The Future of Brain Trauma

The number of veterans of the Iraq and Afghanistan wars who have suffered traumatic brain injuries may be staggering, but the casualty count could have been a lot higher. Starting in late 2003 the military employed a newly designed helmet that has done a better job of deflecting and absorbing shrapnel than its predecessors. Known as the Advanced Combat Helmet, the headgear is composed of layers of Kevlar, a synthetic product that is stronger than steel but still retains an elastic quality. Therefore, the Kevlar layers can absorb more of the blow from a bomb blast without tearing. The helmet has even stopped direct shots from small arms, a feat unprecedented in helmet technology.

Adrian Danczyk’s life was saved by an Advanced Combat Helmet. While serving in Iraq, Danczyk sustained a gunshot wound to the head. “I knew what had happened as soon as I was hit,”⁶⁰ Danczyk said. When examined by a medic, Danczyk was found to have suffered a minor cut only; his helmet had absorbed most of the impact from the gunshot.

The development of the Advanced Combat Helmet illustrates how technology is improving the odds for military personnel who are at risk of sustaining TBI. Elsewhere, engineers are working on new designs for football helmets and other headgear worn by athletes. The new designs are based on medical research that has provided a better understanding of how concussions and other brain injuries are caused. Meanwhile new instruments and surgical techniques are being employed in operating rooms, providing surgeons with tools that can make surgery less intrusive, giving many TBI patients better chances at recovery than they ever had before.

But better helmets and other protective devices only work if people use them. Across the country, the movement to make helmets mandatory for all motorcycle and bicycle riders has stalled. And though many soccer leagues are now requiring players to wear head protection, some soccer enthusiasts are skeptical about the effectiveness of headgear for players.

Motorcyclist Deaths Increasing

A study by the National Highway Traffic Safety Administration concluded that while overall highway deaths have been declining in recent years, the number of fatalities involving motorcyclists has been spiraling upward. In 1997, the association reported, 2,116 motorcycle riders died in traffic accidents. In 2005 the number of fatalities involving motorcycle riders was recorded at 4,553—a 215 percent increase.

The administration said the death rate was 30 percent higher in states that do not require riders to wear helmets. In the 24 states that do not require helmets, 2,590 deaths were recorded in 2005 while in the 26 states and Washington, D.C., that do require helmets, 1,963 motorcyclists suffered fatal injuries. Says a statement by the Insurance Institute for Highway Safety, which lobbies for mandatory helmet laws:

Motorcycles are less stable and less visible than cars and often have high performance capabilities. When motorcycles crash, their riders lack the protection of an enclosed vehicle, so they’re more likely to be injured or killed. The federal government estimates that per mile traveled in 2005, the number of deaths on motorcycles was about 37 times the number in cars. . . .

During the past decade several states have repealed or weakened their helmet laws. In 1997 helmet laws in Texas and Arkansas were weakened to apply only to younger riders. Kentucky weakened its law in 1998, Florida weakened its law in 2000, and Pennsylvania weakened its law in 2003. Louisiana weakened its law in 1999 but reverted to universal coverage in 2004. Repealing or weakening helmet laws so they don’t apply to all riders has been followed by increases in deaths. In contrast, benefits return when helmet laws applying to all riders are reinstated.

“Fatality Facts 2006: Motorcycles,” Insurance Institute for Highway Safety. www.iihs.org/research/fatality_facts_2006/motorcycles.html.

Indeed, safety advocates know they still have a lot of work to do to persuade people to take simple precautions against what can be devastating injuries.

Blowing the Whistle on Concussions

In light of the brain trauma suffered by such high-profile stars as Andre Waters, Mike Webster, and Justin Strzelczyk, the National Football League has instituted some reforms designed to reduce the number of concussions suffered by players. In 2007 the NFL conducted a summit on concussions for team trainers, physicians, and other officials, providing them with the latest information on the causes and treatments of head injuries. Participants also exchanged ideas on how to better recognize head trauma in players who have always been reluctant to tell their trainers and coaches about on-field injuries.

Among the changes in league policy adopted as the result of the meeting was the establishment of regular neurological tests for all NFL players to determine whether they may be suffering from brain trauma. The tests are administered to the players prior to the season so that physicians can develop a baseline record of players’ reactions and responses. By putting the athletes through a series of tests, physicians develop data on the attention span of the players as well as their motor coordination and balance. After the initial tests, the players are assessed again from time to time during the season to determine whether their abilities have deteriorated, which could indicate that they are showing the first subtle signs of brain injury. In the event a player sustains a concussion, doctors recommend holding him out of competition until the athlete’s neurological signs reach preseason levels. That way players and team officials alike can be more confident that a player has completely healed before he resumes play. Many colleges have also adopted preseason neurological testing for players.

Another policy change that was adopted as a result of the concussion summit was a very simple change in league rules: All players are now required to snap their chin straps. It was a minor change in league rules, to be sure, but a helmet doesn’t provide much protection unless it fits snugly on the head. Finally, the NFL established a “whistle-blower” program enabling any member of an NFL team to anonymously report players who take the field even though they may be suffering from brain trauma. Whistle-blowers are also encouraged to tell league officials about coaches they believe are pressuring brain-injured players to participate in games or practices. Troy Vincent, the president of the NFL Players Association, the union that represents professional football players, said the whistle-blower program may be helpful because players often have to be protected from themselves. “To ask a player with a head injury if he wants to go back into a game, that’s not exactly the best thing,” said Vincent. “Most players are going to make the emotional decision. They’re going back onto the field.”⁶¹

Advances in Helmet Design

Away from the field, equipment manufacturers are studying ways in which the design and manufacture of football helmets can be improved to minimize concussions. Indeed, football helmets have evolved a great deal since the first helmet was worn by a player in the 1893 Army-Navy game. That helmet was fashioned from leather by a shoemaker for a player who had already sustained head injuries and had been warned by a doctor that another severe blow to his head could cause permanent injury. Today regulation helmets are made of rigid plastic. In 2002 manufacturers altered the design of the helmets after a study found that most on-the-field concussions are caused by blows to the side of the head, rather than as a result of head-on collisions. The new design extended the helmet’s protection to the jaw area and also increased padding, providing more distance between the head and the helmet so that more of the shock is absorbed by the padding. Manufacturers have made the new helmets available to professional, college, and high school teams.

Advances in helmet design are continuing. Some colleges have started using helmets equipped with sideline response system technology—electronic sensors that send signals to an off-the-field monitor that gauges the impact of a hit on a player’s head. If the system detects a hit hard enough to cause a concussion, the team’s medical staff is instructed to pull the player out of the game for an immediate evaluation. In fact, trainers and doctors standing on the sidelines are wired right into the system; when the buzzers hooked to their belts go off they know immediately that a player has been hit in the head too hard. Laptop computers wired into the system record the force of the hits and the identities of the players who sustain them. Since many players refuse to tell the medical staff about hard hits because they don’t want to be pulled out of the game, the new technology will make it impossible for players to cover up their injuries. Other colleges plan to adopt the new helmets, and the NFL is also expected to introduce the helmets on a trial basis.

The University of Minnesota adopted the technology for its team in 2007. Defensive back Jamal Harris said he welcomes the device. Harris is known as a hard hitter. He has never suffered a concussion—at least he is not aware of ever suffering a concussion. Still, Harris said he is aware of the danger of head injury on the field. “It makes you feel better, so if I get my bell rung I know they’re watching out for me,” says Harris. “It makes me feel comfortable and everyone else feel comfortable. You know they don’t want you to get hurt.”⁶²

At this point, only a handful of high schools have adopted the technology, mostly due to the high cost of the devices. It costs $1,000 to outfit each player’s helmet as well as another $30,000 in equipment to monitor the impacts on the sidelines. One public school that has shouldered the expense is Tolono Unity High School near Champaign, Illinois. In 2007 the pagers and laptops alerted Tolono trainers to hard hits an average of three times a game, and helped the medical staff diagnose three concussions over the course of the team’s first six games. One of those concussions was sustained by offensive tackle Jonathan Conlon. Struck hard in the head, Conlon wobbled back to the sidelines. By the time he made it to the bench, the medical staff had already concluded he suffered a concussion—the laptop computer told them so. “I guess I was kind of glad we had it,” Conlon said of the device in his helmet. “If I didn’t know how hard the hit was, I probably would have wanted to go back in the fourth quarter and maybe get hurt more.”⁶³

Soccer Headgear

There is no question that football is a contact sport that requires players to protect their heads. Many fans of soccer, on the other hand, don’t regard the game as the type of sport that requires padding, including protective headgear. In light of the evidence that has surfaced linking TBI with heading the ball, however, many soccer leagues have started mandating that players must wear headgear as well. In 2003 the International Federation of Association Football, the world governing body for soccer, approved the use of headgear for soccer players; that year, players in the Women’s World Cup wore headgear for the first time, and in 2004 soccer players wore headgear for the first time in the Olympics.

In the United States many scholastic soccer teams as well as youth soccer associations have adopted the use of headgear, but not all soccer experts are sold on the equipment. The head-gear resembles an enlarged headband. It is padded with shock-absorbing foam around the sides and back. In the United States soccer has often been promoted as a safe alternative to football. Some soccer enthusiasts fear that if headgear becomes mandatory for young players, parents will withdraw their children from the teams rather than risk any head injuries at all. Jeff Skeen, head of Full90, which manufactures headgear for soccer players, says, “They are trying to thwart the evolution of headgear in soccer because they think it will scare soccer moms away from the sign-up table and because they think it could be viewed as an admission that heading the ball itself is dangerous.”⁶⁴

Optional Gear

Off the athletic field, people who ride bicycles and motorcycles are now subject to a variety of laws regulating who must wear helmets. While many states have not enacted laws requiring motorcycle riders to wear helmets, city and local ordinances do make helmets mandatory. Some states allow adult riders to go helmetless but require young passengers to wear helmets. To date twenty-four states have no laws requiring motorcycle riders or passengers to wear helmets. Similarly, twenty-nine states do not require helmets for bicycle riders.

There is no nationally coordinated campaign to press for more comprehensive helmet laws or the establishment of helmet laws in states where none exist. Some groups representing motorcycle riders have successfully lobbied state lawmakers to sponsor legislation making helmets optional and, in some cases, the legislation has been adopted.

In 2003, for example, Pennsylvania lawmakers repealed the state’s mandatory helmet law for motorcyclists. Five years later the University of Pittsburgh released a study reporting that since repeal of the helmet law, the number of head-injury deaths in the state rose 32 percent. Despite this startling increase, state officials insist that motorcyclists should decide for themselves whether to wear helmets. Pennsylvania governor Edward Rendell’s spokesman Chuck Ardo remarked, “The governor understands the statistics and he encourages all motorcycle riders to wear a helmet. But he believes it is a matter of personal choice.”⁶⁵

On the other hand, some states have enacted stricter helmet laws, often at the urging of insurers. In 1999, for example, Louisiana repealed its mandatory helmet law, then reinstated it five years later after the death rate for motorcyclists increased by 100 percent. Advocates of stricter helmet laws have settled in for a long, state-by-state campaign that, at least for now, appears to be making little progress.

The campaign to adopt mandatory helmet laws in America may be stumbling along, but that is not the case in other countries—particularly places where motorcycle and motorbike riding is a main form of transportation. In Vietnam, for example, motorcycles and motorbikes account for some 90 percent of all traffic on the country’s roads. By 2007 the death toll from motorcycle and motorbike accidents stood at a staggering thirty a day. Rose Moxham, an Australian living in the Vietnamese capital of Hanoi, witnessed a fatal accident: A group of motorcycle riders were stopped at a red light when they were struck from behind by a rider who failed to stop. One woman sitting atop her motorbike waiting for the light to change was knocked over. Her head struck the ground. “She dropped her bike, fell off, hit her head on the road and died,” said Moxham. “Just like that. Dead.”⁶⁶

In response to such incidents, the Vietnamese government has mandated that all motorcycle and motorbike riders must wear helmets. Prior to enactment of the law, it was estimated that fewer than 10 percent of riders in Vietnam wore helmets. Since establishment of the law, traumatic brain injuries caused by traffic accidents have been reduced by nearly 30 percent. Etienne Krug, director of Violence and Injury Prevention for the World Health Organization in Geneva, Switzerland, contends, “The countries that adopt and enforce helmet legislation reduce injuries and deaths. And the states that repeal them see an increase. It’s just a fact.”⁶⁷

No Bans on Pro Boxing

Another organized effort that seems to have stalled is the movement to outlaw professional boxing. (Several features of amateur boxing significantly reduce the risk of TBI. Amateur bouts are limited to four rounds instead of the ten or twelve rounds in traditional professional bouts. All amateur participants wear headgear and the goal of the competitors is not to knock out or bloody an opponent, but to score points by landing punches. Nevertheless, many amateur boxers eventually find themselves at risk of TBI because they turn professional.)

The American Medical Association (AMA) has been on record since 1983 calling for a professional boxing ban. Professional boxing is typically policed by state athletic commissions that establish their own rules for regulating bouts and ensuring the safety of the fighters. Each state has set its own rules regarding the weight and padding required in boxing gloves, important factors in the cause of head trauma. Moreover, in recent years a new version of boxing known as ultimate fighting or mixed martial arts has gained popularity. Perhaps even more brutal than boxing, ultimate fighting permits head-butting, kicking, and almost any other tactic a competitor might use to bloody and knock out an opponent. State athletic commissions are now policing those competitions as well. In 2003 U.S. senator John McCain, who fought as an amateur while attending the U.S. Naval Academy, proposed legislation giving the federal government authority over the sport of boxing. The act would establish a federal boxing commissioner as well as one set of rules for all professional boxing, but the legislation has failed to gain support in Washington. Marc Ratner, executive director of the Nevada State Athletic Commission, states, “The U.S. government has a lot more to worry about than the sport of boxing.”⁶⁸

In the meantime, no state has banned boxing but doctors still speak out. George A. Lundberg, the Louisville, Kentucky, physician who wrote the original AMA editorial calling for a ban on boxing, said that a knockout renders the opponent unconscious, which is a form of brain trauma. “That is morally just flat wrong,”⁶⁹ he says.

Advances in Medicine

As politicians wrestle with legislative issues, advances in medicine have improved the prognoses for many TBI patients. A new robotic arm guided by brain surgeons, for example, can perform microsurgery with far more precision than a surgeon can achieve with his or her hands. During the procedure the surgeon’s fingers do not enter the brain of the patient. Rather, the surgeon controls the robotic device from a computer terminal in another room. To perform the surgery the physician works from a map of the brain provided by a real-time MRI scan. The MRI provides surgeons with more detail than they can see with their eyes. The robotic surgery has been performed in Calgary, Alberta, by neurosurgeon Garnette Sutherland, who has compared it to playing a video game. “We would all agree that our young children who have become immersed in video games represent the future generation of surgeons,”⁷⁰ Sutherland says.

Meanwhile, new imaging equipment developed in part by the National Aeronautics and Space Administration (NASA) provides neurosurgeons with three-dimensional images of the brain, actually enabling physicians to look into crevices and around corners in the brain before cutting. The device is similar to an endoscope, a tiny camera that has been used for decades to provide images of human anatomy. NASA has helped develop the technology because a version of the camera may be used on future Mars landing missions.

Neurologists are also developing techniques to better assess patients in persistent vegetative states, and in some cases their prognoses are more optimistic. In the past neurologists gauged a patient’s reaction to noise as a method of determining whether the patient was hopelessly in a vegetative state. Now neurologists are finding some patients respond when they hear familiar sounds—such as the patient’s name or a family member’s voice. It means that the patients may have a slim chance of recovery instead of no hope at all. “We know from extensive research that brain responses of this type do not occur automatically,” says British neurologist Adrian Owen, adding that a vegetative patient’s response to a voice “require[s] the willed, intentional action of the participant.”⁷¹

Stem Cells and Brain Trauma

Stem cell research holds a lot of promise for traumatic brain injury patients, according to research performed at the University of California (UC) at Irvine. According to the 2007 study, mice with brain injuries demonstrated improvements in memory within three months of receiving the stem cell treatments.

Stem cell therapy uses cells at the very earliest stage of development—from unimplanted embryos at in-vitro fertilization clinics, umbilical cords and placental tissue at birth, and cells withdrawn from aborted fetuses—because research has shown that these cells are undifferentiated “blank” cells that can develop into all kinds of different tissue and organs for many different therapeutic purposes. Stem cells have the potential to replace damaged or diseased cells. Many conservative politicians and the antiabortion movement oppose embryonic stem cell research, however, arguing that embryos are persons and the research destroys human life. The controversy continues; meanwhile, stem cell research has been slowed in America because the federal government has refused to provide grants to universities and institutions conducting research.

Still, research has continued without federal aid. At UC Irvine, neurobiologist Frank LaFerla said, “Our research provides clear evidence that stem cells can reverse memory loss. This gives us hope that stem cells someday could help restore brain function in humans suffering from a wide range of diseases and injuries that impair memory formation.”

Medical technology that can help traumatic brain injury patients may be advancing, but there is no question that TBI remains a frightful, heart-wrenching, and devastating disability. Abundant evidence proves that motorcycle riders, bicyclists, and others can avoid traumatic brain injuries by wearing their helmets. Meanwhile, doctors and team trainers continue to counsel young athletes to recognize the warning signs of concussion and to realize that taking a seat on the bench may be the wisest way to respond to a blow to the head.