what's going on.

And, you know, we said at the beginning, we're still in the toddler stage of concussion management, so we don't know a lot about what's going on.

When I started 30 years ago, the way we.

Managed to.

Manage to.

Manage to.

Manage to.

Manage to.

Manage concussion was with an ammonia capsule under their nose.

They'd wake up and you go, are you good?

And they say, yeah, I'm good.

And you say, OK, get back in.

And people didn't even come out of play.

And that was the standard of care 30, 40 years ago.

I mean, it was a badge of honor at that point.

And over this 40 years, you know, we now know that this is serious, that this is something we need to really look at.

That the brain does heal.

And it takes some time to heal.

And we have to give it that time.

But we don't know whether the time you need for your brain to heal is the same as the time my brain needs to heal.

And what does that look like?

So we're really kind of doing the best we can.

As you've seen, the concussion protocol, even over the last three or four years, continues to evolve.

You know, we've gone from this is what you have to do.

To having an athletic training.

And we've gone from this is what you have to do.

To having an athletic training.

To having an athletic trainer who's up in the booth, who can stop the game.

To a second athletic trainer in the booth.

To the unaffiliated neurotrauma consultant that's on the sidelines, on both sidelines, kind of looking at all of this.

You know, and if this were left guard, we probably wouldn't be having this conversation.

Because, you know, you can probably name 80% of the starting quarterbacks in the NFL.

But you probably can't name the left, the starting left guard.

But you just need to name 90% of the starting left guards of all these teams, or if you find any of the left guards missing, I might want to say a 15-year-old movie star.

So to-a's too-a.

So it's a different level of do you put them back in, you know?

This is a game-changer if he's not in.

So to-a's too-a.

So it's a different level of do you put them back in, you know?

This is a game-changer if he's not in, that should not come into play.

So to-a's too-a.

But everyone's human in all of this.

So there is a piece of that that happens.

And I do, Dr. Seott, want to thank you so much for coming on Courtside Club.

Because I, you change my mind a little bit and help just inform me about the game.

situation from a fan's perspective from the media's perspective we don't know all that's

going on on the sidelines or in the doctor's office and and it's good to just to shed some

light on on something that is a very serious topic of conversation um but also to to help all of us

you know take a step back and and trust the professionals and know that it seems like

everybody's doing the best that they can with the information that we have well the only other

thing there are probably 10 health care professionals on the sideline at an nfl game

you got the athletic trainers you got multiple physicians and at the end of the day what really

needs to happen is some of these health care professionals on the sideline absolutely are

are emboldened

you know

to step on the field stop the game and say this person needs to come off you know we've added

layer on layer but at the end of the day if you tell me that people didn't see the sunday hit

and to get up and shake his head and stumble and that there are all the health care professionals

on the sideline and no one saw that and thought oh this isn't good i'm not gonna believe it

having all these different people on the sidelines is

is to try and remove some of that heat of the moment i've got to make this quick decision

that potentially impacts lives of individuals outcomes of games outcomes of seasons and

championships and everything else so it's a you know it's not just a uh a moment in time that

they're in the tent and okay there is no other pressure on the folks in the tent

but we're very aware that there's a game going on and our decision is going to impact uh the game

dr stewart thank you so much for this conversation this morning taking time out of your busy day to

help inform me help inform the courtside club audience and hopefully anybody who

turns tunes into this podcast into this video will take something away from it and and we'll

see where the nfl goes from here if there's any changes to the protocols um if there's any more

information that comes out about

to us

evaluation and obviously we're just hoping for everybody's you know safety and and health

throughout this but thank you thank you so much for coming on this was great you're very welcome

thanks for having me