Millions of Americans are expected to gather around their flat screens during Christmas week this year to watch football, America’s most popular sport.

As they do, others will head to theaters for a movie focused on controversy at the game’s very core: sports-related brain trauma, the long-term health effects, and whether they can and should be avoided in football.

Concussion, produced by Sony Pictures Entertainment and starring Oscar-nominated actor Will Smith, premieres on Christmas Day. The film will dramatize the story of pathologist Bennet Omalu, who in 2002 first discovered and named the degenerative and potentially devastating condition chronic traumatic encephalopathy or “CTE” in professional football players – and then faced opposition from the National Football League and its medical representatives as he attempted to share and build upon the sentinel case.

Smith was once deemed “the most powerful actor in Hollywood” by Newsweek. His portrayal for mainstream audiences of Omalu’s uphill battle to warn the league and the public about CTE could mark another significant milestone in heightened national dialogue about the true effects of concussions and other traumatic brain injuries or TBIs – especially in “collision sports” such as football, hockey and boxing, where bodily impacts are not just incidental, but fundamental and celebrated.

Omalu, who made his initial discoveries in 2002 as a junior pathologist in Pittsburgh, now serves as chief medical examiner of San Joaquin County, Calif., and lectures physicians-in-training as an associate clinical professor of pathology and laboratory medicine at UC Davis.

Researchers in pathology and several other disciplines at UC Davis have also worked for years to improve diagnosis, treatment and prevention of TBIs and dementing diseases, whether caused by sports, playground falls, car crashes, wartime or aging.

“The UC Davis pathology department has been wonderful to me, and I’m deeply grateful and hopeful,” Omalu said about his teaching activities. “I’m very pragmatic. I share my firsthand experiences with students – not textbook stuff, but the real, firsthand experiences.”

Discovering CTE

Those experiences began with Omalu’s immigration to the U.S. from corruption-plagued Nigeria, and have progressed through roles as a junior pathologist, a forensic pathology pioneer, a thorn in the side of an $11 billion professional sports league and a member of America’s canon of David-vs-Goliath figures.

The CTE discovery itself began in earnest in 2002 with Omalu’s autopsy of NFL Hall-of-Fame center “Iron Mike” Webster, who suffered severe depression, dementia, erratic behavior and stints of homelessness before dying at 50 from a heart attack.

As an offensive lineman, Webster didn’t face the high-speed, crunching tackles wide receivers and other flash players do, but instead made lower-level contact with other hulking men on a more constant basis – almost every play. He likely absorbed hundreds of thousands of such collisions during a nearly 17-year football career with the famed Pittsburgh Steelers.

Omalu had followed Webster’s post-retirement troubles in the media with curiosity, and during his autopsy was puzzled by the lack of a physical explanation for his mental decline using the pathologist’s standard tools of visual inspection and CT and MRI brain scans.

“When Mike Webster died, no one could actually explain the profile of his life after football,” Omalu said. “When he died, on TV people were ridiculing him, pretty much making fun of him and other retired NFL players who, for whatever reason, did not do so well after retirement.

“So when I heard their stories, I was a bit intrigued. I wondered if their profiles could be due to brain trauma.”

Omalu obtained permission from Webster’s family to conduct a microscopic analysis and, after methodically studying brain tissue, uncovered the abnormal protein deposits scattered throughout key brain regions that would characterize CTE.

The deposits are also common to Alzheimer’s disease – although in different patterns – and block communication in regions that oversee mood, emotions and executive functioning.

Clash with the titan

Omalu published his landmark findings from Webster’s autopsy in the Journal of Neurosurgery in 2005–and formally drew fire from NFL medical advisors, who tried unsuccessfully to have the article revised or retracted. Meanwhile Omalu continued to discover CTE in autopsies of several other former pro football players and wrestlers who suffered mental impairment and took their own lives.

The New York Times, national magazines such as the The Atlantic Monthly, The New Yorker and GQ, and other major media have since reported extensively about CTE’s emergence and the various reactions and interactions among pro football officials, advisors, players and others.

The Public Broadcasting Service (PBS) and its Frontline public affairs series also released a two-hour documentary and companion website in 2013 exploring the issue. According to Frontline, “League of Denial: The NFL’s Concussion Crisis” investigates how “for years, the league denied and worked to refute scientific evidence that the violent collisions at the heart of the game are linked to an alarming incidence of early-onset dementia, catastrophic brain damage and other devastating consequences for some of football’s all-time greats.”

Journalists associated with “League of Denial” – one of them a Pulitzer Prize-winning former war correspondent – called Omalu’s autopsy of Webster “one of the most significant moments in the history of sports.”

An ongoing dialogue

In the years since Omalu’s discovery, thousands of former NFL players have filed a class-action suit against the league over medical issues about repeated head trauma, leading to a 2013 settlement that could cost the organization up to an estimated $1 billion over decades through player payouts.

Other researchers continue to link football and CTE; one Department of Veterans Affairs and Boston University study released this fall found signs of the condition in 87 of 91 deceased former NFL players.

Meanwhile the NFL says it is committed to making football as safe as possible for all players and to helping create a safer experience for athletes across all sports. A 2015 NFL Health and Safety Report on the health and safety branch of the league’s website states that football has never been safer, noting changes to league rules, protocols and culture as well as funding for new or ongoing health research, such as $30 million granted to the National Institutes of Health in 2013 for CTE and other brain injury work.

How much those efforts will resonate remains to be seen, as dialogue and concern in American homes about collision sports has even reached The White House. In late 2013, President Obama – reportedly a Chicago Bears fan – told The New Yorker that he would not let his son play pro football, and compared participating in the sport to using tobacco due to increased knowledge about health risks.

Omalu, CTE’s discoverer, takes pains to warn that those risks can include brain effects from the kind of repeated lesser blows or “subconcussions” that Webster experienced, as well as the full-on concussions that have increasingly become the subject of sports-league protocols.

“What causes CTE is blows to the head,” Omalu said in an interview. “And then blows to the head can cause subconcussions, concussions, post-concussion syndrome, post-traumatic encephalopathy [PTE] and chronic traumatic encephalopathy [CTE]. It’s a spectrum, a continuum of syndromes caused by blows to the head.”

Better on-field assessment

As Omalu continues his outside research – he is currently trying to detect CTE in the living, in hopes of opening the door to possible treatments – multiple UC Davis experts are also probing different aspects of the overall TBI spectrum in efforts to better understand the brain, improve TBI diagnostics and test possible treatment avenues.

For example, Khizer Khaderi, director of neuro-ophthalmology at the UC Davis Eye Center, is collaborating with Melita Moore, UC Davis head team physician and assistant clinical professor of orthopaedic surgery, to study how biometrics can guide more objective determinations about an athlete’s health immediately after a blow to the head.

Returning to play too soon after a concussion creates risk of more serious injury or even sudden death – so authorities try to detect the injuries by asking athletes questions that are compared to baseline responses. But ultracompetitive players still have wiggle room to fudge results.

Khaderi and his team identified three established tests they believe may greatly increase accurate on-field assessment. One gauges eye movement, which often slows involuntarily after brain injury, and another measures pupil dilation and function with image-driven psychological tests. A third metric being developed employs electroencephalography to measure brain waves.

Khaderi hopes to package existing hardware and a cloud-based application developed by his team for easy access via tablet or other sideline-friendly mobile devices. He and Moore plan to deploy the vision screener with UC Davis athletics this fall.

“The goal is to create an easy- to-use, inexpensive, reliable mobile screener for everyone that enjoys an active lifestyle,” Khaderi said.

Appropriate off-field screening

Nathan Kuppermann, UC Davis professor and chair of emergency medicine, has been a driving force in developing data-backed guidance about whether a child with suspected head trauma will truly benefit from diagnostic imaging – or whether “watchful waiting” without radiation is a safe first option.

Head trauma in children results in nearly a half a million visits to U.S. emergency departments annually, where physicians – often urged on by worried parents – frequently use CT scans to search for potentially life-threatening brain bleeding. 

But radiation exposure to the brains and bodies of developing children is of particular concern, and CT scans carry a small but quantifiable long-term risk of cancer death. Radiation from one head scan for a child, based on age, is the equivalent of approximately 140 chest x-rays.

Kuppermann is a co-founder of the nation’s first federally-funded network for pediatric emergency medicine research, and he and network colleagues have systemically explored pediatric acute head trauma in studies in The Lancet, The New England Journal of Medicine, JAMA Pediatrics and Annals of Emergency Medicine.

The effort produced a set of decision rules meant to assist doctors and parents in shared decision- making about whether the benefits of diagnostic CT for a child patient will outweigh the risks.

Handle with care

Meanwhile, the university’s football program is collaborating with the health system to increase on-site clinical management of major head or spine trauma, such as brain hemorrhages or cervical vertebral fractures.

While it’s typical for sports medicine specialists or orthopedists to be available on sidelines, UC Davis neurosurgeons now join them at Aggies home games at Moore’s invitation. UC Davis concussion assessment expertise and procedures were already at the standard level of care, but Moore sought to enhance evaluations for major trauma as well.

UC Davis neurosurgeon Kia Shahlaie has organized neurosurgeon volunteers to attend home games and provide evaluations. When needed they’ll help stabilize athletes, ensure adequate blood pressure support and ventilation, and help to guide paramedics.

UC Davis currently leads its conference in elevating sideline care to this level, which now matches the highest current standard of domestic professional leagues.

“UC Davis Medical Center is a very busy level 1 trauma center, and our neurosurgery group evaluates and treats over 700 head injuries each year,” Shahlaie said. “That level of experience and expertise is what we’re trying to bring to our student athletes and athletes from the visiting team.”

“The sooner they are stabilized, evaluated, and treated for a possible head injury, the more likely they are to recover from the event.”

A conversation with Concussion's Bennet Omalu

How he dealt with adversity during his discovery of CTE, how he proposes handling youth collision sports, the intersection of his religious and scientific backgrounds, and more. Read More...