An 'A-to-Z' Odyssey Through Neuroscience, Brain Trauma, and What the Sports Fan Should Know

The following two stories illuminate the complexities of the human brain, and so I'd like to share them. Consider an otherwise intelligent man who believes his biological mother is an imposter. The sight of her face triggers a delusion that she is not who she says she is. Because of a stroke, he's developed this specific delusion; a delusion that can be extrapolated to involve aliens, or government conspiracies. No, the man is not a character out of a Robert Heinlein novel. He's suffering from Capgras Syndrome; a brain specific delusion, measured by the galvanic skin response, used in lie detection, which detects micro-secretions of sweat in your palms whenever you experience an emotion.

And we can observe abnormalities in areas of the brain involved in facial recognition, and emotion processing, suggesting, as the Director of the Center for Brain and Cognition at the University of California, V.S. Ramachandran, argues, that the two are disconnected, leading to the brain's own peripheral rationalization: 'because the image of her does not evoke the feeling of her, she must not be my mother, and is therefore someone pretending to be her'. 

Or consider this otherwise intelligent woman: she eats food, only on the right side of her dinner plate. Ignores the left side of her hair when she combs it, and upon brushing her teeth, scrubs to the right, never veering off to the left. Ask her to draw a flower, and the left half is missing. Ask her to number a drawn clock on a piece of paper, and the numbers 1 through 12 are cramped into the right side. She's not crazy. She's suffering from Hemispatial Neglect.

These are interesting case studies because they reveal the seemingly paradoxical nature of the mind. In the latter case, we see that blindness is not physiologically restricted to simply vision, and in the former, we see how an irrational brain state can arise when emotion is not an element of perception...forming what neuroscientist Antonio Damasio famously labeled as, "Descartes' Error". The subject of brain trauma in sports reveals quirks that characterize other brain phenomenon, and so I'd like to return to the topic once more.  

Ivan Trembow famously bowed out of writing for MMA, citing his knowledge of brain trauma, what he learned, and how his decision to stop watching was a moral one. I respect that decision, but despite the nobility of his intentions, I have to disagree with his method. Any moral platform shouldn't be distanced from discussion, or discourse among people that need to be inspired to participate. We should all be "socially conscious", but that awareness needs to be channeled through people that are skeptics. However critical of his actions I am, we can't get away from the message.

It's possible there's an oncoming crisis in combat sports, in the same way there is in football, but the discussion needs naunce. People that make a living off of athletic ability won't go away. So it's important, now more than ever, to properly define the hazards involved for its athletes. And so in this digestible, but 'TL;DR' package (some of which I've cribbed from my earlier essays), we'll talk science. We'll talk statistics. But most importantly, we'll talk hope.   

The Concussion at a Cellular Glance

So what exactly happens to the brain when it's rattled? In a mild concussion, a split second hurricane of neural events occurs in which too much calcium impairs the mitochondria cells (the power centers), and leaves the brain lacking in the ability to sufficiently restore glucose in the brain. The younger you are, the more susceptible you are to long term damage. And this damage manifests itself with many different symptoms: dizziness, sensitivity to light, mood disorders, vomiting, confusion, slurred speech, and fatigue. But to dig even deeper on exactly what is being done to the brain upon trauma, experiments with axons have been highlighted off the work of Douglas Smith at the University of Pennsylvania.

Smith builds miniature brains out of rat neurons, which are then ‘hit’ with controlled puffs of air to simulate brain trauma at a molecular level. The axon is like a paperboy, sending neurological news, referred to as neurotransmitters, to "homes" called dendrites. The findings show that as axons stretch upon trauma, like a worn rubber band, they lose their elasticity after swelling, where proteins then block the proper neural absorption until the axons fall apart (called Diffuse Axonal Injury). Axons are considered vulnerable even "months after an initial stretch", according to Smith, emphasizing the fragile nature of the brain in general, and the fragile nature of the axon, specifically.

This "traffic jam" of hoarded proteins, caused by the sudden acceleration/deceleration of the head, destroys axonal connections, which are important for the function of neurotransmitters that often do wonderful things. They inform sociability (seratonin), optimism, and persistence (dopamine), and even, as love expert and anthropologist, Helen Fisher has argued, the characteristics that model our capacity for romantic love, such as excessive energy, sleeplessness, loss of appetite, and the type of acute memory for new stimuli that allows us to keep from perceiving time spent with an intimate partner as trivial (associated with norepinephrine). Is this why athletes with a history of concussions are statistically more likely to suffer from clinical depression (20% in males with a history of concussions as opposed to merely 6% in your average male)? Are they being deprived of the chemical cocktail that helps sketch the foundation of our many different emotions, and instincts? The idea that "you are your brain" is an absurdly reductionist concept, but that's not to say it's not without a percentage of truth.

One Concussion Too Many, and the Problem of Not Just Chronic Traumatic Encephalopathy (CTE)

CTE is the Alzheimer's of the sports world. It's a brain disease specific to contact sports, caused by the accumulation of blows to the head. Unfortunately the diagnosis for it only exists in the deceased: only an autopsy can reveal the buildup of tau (a cell killing protein also found in Alzheimer's). Ann McKee of Boston University, has done over 50 autopsies on athlete brains, and has found more than the presence of CTE, but also a motor neuron disease similar to amyotrophic lateral sclerosis (Lou Gehrig's disease), in 3 out of 12 deceased athletes, suggesting an elevated risk of voluntary muscle movement for athletes in contact sports as well. However slim the data, McKee is adamant about what the data suggests:

 "A long time ago, someone suggested that the [C.T.E. rate] in boxers was twenty per cent," McKee told me. "I think it’s probably higher than that among boxers, and I also suspect that it’s going to end up being higher than that among football players as well. Why? Because every brain I’ve seen has this. To get this number in a sample this small is really unusual, and the findings are so far out of the norm. I only can say that because I have looked at thousands of brains for a long time. This isn’t something that you just see."

Moreover, the presence of CTE does not discriminate by age, nor are concussions themselves linked with CTE. While the Owen Thomas case is probably the most famous, given how young Owen was, he's not the youngest: one of McKee's cases involved an 18 year old boy. However, Owen Thomas’ case highlights something else. Chris Henry’s brain (the former Cincinnati Bengal), for example, contained an apolipoprotein E3 allele: the same gene found in most brains with CTE, revealing that some people are (perhaps) genetically predisposed to this disease. In the case of Thomas, as well as Henry, neither one had ever been diagnosed with a concussion. Which brings us to the next point.

The Concussion That Wasn't There

To personally chop down a tree, what method works best? A single, heavy swing with an axe or a lot of small, minor swings? This is the truth about concussions. Football receives the most attention for its superhuman collisions on the field, but the dramatic 'decleaters' seen on special teams, and in the open field are the red herrings of brain trauma. The majority of NFL players being diagnosed with CTE are linemen. This phenomenon is emphasized in the rate of concussions in other, ostensibly less violent sports. Consider soccer:

In one study, 33 amateur players (seven of whom had sustained two or more concussions) underwent a battery of interviews and neurological tests. Matser and Lezak compared the results with those of 27 swimmers and runners and found the soccer players were three to four times more likely to show deficits in memory and planning skills. The more concussions players suffered, the lower their scores on three of the 16 tests.

Researchers elsewhere have come up with similar results. Two Florida Institute of Technology researchers looked at male players from high school through the professional leagues. They reported that the more someone heads a soccer ball, the lower that player will score on tests measuring attention, concentration, and general intellectual functioning.

Or consider equestrian sports (!): in my interview with David Epstein, a lone survey found that of the people questioned, 90% had suffered a concussion (often the result of hitting your head on a branch on a trail, or during the grooming of the horse).Think that's weird? It gets even weirder. Consider this quote from the U.S. News and World Report: "More than two-thirds had suffered significant head injuries, defined as loss of consciousness, hemorrhage or skull fracture". Think that's a report on the head injury rate for Mad Max at the Thunderdome? Nope. It's a quote from a survey taken on the golf field on Golf-Cart related injuries (amusingly, the presence of alcohol as a contributing factor in this survey suggests drunken golf-cart pedaling might be an issue worth addressing).     

Or consider Women's college hockey. Despite the fact that checking isn't allowed, it has a higher concussion rate than the NFL. The purveying wisdom is that women have "weaker" necks, and are more honest with self diagnosis. What's interesting about the incongruity between genders is that males should theoretically deal with more impact, alluding to what may be an understatement on the concussion rate in the NFL, NHL, et cetera. When the Associated Press gave a survey to 160 NFL players concerning self-diagnosis this is exactly what they found: that a percentage of players hide or downplay head injuries (30 players out of the group, in fact). 

The logic of hiding such an injury is tragically sound: why risk making money over an injury that can be easily played through? Any athlete recognizes the limited window they have to earn a living. NFL teams that make the postseason win an extra few thousand dollars, while winners can make up to 80+ thousand per man. Why jeopardize that? Specifically, why jeopardize that in a sport like MMA, or kickboxing? As Todd Martin astutely points out:

These problems are magnified in sports where athletes are paid less. Combat sports such as boxing, mixed martial arts and kickboxing don’t pay low end competitors hundreds of thousands of dollars. They often have to keep taking fights just to make ends meet, which creates every incentive to ignore the risks of repeated concussions.

Getting back to concussions, what's more pertinent is that we're getting data in real time: documenting the type of impairment scientists would expect to find in the brain even in the absence of a concussion. To recap on the famous Purdue research, a high school football team had accelerometers implanted in their helmets to log the amount of force players are accustomed to taking, and then put them underneath an fMRI while taking cognitive tests (specifically ImPACT, and a continuous performance task known as n-back) to see what effect, if any, trauma has on memory, focus, language, and visual processing. In the most recent study published in April of this year, "of the 31 times that the researchers brought in non-concussed players to do neurocognitive testing, 17 produced impaired scores. "That's 17 players who were not expected to be impaired," said Tom Talavage, a Purdue associate professor of biomedical engineering and electrical and computer engineering".

While it has always been a useful soundbite in the argument against the brutality of the sport toward critics, that 'MMA is safer than boxing', it's a soundbite that ignores the reality of the risks involved in any sport where trauma to the head is inevitable (as well as in sports you wouldn't expect to involve such risks). MMA, in theory, is likely to be just as risky, since it involves the exact same training required for boxing, kickboxing, and Muay Thai. But something else that has fascinated me about brain trauma is where in the brain, to expect trauma to typically occur. So please humor me as I (sort of) digress.

A Digression: You Are Your Frontal Lobe

You are what allows me to navigate through social situations. To store long term memories related to the social norms and expectations I've grown accustomed to. I let you take control when my instinct to say something inappropriate in a fit of rage boils to the surface. I turn to you in the face of moral dilemmas, and seek your guidance when I arrange goals for myself. In short, you are the '"Promethean Script of human evolution".

So your brain is divided into 4 main lobes, each of which are more or less specialized. Some process speech, auditory information, language, others process spatial navigation, but the frontal lobe "specializes" in very broad functions, like social intelligence, and moral judgment, and how these functions work together to suppress our behavioral impulses. It is this unique lobe that brain trauma research indicates is most at-risk (and where CTE appears to be localized). And it makes intuitive sense. Most of the damage incurred in any contact sport will likely occur around the forehead area. When you spearhead another player in the open field, bounce a ball with the tip of your head into the goalpost, or take a punch to the head, it's the forehead portion of your head most likely to be the bullseye on the sports dartboard.

Damage done to the frontal lobe produces some well documented results, that are sometimes sexual, and aggressive (sometimes in tandem) in nature: the most popular "case" being that of Ben Roethlisburger. It is a part of the brain that is highly active in complimenting the act of looking at a beautiful vista, hearing a terrible song, or leering at the pretty girl across from you at the bar with emotional triggers. It chains emotion, memory, and aesthetic together to produce the cultured mind.

But the symptoms associated with trauma to the frontal lobes are not restricted to perversity. In addition, case studies involving damage done to this particular area can lead to a very literal emotional loss. It's apathy in a sense-perceptive way, as opposed to being the product of the kind of faux-cynicism you'd expect from someone reading a Nietszche essay on a MacBook. And it plays a role in decision making insofar as many goals, both minor, and major involve emotions: emotions give goals sophisticated immediacy. As Jonathan Haidt, Associate Professor of Psychology at the University of Virginia, elaborates:

The neurologist Antonio Damasio has studied people who, because of stroke, tumor, or blow to the head, have lost various parts of their frontal cortex....they report that when they ought to feel emotion, they feel nothing, and studies of their autonomic reactions confirm that they lack the normal flashes of bodily reaction that the rest of us experience when observing scenes of horror, or beauty.

Yet their reasoning and logical abilities are intact. So what happens when these people go out into the world?...They find themselves unable to make simple decisions or to set goals, and their lives fall apart. When they look out at the world and think, "What should I do now?", they see dozens of choices but lack immediate internal feelings of like or dislike...When the rest of us look out at the world, our emotional brains have instantly and automatically appraised the possibilities.

And this area plays a role in the degree to which you are more chemically inclined to approach any given person, place or thing, or the degree to which you are more chemically inclined to withdrawal from any given person, place, or thing (known as your "affective style" in Psychology). Haidt continues, noting of this process, that the level of cortical activity plays a role in how "subject you are to depression", how quickly you "recover from negative experiences", and the degree to which you experience "fear, anxiety, and shame".

Given the evidence of CTE, is it too far fetched to think a similar decline may be occurring in some athletes? When you look at Mike Webster, the Pittsburgh Steeler who lived the remainder of his life out of his truck, or Terry Long, who killed himself by drinking antifreeze, can it be said that the trauma suffered in sports has burglarized this 'Promethean Script'? Is CTE shutting down activity in the approach/withdrawal systems of the brain? Does it threaten even the simplest forms of goal dependent decision making?    

On a moderately more positive note, despite the fragility of the brain itself, the frontal lobe is surprisingly durable. Don't believe me? Check out the infamous case of Phineus Gage: Yes, that metal rod impaled his head, but even more curiously, the side effects were minimal...for a time at least. For a wonderful historical exploration of Gage, check out Moheb Costandi's (writer for SEED) neuroscience blog on the topic. Gage's life was relatively normal until his personality took a radical shift years later. Gage is not necessarily a freak in frontal lobe damage control either. In fact, the frontal lobe is known to house tumors that sometimes fail to show any noticeable symptoms. None of this is to deny that Gage didn't suffer some radical effects from his brain injury, or that frontal lobe tumors stay "silent" for long. But perhaps there's something to be said, given how CTE is typically concentrated in the frontal lobe, for how dramatic symptoms are not guaranteed with CTE because of this area's durability.

The Criticism

Watching Derek Suboticki's post on Wanderlei Silva from the sidelines was a polarizing experience for me: I sort of agree with Derek. Just not in the fashion that he argues his case, and specifically the fashion in which he assumes competence on the part of the athletic commissions. And I sort of agree with those who felt like Trembow did a great job of showing just how significant the issue is, but I have to take issue with comments like this (again from Trembow): 

Some of these athletes had drastic behaviorial changes before their deaths, some of them developed Alzheimer's-like syndromes, some of them developed ALS-like syndromes, some of them killed themselves, and some of them killed others before killing themselves (such as pro wrestler Chris Benoit, who murdered his wife Nancy and his seven-year-old son Daniel before killing himself in 2007).

This is a dangerous approach to the issue because it seeks to lay blame on one health issue while ignoring the rest (to say nothing of the fact that such tragedies should be evaluated on a case by case basis). Throughout this post, I've highlighted some startling facts, as did Trembow. But now it's time to emphasize something else: CTE research is woefully slim. The extent of the research is limited to the brains of deceased athletes. No mind, scientific or otherwise, can pretend to think the body of knowledge over this topic is brimming with information. The impression from most experts of CTE is that most athletes will show signs of the disease at some point. So where are the rest of the athletes requiring behavioral therapy? Or suffering from dementia? If the projected number is so high for the disease itself, why are the dramatic symptoms so low? For every Mike Webster, there is a Troy Polamalu: Polamalu is by all accounts, a soft spoken, intelligent man. He used the lockout time to finish his Bachelors. He also plays one of the most violent positions in the NFL, and has suffered at least seven concussions. And no one is calling for him to retire. This is not to compare Polamalu with Wanderlei, but rather, to emphasize the nuance required for such a complex issue, especially where an individual's livelihood is concerned. 

None of this is to downplay the physiological symptoms of CTE. My contention is that pointing the finger at CTE ignores the unique nature of an athlete's biology. These are bodies not just traumatized by violent contact to the head, but bodies hooked on drugs. When discussing the CTE autopsies from the New Yorker article, Gladwell went on to note of McKee's findings:

At least some of the players are thought to have used steroids, which has led to the suggestion that brain injury might in some way be enhanced by drug use.