Dr. Charles Bernick was never much of a fight fan before he devoted himself to studying the brains of the people who get hit in the head for a living.

He still isn’t, if you want to know the truth. Three years into his research at the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, he’s met hundreds of pro fighters, even has a few favorites (“I watch ‘Big Country’ Nelson,” he said), but as far as he’s concerned he could just as easily be studying pro football players.

Maybe he would, too, if there were an NFL team around.

“This is Las Vegas,” Bernick said with a shrug. “It’s the fight capital of the world.”

That’s a good thing for Bernick’s research on brain trauma. As Nevada State Athletic Commission executive director Keith Kizer pointed out, while Las Vegas might not be a city normally associated with important scientific studies, it does offer something that university laboratories don’t.

“You can’t ethically or legally hire a bunch of college students and hit them in the head to see what happens,” said Kizer. “But you know that on Nov. 30 there’s going to be 22 fighters here for the UFC, and even the winners are going to get hit in the head a few times.”

The question Bernick is trying to answer is, what happens to them after that?

For MMA fighters and even fans, the questions are more pointed still. After years of telling ourselves that our sport is safer than boxing or football – both of which have been linked to diseases like chronic traumatic encephalopathy (CTE) – what if we’re wrong? What if MMA is just as bad for your brain (and, as an extension, the rest of your life) as those other sports? What if it’s worse?

A ‘degeneration of cells’

Bernick’s study – officially dubbed the Professional Fighter Brain Health Study – is still in the early stages. Since 2011 he’s examined nearly 400 pro fighters – about 60 percent MMA fighters, 40 percent boxers, according to his estimates – using advanced MRI scans, neurological exams, tests to track changes in speech, balance, mood, reaction time, cognitive abilities and more.

While it may be years before he has anything definitive to report, the study has already broken new ground in at least one area: the relationship between fighting and decreased brain volume.

“In general, it’s what you’d expect,” Bernick said. “The more fights you’ve got, the lower the volumes are. But what’s really the finding is that it’s in very particular parts of the brain.”

Using advanced MRI scans, Bernick explained, researchers are able to essentially capture an image that divides the brain into different regions. Then, he added, “You can isolate that region and in some sense measure it.”

What Bernick is seeing in the preliminary findings across both boxing and MMA, he said, “suggests that repetitive head trauma does cause degeneration of cells, and the areas shrink.”

So what does that mean for the fighters?

“We don’t know,” Bernick said. “It may not mean anything. Lower volumes are associated with worse performances on cognitive tests, so there’s a relationship there. So the thought is, if you progressively lower volumes, that may be an indicator that you are at risk of having worse performance mentally. But the only way we’re going to know is to follow that over time.”

How to do the right thing … and be hated for it

To hear Kizer tell it, he’s been waiting for a study like this since he took over as the executive director of the Nevada commission in 2006. Ever since the revelations about CTE hit the NFL, he said, doctors and researches have been “tripping over themselves to go hang out with Peyton Manning, but who’s knocking on my door?”

Since the study’s inception, Kizer said, the NSAC has encouraged fighters to participate. Cleveland Clinic brochures are available at the NSAC office’s front desk, he noted, and commissioner Pat Lundvall begins her comments at the start of every meeting with an exhortation to fighters to sign up and be part of the ongoing research.

Partly responsible for Kizer’s enthusiasm is his hope that the study could do more than just explain what’s happening to the brains of fighters.

“This could not only make the sport safer – it’s never going to be totally safe, and there’s always going to be inherent risks – but this could also lead to advances in treatment for other head injuries, whether it’s car wrecks or falling off a ladder or getting mugged,” Kizer said. “It could maybe even go further than that, toward a cure for Parkinson’s or Alzheimer’s.”

The UFC also has been heavily involved in encouraging fighters to participate, according to Marc Ratner, the promotion’s vice president of regulatory affairs.

“When we have our fighter meetings where we bring them all in once a year, we get quite a few done then,” Ratner said. “It doesn’t matter where they’re fighting, whether it’s Nevada or somewhere else. We want to get that study as big as possible.”

Still, it’s hard not to wonder if the UFC, which long has bragged about MMA’s safety record compared to boxing and football, will necessarily be pleased with the results of a study that looks at MMA’s impact on the human brain.

Dr. Margaret Goodman, a Las Vegas neurologist and former ringside doctor for the Nevada commission who calls herself an “admirer” of the Cleveland Clinic’s work, pointed out that many promoters and regulators are fond of increased testing and safety standards, at least until they get in the way of a big fight. She was part of the commission that, in 2000, denied boxer Terry Norris a license based largely on noticeable changes in his speech.

“That was the main thing we had,” Goodman said. “Because the other tests that we have don’t prove it. You can do a thousand MRIs on MMA fighters and you probably won’t find out when someone has taken too many shots.”

If you do find out – whether through neurological exams or other tests like the ones employed by Bernick’s study – telling professional fighters that their careers are over is bound to be an unpopular job, Goodman added.

“A few years ago Dr. Homansky gave a talk called ‘How to become the most hated person in boxing, and do the right thing.’ It’s not easy,” Goodman said. “It’s the hardest job that anybody can do in a regulatory body, but it’s the most important job they have. Not collecting tax money and not protecting the governor, but actually doing the right thing and telling someone when they need to quit.”

Bernick’s team shares none of its findings about specific fighters with either the UFC or the NSAC, he said, so even if he does discover that current fighters are showing signs of significant brain trauma, he can’t raise the red flag with the powers that be in the sport.

“Even if we found something that we thought was a medical issue, we would only tell the fighter,” Bernick said. “We wouldn’t go anywhere other than that. Then it’s up to the fighter if they want to tell somebody. It’s a study. Everything’s confidential. That’s the only way really to do it.”

Young man’s enthusiasm, old man’s consequences

When recently retired UFC fighter Aaron Riley got involved in the study a couple of years ago, he didn’t do it for the most altruistic of reasons.

“I just remember someone saying, ‘Free MRI,'” Riley laughed.

He was more than 30 at the time, trying to get licensed for a fight. The commission required an MRI, which could have cost Riley a couple thousand dollars if he paid for it out of his own pocket. One of the Cleveland Clinic’s major appeals to fighters is the offer of a free MRI and other necessary medical tests in exchange for a fighter’s participation in the study.

Riley didn’t know much about the research at the time, he said, “But when I got out there and they explained to me the full scope of the study, what it was going to entail, that roped me in. I was very interested. Matter of fact, I was a little disappointed that since then I haven’t been able to go back there and have them test me now to see if there are any changes.”

That’s one of the downsides of retirement for Riley, who declared he’d “had enough” after a decision loss to Justin Salas at UFC on FOX 8 in July. Information on brain health and services like the ones provided at the Cleveland Clinic was easy to come by when he was on the UFC roster, but far less so now that he’s retired.

“In the fighter summit we’d get brought up to speed on a lot of those things, but now that I’m retired I probably won’t make it to too many fighter summits,” Riley said.

Riley is quick to admit that things like brain research are far more interesting to him now that he’s 32 and retired than they were when he first started out as a teenager. He feels no ill effects from his 16-year career in MMA, he said, but he’s read enough about ongoing CTE studies to know that the damage isn’t always immediately apparent, and it isn’t as simple as adding up the number of blows you’ve taken over the course of your career. As Bernick stressed at a recent presentation in Las Vegas, you don’t need to be knocked unconscious to suffer a concussion, and you don’t need to suffer multiple concussions to suffer long-term brain trauma.

It’s revelations like these, rarely discussed as recently as a decade ago, that Riley considers now.

“When I first started out, people would always compare it to boxing and say, ‘You’re going to end up like Muhammad Ali.’ My response was, well, I won’t stay in it that long,” Riley said. “But now we learn that it’s not just the lifespan of your career. There are different factors. I guess it’s like a genetic lottery in some ways.”

That’s one of the many aspects of the brain’s response to repeated head trauma that remains unclear to Bernick and his team. Why does one person develop these issues, while another person who may have taken just as many blows doesn’t? In general, Bernick said, a higher number of fights suggests a lower brain volume, and boxers tend to have lower volumes than MMA fighters, but the study is still so young.

“The whole thing is numbers,” Bernick said. “If you look at a small number of people, you can come up with these crazy results. We’ve done it ourselves. Then we look it after we have 100 more people and the result goes away. If it comes out when you look at 50 people and then 100 people and then 150 people, then it’s probably your real finding. I would hope that at least some new information, useful information, will come out in the next two or three years. But I think we’re going to need that time to really be confident of what we’re finding.”

That time is afforded by funding from “a lot of different sources,” according to Bernick. Some comes from philanthropic groups or donations from private individuals. Some is from a Department of Defense contract. The Cleveland Clinic contributes certain resources, but it’s still not a cheap undertaking. Even Bernick can’t be sure how long the study will last.

“It’s like the Framingham Study: as long as we can pay for it, it’s going to continue,” he said. “We know we have funding for four, probably five years. But hopefully we can keep it going, because that’s the only way we’re going to learn.”

Bernick is hopeful that soon researchers might have some data that will aid regulatory bodies like the NSAC. That’s a hope shared by Kizer, who said that while he doesn’t believe combat sports like boxing or MMA can ever be entirely safe, there must be ways to improve existing precautions and spot signs of trouble earlier on.

“Any information, even if it’s just a red flag, is going to help,” said Kizer. “Because right now our red flags are really just things like, if a fighter is a certain age or has lost a certain number of fights, been stopped in a certain number of fights, then we’d look closer at the guy. That, or a situation like Terry Norris where we can look at the change and say, ‘Sorry, it’s a no.'”

Norris, a former light middleweight champion boxer, is now 46 and, according to a recent Las Vegas Review-Journal article, struggling with signs of CTE. The Nevada commission’s decision to deny him a license stopped him from fighting, but by that point the damage had been done.

That’s the problem with something like this, where the older man is forced to pay for the mistakes of his youth long after it’s too late to do anything about them.

It’s something Riley thinks about, especially after beginning his career training at Pat Miletich’s gym in Iowa, where training sessions were notoriously brutal in the early days of the sport. Riley said he regularly saw fighters knocked unconscious in training. Even then he knew that had to be bad for your brain. At the same time, he also knew fighting in general couldn’t be all that safe, and that didn’t stop him.

“I just didn’t care about any of that when I first started,” Riley said. “It’s like anything else, where you know that stuff happens in the world, but you think, ‘It won’t happen to me.’ That’s a young guy’s outlook on everything.”

As the UFC’s Ratner noted, MMA is still very young, so there aren’t many prolonged case studies to tell us what may lie ahead for aging fighters.

“So far I haven’t seen anything from the older fighters, but I don’t see them that often,” Ratner said.

The best indicator of what the future may hold for MMA fighters could come from Bernick’s research. While he stressed that the findings are still in the preliminary stage, the study has already provided new, potentially useful information.

“Like the volumes, nobody’s ever really described that before,” Bernick said. “But now we can see over time if that pans out.”

As for Bernick, all this time spent talking to and studying fighters still hasn’t made him a fan, he admitted, but it has made it more interesting for him to watch MMA and boxing events. For two reasons, really.

“One is, I appreciate the skill of these guys,” he said. “The other is looking at how they protect their heads, seeing who’s protecting their head and who isn’t.”