Traumatic Brain Injury: A serious and underdiagnosed condition

I’m awoken in the middle of the night to my husband mumbling gibberish. During the day, he can’t recall words, such as magazine, in normal conversation. He has difficulty concentrating when reading dialogue. He loses his balance on a casual walk around our block.

You may be thinking that my husband is elderly or afflicted with dementia, but you’d be wrong. He’s a healthy guy in his late 20s. His symptoms are the result of a severe brain injury he sustained. For several months after his injury in 2009, I witnessed the life-altering effects that a brain injury can have and the frustration that my husband experienced dealing with his new condition.

In honor of Brain Injury Awareness Month, I wanted to provide information about monitoring and diagnosing brain injury because the outcome of a person who has sustained a brain injury depends on a quick and accurate diagnosis. I’m happy (and lucky) to report that my husband has recovered fully from his brain injury.


Traumatic brain injury occurs when a sudden trauma causes damage to the brain (NINDS, 2002). An estimated 1.7 to 3.6 million traumatic brain injuries (TBI) occur in the US every year, with annual health care-related costs of more than $48 billion (CDC, 2010; Langlois et al., 2006). Most of these injuries are closed head traumas, which include concussions, meaning that the skull remains intact even though the brain tissue is injured.

Artist's rendering of a closed brain injury.
Artist’s rendering of a closed brain injury. Courtesy of the US Department of Defense.

After sustaining a brain injury, a person can have symptoms as varied as difficulty remembering new information, nausea, anxiety, or insomnia. Some of these symptoms can last weeks or longer after the injury. (CDC Brain Injury Fact Sheet [pdf])

• No two brain injuries are exactly the same.
• The effects of a brain injury are complex and vary greatly from person to person.
• The effects of a brain injury depend on such factors as cause, location, and severity.

The Brain Injury Association of America offers these reminders as well as information on what happens when the brain is injured.


For mild brain injury, experts agree that increased rest and limited exertion are important to facilitate the patient’s recovery. Someone who has had a head injury should consult their health care provider and proceed with caution when returning to driving, work, or school. Patients should get adequate sleep at night and take daytime naps or breaks when they are tired.

Symptoms typically worsen or re-emerge with exertion. There is evidence that the brain is more susceptible to a subsequent head injury while recovering from one.

When someone has a moderate to severe brain injury, treatment may be needed for physical, occupational, or language rehabilitation, as well as psychological issues. There are many health care providers and community resources available for individuals with brain injury and their caregivers.


From the Institute of Medicine’s Sports-related Concussion in Youth report (emphasis is mine):

“Despite increased knowledge about concussions and a growing recognition in recent years that concussions involve some level of injury to the brain and therefore need to be diagnosed promptly and managed appropriately, there is still a culture among athletes and military personnel that resists both the self-reporting of concussions and compliance with appropriate concussion management plans.”

How do you know if an athlete had a head injury? ThinkFirst offers these guidelines:

Observed Signs:

  • Appears dazed or stunned
  • Confused about assignment or position
  • Forgets an instruction
  • Is unsure of game, score or appointment
  • Moves clumsily
  • Answers questions slowly
  • Loses consciousness (even briefly)
  • Exhibits mood, behavior or personality changes
  • Can’t recall events prior to hit or fall

Symptoms Reported by Athlete:

  • Headache or pressure in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling sluggish, hazy, foggy or groggy
  • Concentration or memory problems
  • Confusion
  • Just does not “feel right”

If any of the above signs or symptoms occur, the athlete should be kept out of play the day of the injury and seen by a health care professional skilled in evaluating concussions.

The CDC offers “Heads Up” toolkits and online courses that provide important information on preventing, recognizing, and responding to a concussion. The information is tailored to sports coaches, physicians, school personnel, and parents.

Several companies offer devices to monitor head impact while playing sports. X2 Biosystems bundles a sensor, which can be worn behind the ear, and monitoring software to analyze head impact and concussion symptoms in real time. Quantum Institute offers mobile quantitative EEG (electroencephalography) that shows changes in brain electrical activity after sustaining a blow to the head. Sporting-goods manufacturer Reebok developed a sensor, which can be worn under a helmet, to indicate linear and rotational movements to the head that exceed thresholds for moderate and severe impacts. Triax Technologies employs a similar measurement with a headband-mounted sensor that sends impact data for up to 63 sensors to a sideline computer.

Athletic programs can use lower-tech solutions as a first-line assessment for concussions. A recent study showed that athletes who had suffered a concussion had significantly slower reaction times to grasp a falling stick than athletes who did not suffer a concussion. While it was known previously that reaction times increase substantially after a head injury, these researchers showed that the reaction time can be assessed with an inexpensive setup that doesn’t require extensive computer analysis.

Note that “there is limited evidence from epidemiological and biomechanical studies that current helmet designs reduce the risk of sports-related concussions.” (IOM, 2013)


From 2000 to 2012, more than 260,000 military service members had a traumatic brain injury. TBI is often referred to as an “invisible wound of war” and has been a signature of the wars in Iraq and Afghanistan.

Incidence of traumatic brain injury cases documented for US military service members by severity, 2000-2011.

The Department of Defense presents a special report on TBI that covers diagnosis and management, ongoing research, and personal stories from service members.

The Report to Congress on Traumatic Brain Injury in the United States (2013) compiles information about how brain injury occurs, how it is diagnosed and treated, and makes recommendations for future research to address the knowledge gaps in TBI.

Estimates indicate that 10% 50% of persons with a mild TBI experience long-term health issues such as persistent headache, difficulty with memory or concentration, or mood changes (Moppett, 2007; Thornhill et al., 2000).

Most of the information in the report to Congress is linked back to brain injury in the military, but a significant portion of the background material is relevant to TBI in general.


New research on traumatic brain injury is published regularly. Since the public’s awareness of TBI has increased, so too have funding and research output. Below I’ll highlight two recent TBI studies that intrigued me.

In patients diagnosed with mild TBI, researchers noted that elevated levels of C-reactive protein at diagnosis were associated with persistent post-concussion syndrome, psychological problems, and cognitive impairment. (Su et al., 2014) If further studies confirm this association, C-reactive protein levels may be used to predict persistent problems following mild brain injury.

From a small group of retired NFL players, positron emission tomography (PET) scans of the brain showed patterns of PET signals that were consistent with patterns of tau protein observed in autopsies of subjects with chronic traumatic encephalopathy (CTE). (Small et al., 2013) The authors hope that PET scanning could be a method to detect early changes to brain tissue following traumatic brain injury.


Head Games movie (2012) about sports-related head injury

PBS Frontline episode (from 10/8/2013): “League of Denial: The NFL’s concussion crisis

National Resource Center for Traumatic Brain Injury

BrainLine is a national multimedia project offering information and resources about preventing, treating, and living with TBI. BrainLine includes a series of webcasts, an electronic newsletter, and an extensive outreach campaign in partnership with national organizations concerned about traumatic brain injury.