How Do Brains Get Traumatized?

Traumatic brain injuries can occur anywhere at any time but at least one in five occur on football fields, in boxing rings, on hockey rinks, and in similar places where contact sports, both amateur and professional, are played. Professional athletes may have access to the best protective gear, sports medicine specialists, and treatments available and still sustain brain trauma. The case of Eric Lindros provides an example of a highly skilled professional athlete whose career was cut short by TBI.

Lindros, an all-star center for the Philadelphia Flyers in the National Hockey League, sustained a head injury in a 2000 game. Elbowed in the head by an opposing player, Lindros collapsed to the ice. His regulation helmet had failed to provide his brain with adequate protection. Lindros was helped to the locker room, where he vomited. After the game, Lindros suffered from a severe headache and complained of seeing strange colors. The team doctor gave him ibuprofen, an over-the-counter pain medication, and cleared him to play in the team’s next game. “I knew that things were not good, and I tried to convey that through my symptoms,” Lindros said. “But I was not going to pull myself out of the game.”¹⁴

Lindros’s symptoms persisted. Nine days after the injury, Lindros finally saw a specialist in brain trauma who diagnosed a moderate concussion. The doctor told Lindros that if he sustained a second concussion before the first trauma healed, the result could be permanent brain damage. Lindros sat out the next ten weeks of the season but soon after returning to the team sustained another concussion. This time, doctors advised him to retire. Lindros refused and continued playing until 2007, when he finally left the sport. In the mean-time, he sustained several more concussions and never again achieved the superstar status that he had enjoyed prior to the 2000 season. “I wanted to keep playing,” Lindros said. “That’s the mentality of a player—‘Everything’s going to be fine, it’s going to go away’ and you just keep on playing.”¹⁵

What Is Shaken Baby Syndrome?

Infants are very susceptible to traumatic brain injury. Their heads are the largest parts of their bodies and their necks aren’t yet strong enough to support the weight and movements of their heads. When they are shaken, their heads can whip back and forth violently, causing concussion, ruptured blood vessels, brain swelling, and formation of blood clots. Also, they can sustain eye damage that can lead to blindness—a whiplash motion can result in detached retinas or scarring of their optic nerves.

Today such injuries are known as Shaken Baby Syndrome, or SBS. Typically, a baby is hurt by a parent, babysitter, or other caregiver who is angered by a fussing baby and shakes the infant in a tragically misguided effort to make the baby stop crying. “In other cases,” adds pediatric nurse Celeste Wright, “SBS occurs from an accident. That is, the caregiver or parent might have simply been playing too roughly with the baby, throwing them in the air, holding them upside down, swinging them around, or jumping up and down with them.”

Regardless of the circumstances, Shaken Baby Syndrome can be devastating to the child. A study performed in Canada looked at SBS patients ten years after their diagnoses and found that only 7 percent of the patients were leading normal lives. Twelve percent were still in comas or other vegetative states, 60 percent were living with some degree of mental disability, and 85 percent were found to be in need of ongoing care for the rest of their lives.

Quoted in Kristi Patrice Carter, “Shaken Baby Syndrome,” Pediatrics for Parents, October 2001, p. 9.

Of course, playing sports is only one way in which people can sustain brain trauma. Accidents at home and in automobiles carry a risk of brain trauma. Riders who fall off their bicycles, even if they do wear helmets, can harm their brains. Victims of violent crime also often sustain brain trauma. Soldiers in combat zones are obviously at high risk of injuries of all kinds; in recent years, military personnel serving in Iraq and Afghanistan have been vulnerable to brain trauma from so-called improvised explosive devices, or IEDs. Insurgents in the two wars conceal and detonate these crude explosive devices, which are capable of spraying shrapnel over a wide area and penetrating helmets and armor.

Contact Sports

Lindros is among a long list of professional athletes who have seen their careers affected by TBI. Lindros’s brother, Brett, also had to retire from professional hockey after sustaining a concussion. “My brother came back too soon,” says Eric Lindros. “It wasn’t even a head shot. It was a shot to the chest, shaking his skull. He was in bad shape. For the longest time, he couldn’t even dial a phone. He’d have a phone with these huge numbers on it.”¹⁶

Shortly after retiring from professional hockey, Eric Lindros was named ombudsman for the National Hockey League (NHL) Players Association, the union that represents NHL players. As ombudsman Lindros serves as an advocate for players’ rights, particularly in health-related matters. Since accepting the job, Lindros has pressed the NHL for additional monitoring of players who have suffered brain trauma to ensure that they are not permitted to take the ice before their injuries have fully healed. He has also called for referees to be more vigilant in penalizing and ejecting players who deliver unfair and vicious blows to the heads of other players, which Lindros claims is on the rise. “The game has changed and the respect level has truly changed in what I’ve seen in the last seven years,” says Lindros. “There’s an unwritten code of conduct being stomped on and walked over. I don’t ever recall seeing so many questionable hits as now.”¹⁷

High-profile veterans such as Lindros have raised awareness of brain injury in professional sports. Athletes at other levels are not as fortunate. Even though the action may be slower and the hits not as hard, head injuries are still very common in college, high school, and community league sports, where they may go unreported and where the risk may be less well recognized.

Rick DiBlasi Jr., age thirteen, played in a spring hockey league in Buffalo, New York. During a game, he was sent sprawling by a hard check from an opposing player. After sustaining the hit, DiBlasi got to his feet, skated to the bench, and told his coach he felt fine. After resting for a few minutes, he skated back into the game.

After the game, though, DiBlasi complained of a headache. His parents gave him a Tylenol to ease the pain. Later DiBlasi went to a friend’s house, where he played street hockey. After the game, he started vomiting. His friend’s parents called an ambulance. At the hospital, DiBlasi was diagnosed with a concussion—which came as something of a relief to his parents, who thought his injury could have been much worse. “I started panicking,” said DiBlasi’s father, Rick DiBlasi Sr. “It was hours later, and I’m thinking it’s something like a blood clot.”¹⁸

DiBlasi may have avoided a much more severe head injury such as a blood clot because helmets, which can provide at least minimal protection, are standard equipment in ice hockey leagues. But helmets are not worn in all sports, and sometimes the lack of protection can prove unhealthy.

As a high school freshman in Buffalo, Jessica Montmarquet earned a starting position on the varsity field hockey team. Generally, field hockey players do not wear helmets, though the action during a field hockey game can be quite physical. During a preseason practice, Montmarquet collided with another player and sustained a concussion. Suffering from severe headaches, dizziness, and nausea, she was forced to miss three weeks of the season. Her headaches continued after she returned to the lineup. At first her parents told her to tough it out. “Nobody wants their kids to be wimpy,” said Montmarquet’s mother, Kathy Montmarquet. “We told Jess that headaches are going to happen and you either sit out or play through it.” Weeks passed, though, and Montmarquet’s headaches persisted. During a game, she was jostled and felt the pain in her head intensify; she also felt dizzy and nauseated. After the game, Montmarquet underwent a CT scan, which showed no further brain damage but confirmed she suffered a concussion. This time, Montmarquet was benched until her headaches went away. “If I knew what I know now, I wouldn’t have let her play [so soon],” said Kathy Montmarquet. “I guess, for us at least, initially you hear about concussions but you don’t think about it being as serious as it is until in her case it continues as long as it did. It took me awhile to grasp the seriousness of it and what could ultimately happen.”¹⁹

Heading the Ball

The incidence of concussions and other TBI is well known in contact sports such as ice hockey and field hockey. It is less well known that they are also common in games not regarded as contact sports, such as soccer. Justin Rutland, a thirteen-year-old boy from West Chester, Pennsylvania, died of brain trauma during a soccer match. After heading the ball, Justin returned to the sidelines where he complained of dizziness and a ringing in his ears. “He was sitting out and he fainted,” said Justin’s sister, Jiea Rutland-Simpson. “He never regained consciousness.”²⁰ An autopsy determined that Justin had massive bleeding in his brain after heading the ball—an injury that might have been avoided if Justin had worn headgear or if the technique of heading had been outlawed in youth soccer, as many advocates have demanded.

A 2000 study reported in the Journal of Trauma, Injury, Infection, and Critical Care found that the force of a soccer ball striking the head is 160 to 180 percent greater than the force of routine impacts sustained by football or ice hockey players who wear helmets. Said the author of the study, “It strikes me that any coach who permits or promotes heading a soccer ball by junior high school, high school, or college students puts not only the students at risk but is also personally at risk [for lawsuits]. Physicians involved with student athletes should take note of these findings and parents should also become concerned.”²¹

Another study reported that concussions are quite common in soccer. A report prepared for the National Collegiate Athletic Association (NCAA), the governing body for most intercollegiate sports in America, found that concussions account for 11 percent of all injuries sustained in women’s soccer as well as 7 percent of all injuries sustained in men’s soccer.

Other evidence suggests that even mild blows to the head during soccer games may have a cumulative effect. A study performed by the Medical College of Virginia tested sixty soccer players who said they frequently head the ball, and found that their levels of concentration, attention span, and overall mental functioning were lower than those of soccer players who said they generally do not head the ball during matches. The American Journal of Sports Medicine reports, “The cumulative effects of repeated injuries, even mild injuries, over time remains a serious concern to those involved in sports medicine. The fact that some athletes do not recover as expected from concussions and are hampered by persistent symptoms for weeks or months is troublesome.”²²

Weekend Chores

While brain trauma is always a concern on the athletic field, at least many athletes do take precautions. Helmets are common in contact sports such as football, ice hockey, and lacrosse. Baseball and softball players typically wear helmets when they bat and run the bases. Even youth T-ball leagues require their very young players to wear helmets. Participants in equestrian events wear helmets as they compete on horseback. Amateur boxers also wear padded headgear that provides them with some protection against blows to the head. Race car drivers wear helmets as well.

But head injuries outside of the sports arena usually occur when people are not wearing head protection. People involved in car accidents and people who slip on icy sidewalks or in their bathtubs cannot rely on even the modest protection that helmets provide. It is true that many construction workers, heavy machinery operators, and other laborers wear protective headgear on the job, but it isn’t likely that a homeowner undertaking a weekend fix-up chore dons a helmet before climbing a ladder.

Robert Anderson, the superintendent of the Jamesville– DeWitt School District near Syracuse, New York, had been spending the Labor Day weekend in 1995 painting the second-story trim of his house when he fell off a ladder and struck his head on his concrete driveway. “I had just painted that part of the house the day before,” Anderson said later. “Why I fell, I don’t know. I’ll never know. No one saw it. My son was home, and he came out and found me on the ground.”²³

Anderson was unconscious when his son found him sprawled on the driveway. The school superintendent spent the next five days in a coma. After regaining consciousness, Anderson was forced to undergo months of physical and mental therapy before he was able to return to his job.

Working atop a ladder is the type of risky activity that can result in TBI as well as broken bones. According to the U.S. Consumer Product Safety Commission, each year more than 160,000 Americans injure themselves in falls from ladders. Of course, people tend to do other risky things that often result in head injuries. Andrew Klein, sixteen, suffered a fractured skull after the driver of an all-terrain vehicle lost control, catapulting Andrew, a passenger, headfirst into a rocky ridge. Klein spent a week in a coma. When he emerged from the coma, the teen’s first words were, “I’m dying.”²⁴ Though he had regained consciousness, Klein did not recognize his parents. He eventually recovered his memory; he left the hospital and graduated from high school as an honors student. Still, for the rest of his life, he will carry a metal plate in his head, inserted to repair the gash in his skull.

Common Causes of TBI

Falls are the most common mishaps that cause traumatic brain injury, according to the U.S. Centers for Disease Control and Prevention (CDC), which reported in 2006 that 28 percent of all TBI occur when people fall and strike their heads. The second most common cause of TBI is motor vehicle accidents, which the CDC said accounts for 20 percent of head injuries in America.

Another common cause of TBI is what the CDC calls “struck by/against events,” which account for 19 percent of head injury cases. This category includes people who are struck by cars or other moving objects, such as baseballs, debris that might fly about a construction site, or an elbow swung by an opposing hockey player. It also includes injuries sustained by people who walk into objects, such as glass doors they thought were open. Violent crime also accounts for a large share of head injuries. The CDC reports that 11 percent of TBI is caused by assaults.

Other causes of TBI include accidents involving motorcycles and bicycles, which account for 3 percent of brain injuries; mishaps that occur on other forms of transportation, such as trains, buses and airplanes (2 percent); and suicide attempts (1 percent). The CDC reports that 7 percent of TBI is caused by various other factors, and the cause of 9 percent of head injury cases is unknown.

The fact that Klein, a teenage boy, was riding in an all-terrain vehicle without a helmet illustrates an important TBI statistic—teenage boys and young men are more likely than other population groups to engage in risky behavior, and therefore are more likely than others to sustain head injuries. According to the U.S. Centers for Disease Control and Prevention (CDC), each year more than eight hundred thousand people under the age of twenty-five suffer brain trauma, with the age group of fifteen- to nineteen-year-olds most at risk. In this age group, the CDC reports, one in about ten thousand young people are likely to sustain brain trauma and 17 percent of those cases will be fatal. The CDC further reports, that boys are 1.5 times more likely than girls to suffer head injuries.

Other Unanticipated Risks

Most people do not regard the act of riding in a car as risky behavior, but there is certainly a dangerous element to driving—particularly in inclement weather. Melissa Felteau of Ottowa, Canada, was injured in a car accident when the vehicle in which she was riding struck another car head-on during a snowstorm. In addition to serious internal injuries, she suffered significant trauma to the parts of the brain that control vision and other sensory organs as well as cognitive abilities. After her release from the hospital, Felteau, the director of public relations at a psychiatric hospital, developed a stutter, found it difficult to concentrate—she felt as though she was always under sedation—and experienced problems with her vision and memory

Before the accident, she was a gifted athlete and a competitive swimmer, skier, and whitewater kayaker. Her TBI affected her physical coordination, however. After the accident she often fumbled coffee mugs, pencils, and books and found it difficult to keep her balance when she walked. Persistent amnesia has been a problem too. “Names are very important to me,” Felteau says. “You can imagine how embarrassing it was for me to be the public relations director and not remember names.”²⁵

Famous people too have been known to risk head injuries that put their very lucrative careers in jeopardy. In 2006, for example, Rolling Stones guitarist Keith Richards was vacationing on Fiji in the South Pacific when he shinnied up a palm tree to pick coconuts. On the way down, Richards slipped and fell, banging his head on the hard surface below. Richards suffered a concussion. “Picking coconuts is quite common on the island,” a local resident told a newspaper reporter. “It’s just that Keith had a bit of an accident coming down.”²⁶

The mishaps that caused the brain trauma suffered by Anderson, Klein, Felteau, and Richards show how head injuries can occur when people are doing things most people would regard as quite ordinary. The consequences, however, can be catastrophic; according to CDC statistics, some fifty thousand Americans die each year from traumatic brain injuries.

Wounded in War

By 2008 America’s wars in Afghanistan and Iraq had cost the lives of nearly five thousand members of the American military and wounded another thirty thousand soldiers. TBI has become the most common injury among military personnel wounded in these conflicts. Recent studies by physicians at Walter Reed Army Medical Center in Washington, D.C., which treats most of the wounded, found TBI in at least 60 percent of the injured veterans who have returned from the two wars.

Improvements in battlefield medicine and body armor have saved the lives of many wounded soldiers and marines who otherwise would have died from their injuries. However, many of those who now survive even horrific wounds are returning to America to face a lifetime of debilitating brain trauma. “They’re surviving where they wouldn’t have survived before,” says Tim Silver, chief of physical medicine at Hunter Holmes McGuire Veterans Administration Medical Center in Virginia. “But they’re walking away with lasting effects of the head injury.”²⁷

John Sims, a fifty-one-year-old Army National Guard warrant officer, nearly died when his Black Hawk helicopter crashed in Iraq in 2003. He sustained brain trauma in the crash and, after returning to America, could no longer perform his job as a commercial airline pilot. He suffered from severe amnesia and could not even recognize people who are closest to him, including his wife, Violeta. “Six months after the injury, he received amnesia and forgot who I was,” Violeta Sims said. “This is a person with the same body, but he’s different, very different.”²⁸

Army National Guard major Russ Smith sustained a much milder injury in Iraq—he was struck by debris from a missile fired at the U.S. embassy in Baghdad. He was diagnosed with mild TBI; nevertheless, the injury has affected his life. Smith was knocked unconscious by the blast; he lost some of his hearing and suffers from chronic headaches and memory loss. He has also noticed some differences in his personality. Smith says he is more short-tempered and impatient: “I try to be conscious of my moods because I know I’m irritable.”²⁹

The Ultimate Cost

Of course, many members of the military pay the ultimate cost, losing their lives in battle. In 2006 National Geographic reporter Neil Shea accompanied army medic David Mitchell and other medical responders into the field in Iraq to report on their fight to save the lives of wounded soldiers. In one case, Mitchell’s team worked feverishly to save a soldier who suffered a chest wound. During a frantic few minutes, Mitchell and the other medics applied what they believed were lifesaving measures to seal the man’s wounds, stop the bleeding, and help him to start breathing again. After stabilizing the wound, Mitchell’s team turned him over to army doctors, believing they had saved the soldier’s life. Sadly, the doctors discovered a piece of shrapnel had penetrated the man’s brain—it was embedded too deeply to remove through surgery, and within minutes the head wound proved fatal. As Shea reported:

They pumped in pain meds, just in case and waited for his heart to stop. For Mitchell, the flare of triumph dies. He looks at me blankly, then walks away, saying nothing. It doesn’t always end like this. But these are the days the crews must get used to, the ones they never forget.³⁰

Brain injury can happen to anyone—among the people who have suffered concussions and other head trauma are professional athletes like Eric Lindros, teenagers like Jessica Montmarquet and Rick DiBlasi Jr., rock stars like Keith Richards, soldiers like Russ Smith, and homeowners like Robert Anderson. All have something in common: One moment they are going about their lives—skating in an NHL game, enjoying a vacation on a South Seas island, painting the house, or walking point on a surveillance mission in Baghdad—and the next they have suffered a blow to the head, sustaining injuries that could forever change their lives.