Traumatic Brain Injury

by Anna Johnson-Winegar

    The brain is the body's command center. The average human brain weighs about 3.3 pounds, thereby making up about 2 % of a human's weight.  The cerebrum is the largest part of the brain, making up about 85% of the weight.  This part, known as the "gray matter," contains about 86 billion nerve cells (neurons) and billions of nerve fibers (axons and dendrites), which are known as the "white matter".  The neurons are connected by synapses.  The cerebrum is divided into two hemispheres (the so-called left brain and right brain, responsible for different functions).  The left brain is associated with speech, language, mathematical calculation, and fact retrieval, while the right brain plays a major role in visual and auditory processing, spatial skills, and artistry.  Under the cerebrum is the brain stem and behind that is the cerebellum.

    The brain's soft sensitive tissues (about the consistency of gelatin) float in a cushioning fluid within the hard and sturdy skull.  The skull is designed to prevent most traumas to the brain, but it cannot prevent the injuries that can occur from the brain moving around inside the skull.

     Concussion is often used as a synonym for traumatic brain injury.   A more formal definition states:  "Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain”(see Mayo Clinic reference for further definitions). A concussion can arise from the brain moving either rapidly back and forth or banging against the sides of the skull.  This sudden movement can stretch and damage brain tissue, triggering a chain of harmful changes within the brain that interfere with normal brain activities.  TBI can result when the head suddenly and violently hits an object, or when an object of some type pierces the skull and enters the brain.

    More serious brain injuries that involve skull fracture, bleeding in the brain, or swelling of the brain can be detected with X-rays or other imaging methods, but concussion cannot be seen with standard tools. Symptoms may be mild or severe, and include headache, confusion, lightheadedness, dizziness, blurred vision, fatigue, ringing in the ears, and trouble with memory or confusion.   In more severe cases, the headaches are worse, and other symptoms include vomiting and nausea, convulsion or seizures, numbness in extremities, slurred speech, increased confusion, restlessness and agitation.

    1.5 million people suffer from TBI each year, and about 500,000 people die from it. More than 5.3 million people live with disabilities caused by TBI.

    There are three principal kinds of TBI—Concussion, Chronic Traumatic Encephalopathy (CTE), and Shaken Baby Syndrome—and three principal causes: car accidents, firearms, and falls.  Many cases are related to professional and amateur sports (football, in particular), as we know from the news. The two primary physical mechanisms of TBI are Open Head Injury (e.g., bullet wounds, typically with penetration of the skull) and Closed Head Injury (e.g., motor vehicle crashes, falls, sports injuries, typically with no penetration of the skull). Other mechanisms include chemical exposure, tumors, infections, and stroke; lack of oxygen to the brain can also cause TBI.

    TBI is diagnosed by a formal neurological examination. Brain imaging with CAT scans, MRI, or PET is also helpful.  (See general references for descriptions of these tests). Neuropsychological testing can help with cognitive function, and further evaluation by physical, occupational, and speech therapists can clarify the specific deficits in an individual case.  We all need to understand the critical importance of a professional evaluation, since self-diagnosis or inadequate medical evaluation so often occurs, especially with athletes.  How often we hear of an injured player on the field who refuses to take himself out of the game, or who argues with the coach, "Put me back in, I'm OK!"

    In the typical sideline or locker room assessment of potential concussions, the (presumed) injured individual is asked to self-evaluate, using a score of 0-6 (0 = none, 6 = severe), such symptoms as headache, dizziness, difficulty concentrating, or balance problems. The team trainer, or doctor, or coaching assistant, may then ask the player simple orientation questions, such as "What day is it? Where are you?" A simple word-recall test may also be used, giving the individual a list of five words (done three times with different words, and then a delayed recall of the first list).

    Under such circumstances, a meaningful diagnosis cannot be made.  First, there may not be a baseline (perhaps the individual could not have repeated a list of five words even before the injury); second, the individual self-assessment is often clouded by bravado. Furthermore, the results of such test can easily be skewed by stress or excitement, which may or may not be related to a potential concussion.

     A few specific examples can help illustrate the problem.  Consider professional football player Junior Seau, who played linebacker for the San Diego Chargers.  The Hall of Famer committed suicide in 2012 (shooting himself in the heart) following agonizing issues with brain injuries, including madness and despair.  Soon after his death, researchers found Chronic Traumatic Encephalopathy (CTE) in his brain. Seau's family filed a wrongful death suit against the NFL, and rather than reaching settlement, they are pushing to go through a rigorous discovery process that could shed more light on what the NFL knew, and when it knew it, and more information about the long-term risks associated with multiple concussions to the players.
 
    Another player, Dave Duerson, also committed suicide, shooting himself in the chest to preserve his brain for research. A recent report from the Department of Veterans Affairs and Boston University revealed that 96% of deceased NFL players examined by the researchers had CTE (Rose and Glauber). Overall, researchers found CTE in 79% of deceased players who had participated in either pro, semi-pro, college, or high school football.

    In May of 2015, a federal judge granted approval to a proposed settlement between the NFL and more than 4,000 former players who had sued the league over its past handling of concussions (Seau's family and at least 200 others had opted out of this settlement).  Many of the former players are suffering from diseases like ALS, Alzheimer's and dementia, which they claim are related to multiple concussions that occurred while they were active in the NFL. 

    Earlier in 2015 (before the announced settlement), several NFL players made news by announcing their retirements before the age of 30. One of them, Chris Borland, was a 24-year-old San Francisco linebacker who quit after a brilliant rookie year. A rising star with no extensive history of concussions, he would have earned over $500,000 in the upcoming season.  He was quoted, "I don't think it's worth the risk. […] I'm concerned that if you wait till you have symptoms, it's too late" (Washington Post, March 25, 2015).  How many more will follow and how soon? 

     The potential NFL draft class of 2025 is now about twelve years old and needs many years of permission slips from adults to put on pads and helmets.   Despite increasing injury concerns around tackle football, however, the number of American youngsters playing the sport has remained stable since about 2009.  In 2014, 1.88 million children, ages six to fourteen played organized tackle football (and of them, almost 2000 are girls). A recent study involving 42 former NFL players showed that those who started playing football before age twelve did worse on thinking tests than players who started after age twelve, and all of the players scored below average for their age and education (Bowen).  Robert Cantu, in his book Concussions and Our Kids, states that "By age fourteen, our necks are strong and our overall body strength is sufficient to keep the head steady when slammed at the line of scrimmage" (145).

    Could football really just go away?  Or will it wither, just as boxing fell swiftly from a popular American sport to a disreputable guilty pleasure with a limited audience? (Remember the "punch drunk" boxers suffering from a blow to the head?)  Many have expressed the opinion that football is far more dangerous than scientists or the sport itself ever acknowledged. Football's huge problem is that the latest data indicate that repeated blows to the head at any age, not just big hits by big players in the pros or college, can lead to brain damage.  Those cute little kids in their comic-looking big helmets are apparently at risk, too.  A recent article entitled "A Mother holds the line against tackle football" sums up one parent's reasoning for not allowing her son to participate:

    But it's not just football. Let's look at soccer.  Last year nearly 12,000 high schools had boys or girls' soccer teams that totaled about 800,000 players (and that's just high school). Recent analysis of data from 100 schools participating in a longitudinal study showed that 627 girls and 442 boys sustained concussion during practice or competition.

    About 31% of the boys' and 25% of the girls' concussions stemmed from heading the ball.  However, contact with another player while trying to head the ball, rather than actual contact with the ball, was determined to be the main problem.  Most of the injuries occurred during competition, where heading opportunities occur more often than in practice (“Heading the ball…”).  A group called Parents and Pros for Safer Soccer has launched a campaign to ban heading the ball by players younger than fourteen. 

     Brittni Souder, who played soccer in high school, suffers horrendously from post-concussion syndrome, with terrible headaches every day.  She kept playing even after steroid injections into her head, a scalp that has no feeling in the back because she had the nerves surgically removed, and six documented concussions.  Headers were her specialty.  In her senior year at Hood, she was asked why she continued playing, especially at a Division III school, for an average program, with no scholarship and no promise of a professional career, and multiple surgeries to her brain.   She said it was an addiction. She now admits "I was crazy" (Smith).

    Anyone with moderate or severe signs of Traumatic Brain Injury requires medical attention as soon as possible.  Little can be done to reverse the initial brain damage caused by trauma, but early treatment can prevent further injury.  Primary concerns include insuring proper oxygen supply to the brain, maintaining an adequate flow of blood, and controlling blood pressure.  Imaging tests are used to determine the diagnosis and prognosis of a patient with traumatic brain injury.  Patients with mild to moderate injuries usually receive skull and neck x-rays to check for bone fractures or spinal instability.  For more severe cases, the imaging test is usually a CT scan.

    Approximately half of severely injured patients will need surgery to remove or repair hematomas or contusions.  The type of disability and the extent of the problems depend upon the severity of the injury, the location of the injury, and the age and general health of the patient.  The most common disabilities include problems with cognition (thinking, memory and reasoning), sensory processing (sight, hearing, taste and smell), communication (expression and understanding), and behavior or mental health (depression, anxiety aggression). The most serious injuries result in stupor, an unresponsive state, coma, or a vegetative state.

    Rest, both physical and mental, is the most appropriate way to allow the brain to recover from a concussion: avoiding physical exertion, including sports, and limiting activities that require thinking and mental concentration.  Pain relievers can be used for headache, but there are no real drugs available to treat concussion.

Current Research

    The increasing number of sports related head injuries has created new interest in helmet design.  Riddell, a major manufacturer and supplier of helmets, has developed a "Insite Impact Response System" that can be used to detect different levels of sensitivity and report data on impacts sustained by the helmet to the trainers and coaches on the sidelines.  This kind of information could be a vital tool in assessing whether a player has suffered a potential concussion that might otherwise go unnoticed.  There are several models of impact sensors now available.  A bill introduced last year in the Maryland General Assembly would have created a pilot program designed to introduce this type of technology to state high school programs.  The Maryland Athletic Trainer's Association lobbied successfully against the bill, stating that "the science just isn't there, and these devices are not ready to be used in a diagnostic manner" ("Impact Sensing Helmets")

    Another effort is being evaluated at Princeton University.  A small sensor, about the size of a quarter, is being affixed with an adhesive patch behind the ear of soccer players.  Volunteers from both the men's and women's teams took part in a season-long study of head impacts on the field using these sensors, which are equipped with an accelerometer and a gyroscope.  The sensors detect, measure, and record the accelerations of the athlete's head.  The goal of the study is to get a scientific estimate of the number and severity of impacts to the head that soccer players experience in a typical game.  The research may also contribute to an understanding of what types of impacts cause concussions, but so far, no Princeton player wearing the sensors has sustained a concussion.  The principal investigator for this study, Dr. Margot Putukian, stated that "while helmet-mounted sensors have enabled similar studies in football and ice hockey, collecting data without the use of a helmet is a relative recent development" (quoted in Tomlinson). Participating students also completed neuropsychological testing before and after the season to determine any change in cognitive function.

    In 2013, President Obama announced the launch of the BRAIN Initiative (Brain Research through Advancing Innovative Neurotechnologies), a program that could potentially do for neuroscience what the Human Genome Project did for genomics. The initiative's five participating federal agencies (Food and Drug Administration, National Institutes of Health, National Science Foundation, Defense Advanced Research Projects Agency, and Intelligence Advanced Research Projects Activity) are joined by such private companies as GlaxoSmithKline, Google, General Electric, with some financial support provided by major foundations and universities. Top scientists have developed a twelve-year strategy for the NIH to lead this effort. " NIH Director Francis Collins states,  “the human brain is the most complicated biological structure in the known universe.  We've only just scratched the surface in understanding how it works—or, unfortunately, doesn't quite work when disorders and disease occur"  ("The Brain Initiative").

    The initiative will accelerate the development and application of new technologies that will enable researchers to produce dynamic pictures of the brain that show how individual brain cells and complex neural circuits interact at the speed of thought.  These technologies will open new doors to explore how the brain records, processes, uses, stores, and retrieves vast quantities of information and shed new light on the complex links between brain function and behavior.

     The NCAA and the Department of Defense launched a $30 million study on concussions and head injuries last year.  About 37,000 student-athletes are expected to be part of the study over a three-year period.  One discovery made by the Combat Casualty Care Research Program at Fort Detrick is a device recently approved by the FDA.  A headset and sensors attached to a smart phone can read electrical activity in the brain and flag symptoms of traumatic brain injury without using X-ray scans or bringing the affected service member to a hospital (Carignan).

    Traumatic brain injury can to a large extent be prevented by following simple guidelines such as avoiding dangerous activities and wearing protective gear when available.

     Broader actions include advocating for anger management classes for parents and child care workers (to reduce occurrences of Shaken Baby Syndrome) and supporting changes in youth sports programs.

     Prevention is the key; there is no cure for TBI. Follow information from ongoing research programs, adopt changes in lifestyle as appropriate or advocate for changes in others who may be at risk, and remember: you only have one brain—do what you can to protect it and it will serve you well!

Works Cited and Consulted

Bi0graphy of Anna Johnson-Winegar

    Dr. Anna Johnson-Winegar earned a BA in biology and subsequently MS and PhD degrees in microbiology.
 
   She spent over 35 years working for the federal government, rising through the ranks from a bench research scientist to a science administrator, and finally serving as the Deputy Assistant Secretary of Defense (Chemical and Biological Programs). 

    She has published numerous technical manuscripts and co-authored several book chapters.  She represented the Unites States on several panels in NATO addressing medical and defense issues and has testified before Congress on several occasions. 

    She received the Lifetime Achievement Award from Women in Engineering and Science, and the Presidential Rank Award as a Meritorious Senior Executive. 

    She did volunteer work for the American Cancer Society for over thirty years and was honored to serve as the National Chair of the Board in 2007.  An active member of her church, she has served in various capacities in the UCC denomination. 

    This paper was presented to the Frederick Torch Club on September 26, 2015.