Change can be slow. Change is often difficult. But change is inevitable. Concussion, the highly anticipated film starring Will Smith that opened on Christmas Day, tells the tale of Dr. Bennet Omalu, the neuropathologist who first identified chronic traumatic encephalopathy (CTE) in an American football player, Mike Webster, upon autopsy in 2002. Dr. Omalu later confirmed the presence of the disease in the brains of several other professional athletes who had experienced debilitating changes in mood, behavior and the ability to function in the years preceding their deaths.

The film reveals in no uncertain terms the journey of the NFL from a stance of first trying to ignore and dismiss Omalu’s concerns, to outright denial and refutation of his findings, and eventually to acknowledgement that CTE does exist, appears related to repeated head impacts and concussive episodes, and must be a focus of future research and review of rules and practices. All this must be done to better understand and reduce the impact of this devastating condition. The parallel to the tobacco industry’s path towards acknowledging the relationship between cigarette smoking and lung cancer was clear, as was the inner conflict experienced by those who were torn between a sense of obligation to protect players and the public/industry pressures to honor and defend the sport of football.

Understanding Chronic Traumatic Encephalopathy

CTE is a devastating neurodegenerative disease characterized by the presence of abnormal protein deposits that form tangles leading to significant neuronal loss. The pattern of abnormalities is distinct from other neurodegenerative conditions (e.g., Alzheimer’s disease). At present, CTE can only be diagnosed post-mortem; and all individuals with neuropathologically confirmed CTE have been found to have a history of repetitive head impacts. Clinically, individuals diagnosed with CTE after death have retrospectively been found to have displayed significant disturbances in mood, behavioral, cognitive and/or motor function during their lifetimes. The onset of symptoms has been characterized as insidious and typically presenting years after trauma (Baugh, et al 2014).

While nothing in Concussion would be particularly revealing to those in the field of brain injury, the film will certainly get many people talking and thinking about the risks, dangers and potentially catastrophic consequences of participation in high impact sports. But as is sometimes the case when the media attempts to distill and present complex and scientifically ill-defined information in a way that will capture the attention of and be understood by the masses, there will be those who come away with misconceptions about CTE, which are not grounded in the current state of the science.

Separating Fact from Fiction

In fact, there is much more we still do not know, versus what we do know, about CTE, including the nuances of the relationship between contact sports and development of the condition. The inferences and conclusions drawn regarding CTE during the timespan covered by Concussion were based upon the post-mortem analysis of brains of just a handful of professional football players. Since that time, interest and research into the condition has exploded. There are now more than 150 documented cases of CTE, including more than 60 in football players; and the condition has been identified and is now being studied in other athletes, as well as military veterans (Maroon et al 2015). Professional football players and military personnel can now register to donate their brains after death to the Brain Bank at Boston University’s CTE Center to help further scientific research into CTE. Still, the field is in its infancy, and many questions remain.

CTE still cannot be definitively diagnosed until after death, and the research to date has been based largely upon retrospective case reports of those involved in high impact sports (and more recently military combat). This biased sample presents challenges in terms of determining incidence/prevalence rates, how other risk factors (e.g., number and severity of head injuries, genetic, pre/co-morbid conditions) may influence development of CTE, etc. And while it seems that repetitive head impacts are necessary for the occurrence of CTE, they are not sufficient. That is, not all individuals with a history of repetitive head impacts develop CTE.

The Road Ahead

To date, no definitive conclusions can be drawn about who is at highest risk for CTE, how the condition can be diagnosed during life, and most importantly, what can be done to eliminate or minimize the risk in those most susceptible. Furthermore, other neurological conditions which can occur as a result of high impact blows to the head (e.g., diffuse cerebral swelling (DCS)/second impact syndrome; concussion; chronic post concussive syndrome) also remain poorly understood yet tremendously impactful (and potentially life-threatening in the case of DCS) to the individuals suffering from these conditions and their loved ones (Jordan, 2013). All these conditions are in need of much further study.

The tide is changing, most certainly. Since the first documented case of CTE in a professional football player, helmet technology has advanced; rules, protocols and codes of conduct on and off the field have changed; and more funding has been made available (including by the NFL) to researchers, as well as individuals and families, to address the problem of concussion and the potential long-term impacts in athletes, military personnel and the general population. One hopes that a balance can be achieved between stoking fears and drawing unwarranted conclusions, and increasing awareness and taking necessary steps to protect our loved ones.

About the Author

Dr. Deborah Benson is senior director of clinical services at Paradigm Outcomes. Over the course of her rehabilitation career, she has conducted basic and clinical research in neuroscience, taught psychology and cognitive rehabilitation, and served as clinical supervisor for graduate neuropsychology students. A New York State-licensed psychologist with a Ph.D. in clinical neuropsychology from the City University of New York and board certification in rehabilitation psychology from the American Board of Professional Psychology, Deborah served on the board of the Brain Injury Association of New York State (BIANYS) and is currently on the association’s advisory council. She has coauthored multiple scholarly articles and books on brain injury rehabilitation and presented at numerous regional and national conferences.