The Trust: Taking a Multidisciplinary Approach to Brain Health in Former NFL Players

By Jay Alberts, PhD; James Leverenz, MD; and Nancy Foldvary-Schaefer, DO, MS

When the NFL Players Association launched The Trust collaboration with a handful of leading medical centers in 2013, it promised to be a clear win-win. On one end, former NFL players would benefit from the chance to undergo a comprehensive brain-body health evaluation to help understand the brain health path they appear to be on, gaining either reassurance or the opportunity for early interventions if indicated. At the other end, brain health specialists at Cleveland Clinic and the other participating institutions would gain an unmatched opportunity to learn from a population with a singular long-term neurocognitive and functional risk profile stemming from the repeated head impacts that can characterize pro football careers.

Now, three years into The Trust initiative, Cleveland Clinic is the program’s highest-volume collaborating center (see box below). Our experience to date has shown that the collaboration’s potential is most fully realized with a broadly multidisciplinary approach that goes beyond neurocognitive function to encompass wellness as holistically as possible. This article outlines the role of two subspecialty centers within Cleveland Clinic’s Neurological Institute — the Lou Ruvo Center for Brain Health and the Sleep Disorders Center — that are working closely with Cleveland Clinic’s Concussion Center to help bring that approach to bear for participants in The Trust.

The player assessment in brief

Under Cleveland Clinic’s protocol, former NFL players undergo an initial assessment at any of four locations (see box above) — three Cleveland Clinic sites, located in diverse parts of the country, or Hoag Health Network in Southern California, which serves as an affiliate of Cleveland Clinic for this program.

The two-day assessment starts with a comprehensive medical exam that includes determining the player’s injury history, any functional symptoms and any personal concerns such as depression or the transition to retirement from pro sports. That’s followed by brain MRIs, neurological examination, cognitive evaluation, psychiatric evaluation, neuropsychological testing, sleep disorders screening, and assessments of postural stability and motor and cognitive function (the latter done using the Cleveland Clinic-developed C3Logix™ mobile app for concussion assessment). Non-neurological evaluations and interventions (e.g., wellness screening, nutrition counseling, life skills consultation) round out the assessment.

Former players are then given a report of findings and recommendations, along with a personalized plan of action including subspecialty referral facilitation in their home community, if indicated. The aim is to provide a comprehensive and objective neurological assessment to identify any neurological dysfunction and give each player a sense of whether his cognitive status appears to be normal for his age —and, if not, what further monitoring or interventions are recommended.

The role of specialized neurocognitive assessment

At Cleveland Clinic, former players’ neurocognitive assessment goes beyond evaluation by general neurologists and concussion specialists to include visits with each of four members of a subspecialist team:

• A behavioral neurologist, who reviews the brain MRIs and performs a focused neurological evaluation addressing cognitive change as well as any other neurological symptoms or complaints
• A psychiatrist, who performs a focused psychiatric evaluation with special attention to mood and adjustment issues
• A neuropsychologist, who administers a several-hour battery of neuropsychological tests of memory and other cognitive abilities
• A health psychologist, who assesses for long-standing conditions that may impact long-term brain health

At each location, the same team sees former players on a regular basis (about one player per week). The behavioral neurologists have deep experience in mild cognitive impairment and chronic traumatic encephalopathy, which they bring to bear in evaluating abnormal findings or providing reassurance about the absence of signs of permanent damage from repeated head trauma.

Giving sleep its due

Chronic sleep deprivation and sleep apnea have been associated with increased risk for various forms of heart disease and metabolic disorders as well as mental health disorders, substance abuse and cognitive impairment.

In view of these associations, participants in The Trust who are evaluated at Cleveland Clinic are given self-assessments for insomnia and sleep apnea. Those with high signals for clinically relevant problems are offered further testing and treatment. Sleep studies are performed at home or in a hotel to record breathing in sleep for the diagnosis of sleep apnea. Players then meet with a Sleep Disorders Center specialist in person or via telemedicine-enabled virtual visits to review results, initiate therapy and monitor progress over time.

Our preliminary experience suggests a high prevalence of previously unidentified sleep apnea in this population, with objective testing confirming sleep apnea for the majority of former players with positive self-assessments. Most players are surprised to learn that they stop breathing in their sleep and are eager to initiate therapy. Others have had high levels of insomnia and opt to complete a web-based cognitive behavioral therapy program for insomnia, called Go! to Sleep℠, developed by specialists in Cleveland Clinic’s Wellness Institute and Sleep Disorders Center. For those with severe insomnia or who are not interested in the online approach, virtual visits with a behavioral sleep medicine expert are available.

These evolving efforts around sleep health make several key contributions to Cleveland Clinic’s execution of The Trust collaboration:

• Adding an important wellness component
• Providing an opportunity for intervention with the potential for near-term clinical benefits
• Offering a clearer window into a participant’s “true” neurocognitive picture — i.e., after any effects of sleep disorders are identified and treated

Drawing on relevant research when possible

While The Trust collaboration currently remains strictly a clinical project, many of the multidisciplinary experts involved in The Trust at Cleveland Clinic play key roles in similar initiatives with an explicit research focus, such as the large ongoing Professional Fighters Brain Health Study and related investigations in athletes. Insights from these studies will inform our counseling of participants in The Trust.

Dr. Alberts is Director of Cleveland Clinic’s Concussion Center and Neurological Institute Vice Chair for Health Technology Enablement.

Dr. Leverenz is Director of Cleveland Clinic Lou Ruvo Center for Brain Health, Cleveland.

Dr. Foldvary-Schaefer is Director of the Sleep Disorders Center.