Release of ‘Concussion’ Begs the Question: Is the Risk Too Great to Play Contact Sports?

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Actor Will Smith as forensic pathologist Dr. Bennet Omalu in the movie “Concussion,” out on Dec. 25. (Photo: Columbia Pictures/Courtesy Everett Collection)

It was a typical Saturday morning in September 2002 for Pittsburgh forensic pathologist Bennet Omalu, MD. He was on call to perform an autopsy. By a stroke of chance, he found Steelers legend Mike Webster on his table.

Omalu, who was born in Nigeria and hadn’t ever paid much attention to American football, didn’t know Webster. And though the longtime National Football League (NFL) star died of a heart attack, post-concussion syndrome was listed as a contributing factor in Webster’s death — and Omalu decided to look into the brain of a man who’d descended into a psychological tailspin in the final decade of his life.

PBS called it “the autopsy that changed football.” Looking at Webster’s brain tissue, Omalu found evidence of the disease he called chronic traumatic encephalopathy (CTE), the result of repeated concussions and other forms of head trauma.

Based on the real-life narrative covered in Jeanne Marie Laskas’ 2009 GQ article, the new film starring Will Smith, Concussion, chronicles the events that unfolded in the aftermath of Omalu’s CTE discovery: bizarre player deaths, questions about brain damage as the culprit, and the NFL’s likely attempts to keep its concussion crisis under wraps. The film is released in U.S. theaters on Dec. 25.

Although research is gaining steam, the understanding of CTE is in its infancy. There is still pushback and speculation from the medical and sports communities about CTE and head trauma, not uncommon in the wake of a new finding. But perhaps part of the pushback, also at the heart of Concussion, comes from questions society is not quite ready to answer: Who should be allowed to play football? Is the brain too vulnerable for contact sports?

WATCH: Why the NFL Doesn’t Want You to See ‘Concussion’:

Video: Yahoo Global News Anchor Katie Couric investigates why the NFL doesn’t want you to see “Concussion.”

“We provide the information to the patient, it is their decision,” Omalu tells Yahoo Health at a recent meeting of the College of American Pathologists, where he spoke about CTE, brain damage, and the role of pathologists in discovering and treating disease. “But let the decision be informed — an educated decision.”

Suspended in cerebrospinal fluid inside the skull, the brain is movable and vulnerable. A blow to the head causes it to rattle, slamming against the front and back of the skull. Many professional football players are in this near-constant state of collision — and have been for most of their lengthy playing careers.

Scientists are still discovering the toll of these repeated traumas. For some, like Mike Webster, it may be CTE — as of Dec. 15 of this year, officially confirmed as a unique syndrome that can be diagnosed by examining brain tissue by an expert panel of neuropathologists.

A brain with CTE may look normal; the condition cannot be diagnosed in a living human, only via autopsy. However, repeated damage can ultimately cause tissue degeneration. Damaging tau protein builds up in the brain (think of it like sludge that devours healthy cells). As the disease progresses, it can lead to symptoms like confusion, aggression, memory loss, problems with impulse control, depression, flawed judgment, and dementia.

And now the NFL is knee-deep in the controversy of an emerging condition.

Related: NFL Legend Frank Gifford Had CTE in Brain: What Is Chronic Traumatic Encephalopathy?

The Current Culture of Concussions in the NFL

No one knows exactly what the NFL knew about suspected brain damage among its players — information that’s now legally locked up. In April, a U.S. District Court judge approved a settlement of at least $900 million between the NFL and 5,000 former players. Under its terms, the League did not admit any guilt and did not have to disclose what it knew about brain trauma.

Concussion is primarily a portrait of Omalu. Born in Nigeria, he embodies the American dream, chasing success and acceptance in a country he always felt was just one step below the heavens. But the film is also a commentary on the early days of a potentially catastrophic problem, starting with the tragic death of Mike Webster and followed by Omalu’s discovery of CTE, and the NFL’s response.

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Dr. Bennet Omalu. (Photo: Getty Images)

Interestingly, by way of the Sony hack, we know certain scenes were cut with the NFL’s response in mind. According to The New York Times, director and writer Peter Landesman said these scenes hit the chopping block to make sure the story was told from a place of fact and truth instead of drama. “We don’t want to give the NFL a toehold to say, ‘They are making it up,’ and damage the credibility of the movie,” Landesman told The Times.

The film does not make a lot of firm conclusions about CTE or brain injury — it more presents and tracks the unfolding narrative. Perhaps the effects of repetitive head trauma has been an open secret for years anyway, underscored by the tragic deaths of former NFL players Junior Seau and Dave Duerson. Both took their own lives by shooting themselves in the chests to preserve their brains for examination. Both were found to have CTE.

Instead of providing answers about how to solve a larger concussion crisis, the film more or less raises the questions more people should be asking. Within the NFL, what is going on that spectators cannot see or hear?

In one scene, former Steelers team physician Dr. Julian Bailes (played by Alec Baldwin) is criticized for sending players with likely impairments back on the field instead of treating them. He responds by saying that the patch-’em-up, send-’em-out strategy was his job. After all, players had to stay on the field to keep the League running.

In March 2015, San Francisco 49ers linebacker Chris Borland announced his retirement from football after just one season and a mild concussion, turning down the chance to make millions of dollars. He has now become a test subject for researchers attempting to solidify football’s effects on the brain and body.

Related: Chris Borland Retires From NFL Over Concussion Fears: ‘I Don’t Think It’s Worth The Risk’

“I think football players are used to downplaying the severity of what they have wrong with them, just because of the culture,” he explained in a New York Times interview. “They’re complicit in those statements of ‘Oh, I’m fine’ when really they might not be.”

However, it’s possible the film’s more pressing implications lie outside NFL lines, beyond adult men who are contracted to play a visibly punishing game. How widespread is the problem of CTE and repetitive head injury? Was the human brain even created to endure a sport like football? Who is most at risk?

When Yahoo Health spoke with Omalu, he did not talk much about the film. He wanted to stay focused on the unfolding science of CTE and brain injury — and what to do about it. “There is no cure for permanent brain damage,” he explains. “The best cure is prevention.” He’s most concerned about the millions of children playing high-impact sports, who are taught to tackle and hit from a young age, and who may be sustaining repeated blows to the head for years to come. He asked if participation in injury-prone athletics is a decision that children should even be allowed to make.

Omalu compares playing a high-impact sport like football to smoking. “Children have not reached the age of consent,” Omalu said. “With smoking, children, by law, are not able to make that decision for themselves. Knowing what we know now, why do we continue to let children be exposed to repeated blows to the head and traumatic brain injuries?

“In my opinion, should we not let children grow up, and then let them decide?”

Related: Men Who Played High School Contact Sports at Risk for Brain Injury

Concussion Dangers, from NFL Players to Kids

Parents have not been immune to the murmurs about head trauma — and fears go well beyond football. According to a recent Harris Poll conducted on behalf of the University of Pittsburgh Medical Center, 89 percent of adults consider concussions to be a moderate or severe health concern. Roughly 25 percent of parents do not let their kids play certain contact sports due to concussion worries.

Treato, a company that analyzes healthcare insights and conversations, has tracked the online discussion on head injury to find that buzz surrounding sports-related concussions has boomed 230 percent in the past decade, with children being the focus of 64 percent of the conversations. Among a sample size of 500 users, Treato found that 41 percent thought football should be eliminated from schools. An additional 21 percent said hockey should also go.

While concerns about concussions and repeated brain trauma are real, it’s hard to negate wide-scale impact of sports on children. The relationship between CTE and brain disease also isn’t currently clear-cut, says neuropsychologist Wayne Gordon, PhD, the Jack Nash Professor of Rehabilitation Medicine and associate director of the Department of Rehabilitation Medicine at the Mount Sinai School of Medicine and the director of the Mount Sinai Brain Injury Research Center.

“It’s a strong statement to say children should not be playing football below the age of 18,” Gordon tells Yahoo Health. “CTE is slowly beginning to emerge based on the pathological relationship to professional athletes, but the childhood relationship is not well-studied.”

What we do know? Some will not fully recover from brain injury. “With concussions of any variety, roughly 15 to 20 percent of the folks have long-term issues from reduced academic function to difficulty regulating emotions,” Gordon says. “We also know that having one concussion increases the risk of another. There are consequences.”

A 2012 study published in Neurology also showed that the more hits you sustain, the more brain effects you’ll likely see. The research looked at non-concussive head impacts in contact-sport athletes in college, comparing their test scores to those of non-contact athletes. At the beginning of the season, all the athletes scored on par with expectations. By season’s end, 22 percent of the contact players scored lower than average versus just four percent of non-contact players.

Related: Concussion Diagnosis Could Take Under 2 Minutes With This Easy Test

However, the youth impact may just be the hidden discussion of repetitive brain trauma, according to Christopher Giza, MD, the director of the UCLA Steve Tisch BrainSPORT Program and a professor of pediatrics and neurosurgery at the David Geffen School of Medicine and Mattel Children’s Hospital at UCLA.

“If you consider the number who participate in youth sports versus professional sports, our attention is inversely proportional,” Giza tells Yahoo Health. “And the young brain is different than the adult brain — in both good ways and bad.”

This month, Boston University announced its plans for one of the most extensive studies on football and brain disease ever conducted. Originally intended to be funded from a $30 million research grant the NFL gave the National Institutes of Health in 2012, the League pulled back. The study is led by a BU doctor who has spoken out against the NFL.

However, the landmark study involving 50 researchers from 17 institutions will still be funded by the NIH. “This problem is larger than the NFL,” said Walter Koroshetz, MD, director of NIH’s National Institute of Neurological Disorders and Stroke, according to ESPN. “We’re trying to get answers for people. There are a lot of concerned people out there, especially parents of kids.”

Should Kids Be Playing High-Impact Sports?

Sports are getting more and more competitive all the time. Plenty of young athletes spend their weekends at tournaments, their nights at practice — at risk of injury every day.

How will a developing brain deal with repeated head trauma? It’s not totally clear, says Giza. Some studies hint that a younger brain is slower in recovery. “A college athlete takes roughly seven to 10 days to rebound, whereas a high-school athlete is around two to three weeks.”

Structures facilitating neural connectivity are still being created. “The wires of a young brain don’t have insulation yet; they conduct electricity, but not well,” says Giza. “The more insulation there is, the faster and more efficiently the brain works — but that insulation is still being laid until the mid to late 20s, meaning it may be more vulnerable.”

Related: Kids and Sports: Is Training Getting Too Intense?

Since the developing brain is still piecing itself together, Giza says that recovery from a head injury or concussion is tricky. “If you’re a kid, and it takes six months to recover your previous cognitive function, you have to recover to where you were before the accident and make up for that lost time [in further development],” he says. “It’s a moving target.”

On the flip side, Giza says that a child’s ability to cognitively adapt is generally greater than an adult’s, which may help boost the healing process. The impact forces of youth sports are smaller than that of college or professional. “Overall, it’s not necessarily pessimistic,” he explains.

Since CTE can only currently be diagnosed on autopsy, with follow-ups about behavioral changes that may have occurred prior to death, Giza says it’s still a “tough thing” to talk about the implications from a medical perspective. “There are a lot of reasons people have cognitive and behavioral changes,” he says. “What’s not so clear is how often do the changes happen with the tau deposits in the brain. … Not every symptom you have after suffering a concussion years ago is dementia.

“When patients come in with chronic conditions after a concussion, maybe it’s dementia, maybe it’s CTE,” he continues. “But I’m looking to diagnose something I can treat.”

Brain injury and its effects are still a black box. How much is too much, how often is too often, and what severity of injury might cause long-term damage is still unknown. “We should stay within the evidence of science, and [CTE] goes beyond the data,” Gordon says. At least right now.

What Should Be Done?

Jeffrey Kutcher, MD, associate professor of neurology and director of the NeuroSport Program at the University of Michigan, says that getting a player back on the field safely is always the goal, and ceasing participation completely is a hard call. The decision is ultimately based on weeks or months of discussion, a battery of tests, attempts to reintroduce the sport-specific skills, family history of conditions like dementia and any behavioral or personality changes. If it seems the problems from the brain trauma will not get better, he recommends the player stop.

But in the middle of the discussion of dangers, many undervalue the meaning of the game to young athletes, whose lives and social circles often revolve around their sports. “If someone plays a sport enough, it’s because they’re drawn to it through abilities,” Kutcher tells Yahoo Health. “It’s a part of who they are. It’s a place for self-reflection and accomplishment… working together for a common goal.”

In fact, “for many athletes, the game is really a part of them. The brain will become organized around, and take on certain qualities, based on the activities a person participates in,” he adds.

Protecting young athletes from brain injury is likely not about taking them off the field. “We can worry about a lot of theoretical things,” Giza says. “It’s important to make sports as safe as possible, while limiting the exposure to hits.”

Part of the issue is opening the discussion about how much contact is necessary, and when, to make every game safer. “In football, how do we tackle safer?” Gordon says. “Maybe it’s not leading with the head, maybe it’s something else. In soccer, we need to be careful about smaller hits like heading, and bumps to the head if they collide with other players. Going up for a rebound in basketball, we should be concerned about the intensity of impact.”

Giza says that coaches and trainers should be educated on reducing trauma and watching for signs of injury. Equipment should be properly maintained and utilized. There needs to be a protocol for assessing potential concussions on the field, ice, or court. Rules that reduce impacts in sports like football, hockey, soccer and rugby must be enforced correctly. And these systems have to be followed, always.

He says asking kids to give up sports isn’t the answer. “One thing to think about is, unlike something like smoking, sports have beneficial side effects, too,” Giza says. “We know that there is a downside to not being active. If we make sports participation scary enough that kids do Xbox instead, we can already measure the effects. It’s obesity, it’s long-term cognition problems.”

The risk of sports-related head injury is real. It must be taken seriously, an issue we are constantly striving to reduce — but perhaps the game’s greatest risk isn’t brain injury. Perhaps it’s not playing at all.

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