Concussion
Sometimes when a movie is based on a book, the book turns out to be better, but in this case, not so much. If you are interested in learning about the science, politics and sociology of repetitive concussive injuries in sports, Concussion, the movie, does a better job than the book of telling the story of how chronic traumatic encephalopathy (CTE) came to be “discovered” and named by Dr. Bennett Omalu, and the consequences of that discovery for him personally and for the National Football League. The book is more a biography of Bennett Omalu than an investigation of the pathology, psychology and treatment of concussion and how the NFL handled all this.
Concussion, the book, is based on “Game Brain,” an article by Jeanne Marie Laskas written for GQ that appeared in 2009. When I agreed to write the review, I thought I would be reading an investigative report about the discovery of CTE and the politics of the NFL. I saw the movie first and expected it to use a lot of artistic license in dramatizing the story, but I never expected that Laskas would also do this in her book. I also wondered how she was able obtain some of the details until I glanced at the Acknowledgements and learned that she used “informed imagination”—some fiction was involved. Perhaps because I was reading the book from the perspective of a biomedical researcher, I found this approach disappointing. She also, I think, did her story a disservice by omitting a preface and waiting until the acknowledgments to explain that her “goal was to tell Bennett’s [Omalu’s] version of the events leading up to, and the subsequent fallout after, his discovery of CTE.” She does this and it is worth doing and in some ways she does it well, making Omalu a vivid, sympathetic character and shedding light on some important points about the sequence of events, research methods, research integrity, motives, and other matters as they apply to Omalu and others involved. Indeed, the book is replete with virtues and vices: it is vivid, sympathetic, in some ways convincing, in some ways balanced; on the other hand, it is dumbed down to the point of being childish, somewhat fictionalized and therefore not so convincing, dramatized via repetition, incomplete sentences (“Bigger than any other sport. Way bigger. Bigger than TV.”) and other conventions of popularization. In fairness, Laskas notes that there are better sources for the full story of the NFL concussion crisis and how the organization hired staff physicians with little or no background in neurology or head injury in an attempt to do damage control for the money machine that is the NFL.
League of Denial, by two investigative reporters, Mark Fainaru-Wada and Steve Fainaru, and the subsequent PBS special of the same name, provide far more comprehensive background on the nature of “mild concussive injuries” than Concussion, but much less about the life story of Bennett Omalu. Laskas’ book is a more subjective, personal perspective that narrates how Omalu worked on his kitchen table to discover CTE. It tells a lot about the man, and the man is interesting and his story engaging and important.
This is a quick and easy-to-read primer with three story lines—the life and character of Bennett Omalu, the science of his discovery, and the struggle with the NFL—that will help families decide whether they want their kids to be involved in heavy-contact sports, where insidious injury processes can have such potentially important consequences.
For me as a laboratory scientist, three strands of this story are of primary interest—the CTE research; protecting athletes and educating parents about risks and consequences of organized sports for their children, and the determination of the NFL to obstruct these objectives; and the still larger picture of the clash between medicine and science—not only the bias of physicians hired by the NFL to discredit research and provide NFL-friendly diagnoses, but the methodological and, yes, philosophical differences between the culture of science and the culture of medicine.
By now, thanks to the publicity surrounding the recent and very unfortunate deaths of still relatively young former NFL and even high school players, much is already known about the growing crisis of sports-related multiple concussion and its potential to cause CTE. It may be worth a moment here to clarify what CTE actually is. First, it is a diagnostic term created by Dr. Omalu. “Chronic” and “traumatic” in this context means that there is “repetitive” injury to the brain that leads to “encephalopathy,” which is a way of saying that after multiple hits to the head, something will go wrong with the brain (encephalopathy). The term says nothing about what is specifically wrong, what the causal factors are and implies nothing about the progress of the condition. Basically you have a sick brain. Omalu’s contribution was the observation that while the brain of someone who has had multiple concussions can look normal at first glance, there can be microscopic changes in nerve cells that could explain the onset of progressively deranged behaviors. Omalu, working alone on his light microscope, even at home on his balcony or in his kitchen, was the first to see and report on the accumulation of abnormal protein (Tau) buildup in NFL legend Mike Webster’s brain cells. Although to the unaided eye Webster’s brain appeared normal, at the microscopic level its cells were more typical of an elderly person with Alzheimer’s disease. Although not every person with accumulation of Tau protein will develop CTE or Alzheimer’s, the pathological development of abnormal levels of Tau in nerve cells is more an end process than a beginning stage of the disease. Omalu’s findings were confirmed in the brains of other NFL players who did not have the same medical history of substance abuse. In the face of NFL fierce opposition, Omalu’s struggle to present his observations to the medical and scientific community and later to the public are the key elements of Concussion, and indeed, it was and continues to be a dramatic struggle.
Are the outcomes of chronic blows to the head over a long period of time likely to be a factor in CTE or PTSD? This is still a big issue for the NFL and also for the U.S. military, where concussions are a major factor in many of the injuries sustained in the two U.S. theaters of combat these last 14 years. Are multiple concussions a medical crisis? The issue is still hotly debated by some, but such a debate seems similar to arguing whether the earth is spherical. Whether the NFL will make any game-changing adjustments to protect its players from CTE is not at all clear. There are now many studies in the scientific and medical literature showing that repetitive concussions can cause neuronal injury long after the initial injury to the brain have passed. Extensive biomedical research has confirmed that even “mild” head injuries can lead to disruptions in the synthesis of RNA, the message part of the genome that codes all the proteins that sustain life. Some individuals, perhaps because of their genomic profile, are more susceptible to disease/injury-induced alterations in their RNA than others. Disruptions in RNA can lead to insidious, often subtle, pathological changes in brain chemistry that can eventually produce chronic brain inflammation, disruption of neurotransmitters by which cells communicate with each other, feed back on RNA to produce toxic proteins, and program genes to kill neurons and other brain support cells. Little by little, the toxic sludge accumulates and breaks down normal cellular function—not just in the locus of an injury, but potentially throughout the whole brain. This process can begin at any time during development and perhaps especially in the more vulnerable developing brain of children. Raising awareness of this process may be the ultimate contribution of Bennett Omalu. He made people think about these issues more carefully. He forced powerful people in the medical community to relinquish well-established dogmas and confront more directly the growing crisis of concussive head injuries. If you think about it, there is nothing “mild” about a disorder that leads to sudden and dramatic personality change, early-onset dementia or post-traumatic stress syndrome. The studies initially done by Omalu and his colleagues are no longer limited to the one or two centers where the research began and which are collecting the brains of deceased football players. Both the pre-clinical and clinical literature present substantive data to suggest that repetitive head injuries can lead to neuronal pathologies, but the frequency and severity of CTE and its consequences are still being debated.
Concussion, coming so late in the game, adds little to the conversation, but it is a quick and easy-to-read primer and perhaps will help families decide whether they want their kids to be involved in heavy-contact sports, where insidious injury processes can have such potentially important consequences. Concussion has three story lines—the life and character of Bennett Omalu, the science of his discovery, and the struggle with the NFL. The last two now have many new chapters and are better-addressed elsewhere. The story of the kitchen-table science and Dr. Omalu’s early struggle with the NFL is history, and as such, of interest, but the telling would be of greater interest with less imagination and more substance.
