It is difficult to find both a comprehensive and accurate overview of statistical and epidemiological information about traumatic brain injury (TBI). It is essential for brain injury survivors, medical professionals, and government officials to be aware of pertinent, accurate, and current statistics about brain injury. Only armed with this information will we, as a society, be able to speak with powerful and informed voices about concussions, brain damage and the delivery of proper and adequate services and support for brain injury survivors and their families. These statistics and information are provided to focus public attention on this silent epidemic and critical public health issue.
Traumatic brain injury has reached epidemic levels in the United States and is a public health crisis.1
The silent epidemic of brain injury must be properly addressed by health care providers, insurance carriers, the federal, state, and local governments, school systems, sports organizations, and our military.
TBI is a significant cause of disability and death in all age groups, and sexes.2 Recognizing the prevalence of brain injury in the United States, the Brain Injury Association of America adopted the slogan “Anytime, Anywhere, Anyone– Brain Injuries Do Not Discriminate” for its brain injury awareness campaign.3
Traumatic brain injuries (TBI) of all degrees, including concussions, have received increased attention primarily due to increased media focus on brain damage and its long-term consequences to professional athletes and members of the armed forces.
Although medical and media awareness have changed over the years TBI is often-misunderstood, unrecognized, and undiagnosed.
Frequently difficult to diagnose, its victims may appear (to an uninformed observer) to have no disability while actually suffering from cognitive, physical, behavioral, and emotional impairments.
Emergency Department visits
TBI related hopitalizations
Using 2013 data, The Centers for Disease Control and Prevention (CDC) reported approximately 2.5 million emergency department (ED) visits, and 282,000 TBI related hospitalizations. This represented approximately 1.9 % of all hospital emergency room and hospital admissions during the year 2013.4
This data underestimates the full spectrum of brain injury. It omits individuals who sustained a TBI but never received care, or only received out-patient care at a doctor’s office or an urgent care facility, military personnel and veterans receiving care by the Veteran’s Administration.5
Largest proportion of TBI related hospitalizations (31.4%) and deaths (2.5%)
TBI disproportionally affects the very young, teenagers, and the elderly. In children (aged 0-14), and senior citizens (greater than 65) the leading cause of TBI was falls. Senior Citizens are especially vulnerable to sustaining a traumatic brain injury.
In an analysis comparing 2007 and 2013 injury reports, the CDC found a substantial increase in traumatic brain injuries to senior citizens caused by falls. This led the CDC to call for an “urgent need to enhance fall protection efforts” in this population.8 Persons aged 75 years or greater had the largest proportion of TBI related hospitalizations (31.4%) and deaths (2.5%).9 In teenagers and young adults (aged 15-34), motor vehicle crashes accounted for most traumatic brain injuries.10
Americans live with a TBI related disability
The economic cost of brain injury to society
Brain injury can cause physical, cognitive, behavioral, and emotional injuries. An estimated one out of every 6 Americans or approximately, 5.3 million Americans live with a TBI related disability.11
The economic cost of brain injury to society is estimated to be $76.5 billion, including $11.5 billion in direct medical costs and $64.8 billion in indirect costs (lost wages, lost productivity, non-medical costs).12
An alarming number of individuals who sustain a concussion and present to health care providers and hospital emergency departments fail to receive a proper diagnosis.13 Equally alarming, many patients with mild traumatic brain injury do not receive adequate follow-up medical care.14
Fifty-six percent of mild TBI cases identified by one study, had no documented mild TBI-related diagnosis in the ED [Emergency Room] record.15 Failing to render a proper diagnosis of concussion or brain injury prevents many individuals from receiving necessary treatment or follow-up care. This failure has important legal ramifications for brain injury victims who are often denied future health care benefits, government assistance, and legal compensation because no brain injury is established following the traumatic event.
Even of patients who received a diagnosis of concussion or mild traumatic brain injury, half failed to receive proper follow-up including, providing educational material, calling patients to follow-up, or scheduling a follow-up visit within 3 months of discharge from the emergency department.16 The study authors concluded their findings by highlighting that “an apparent lack of appreciation by many clinicians of the substantial symptom and life burdens experienced by a significant proportion of patients with injuries labeled mild.”17
Traumatic brain injury can occur in many ways. A brain injury is caused by a “bump, blow, jolt or penetrating wound to the head that disrupts the normal functioning of the brain.”18
Falls constitute the leading cause of TBI (47%), followed by blunt impact (e.g., being struck by or against a moving or stationary object) (15%), and motor vehicle crashes (14%). Other leading causes were self-harm and assaults (10%).19
Among U.S. workers, construction workers have the highest rate of fatal and non-fatal brain injuries.20 The leading causes of construction worker TBI were falls from roofs, ladders and scaffolds.21 These statistics led the CDC to call for improved fall protection, including better harness protection with proper fit and size, improved scaffold railing, guarding of unprotected holes and roofs, and safe ladders.22
of all combat casualties are brain injuries.
active duty service members sustained a TBI between 2000 and 2017.
of reported brain traumas were classified as concussions (2013).
Members of our armed forces returning from recent military engagements have been plagued by violence, suicide, cognitive, physical, and mental disorders leading to homelessness, violence and suicide caused by traumatic brain damage. TBI is the “signature wound” of the United States military conflicts in Iraq and Afghanistan.23 It is estimated that 22% of all combat casualties are brain injuries, compared to 12% of Vietnam related combat casualties.24
While in the military, service members may sustain a TBI similar to the civilian population, such as falls, vehicle accidents, or in sport activities. Active duty personnel may also sustain injury while engaged in military training, or deployment. Blast exposure in the military, from improvised explosive devices (IEDs), suicide bombers, land mines, mortar rounds, and rocket-propelled grenades place service members at an increased risk for sustaining a traumatic brain injury.25 The primary causes of TBI in Veterans of Iraq and Afghanistan are blasts, blast plus motor vehicle accidents (MVA’s), MVA’s alone, and gunshot wounds.26
Over 379,500 active duty service members sustained a traumatic brain injury between 2000 and 2017.27 This figure underestimates the true incidence of TBI in the military, since it fails to account for unreported concussions and overlooks service members who have had multiple TBI’s. Only one injury to a service member is counted for reporting.28
Concussions, so-called “mild” TBI comprise the majority of brain injuries reported. Using 2013 data, 83.3 percent of reported brain trauma, were classified as concussions. If a service member sustained more than one type (mild, moderate, or severe TBI), only the TBI of the highest severity TBI is reported.29
Veterans who have sustained all forms of TBI (mild, including concussions, moderate and severe) are at increased risk for developing early onset Alzheimer’s disease and dementia. Veterans even those with concussions without loss of consciousness had two times the increased in the risk for developing dementia.30
The Defense and Veterans Brain Injury Center (DVBIC) was established by Congress in 199231 to serve active duty members of the military, veterans and family members following a TBI. Activities include clinical care, research, education, and training.32 An interactive map exists to locate the nearest DVBIC location.33
or more of injuries related to intimate partner violence are to the head, neck or face
women are victims of domestic partner violence
Intimate partner violence, also referred to as domestic violence, is often an unrecognized cause of traumatic brain injury. 90% or more of injuries related to intimate partner violence are to the head, neck or face34, and a frequent cause of concussions and other forms of brain injury.
A brain injury caused by domestic violence can include: closed head injuries occurring when the victim is punched, shaken, or shoved. It can also occur when someone’s head is struck by an object or, slammed into a surface. Brain damage caused by lack of oxygen frequently occurs in cases of strangulation or when the head is pushed into the bed, causing breathing difficulty.
Victims of domestic violence are not routinely screened for TBI even when they present at the hospital with physical injuries. Most domestic violence victims receive no diagnosis of TBI, in part because the injuries are invisible, and a lack of screening. This failure prevents victims from receiving necessary services, treatment, and accommodations. A screening tool, known as HELPS has been developed to assist in screening for brain injury in victims of intimate violence.37
The tool recommends these questions be asked anytime intimate violence is suspected to have occurred:
Emergency department visits
TBI related hospitalizations
TBI related deaths
of youths reported at least one concussion in the prior year (2017)
Traumatic brain injury impacts children of all ages in ways both similar and dissimilar to adults. Because children’s brains are still developing, a brain injury can disrupt development, impact education, and lead to emotional and behavior consequences not immediately recognized.38
Using 2013 data, the CDC estimated 640,000 emergency department visits, 18,000 TBI related hospitalizations and 1,500 TBI related deaths among children 14 years of age and younger. In children aged 0 to14 years, falls and being struck by or against an object were the leading causes of injury. In children aged 15-24 motor vehicle incidents and falls were the leading causes of injury.39
Sports and recreational activities accounted for an estimated 325,000 TBI related emergency department visits in children and teenagers using 2012 injury surveillance data. For males, bicycle riding, football, and basketball account for most injuries. In females, bicycling, playground activities, and horseback riding accounted for the largest percentage of injuries.40 A 2017 survey of students in grades 9 through 12, found 15%, equaling 2.5 million youths, in the United States reported at least one concussion in the prior year.41
It is difficult to determine long-term disability in children following a brain injury because “disability” is a term with no consistent definition.42 School performance may be affected by a brain injury. Children who sustained brain injury may require specialized services and supports both in and out of the classroom. A large-scale study found over 61.6% of children with moderate to severe TBI received specialized medical and educational services and 13.3 % of children sustaining a mild TBI received these accommodations.43
Children with brain injury of all severities may experience cognitive and behavioral impairments not initially apparent. As the brain matures and greater cognitive and behavioral demands are placed on children, disabilities may be become more noticeable. Children should receive continuing follow up care to assess on going challenges and deficits following a TBI.44
of all epilepsy is caused by a traumatic brain injury
of individuals requiring hospitalization following a traumatic brain injury developed epilepsy within three years
of patients suffering one seizure following a TBI will develop a second seizure within the next two years
Post traumatic seizures and post traumatic epilepsy are terms used to describe seizures occurring following head trauma. Trauma has been recognized as one of the leading causes of seizure disorders and epilepsy.45 Approximately 20% of all epilepsy is caused by a traumatic brain injury.46 The risk of developing a seizure following head trauma varies between 4% and 53%, depending on the severity of the injury.
Seizures as a result of a traumatic brain injury can occur hours, days, months, or even years after the original brain trauma.47 Seizures may be caused by falls, motor vehicle accidents, and all types of brain trauma. The initial trauma may be mild, moderate or severe.
Approximately 10% of individuals requiring hospitalization following a traumatic brain injury developed epilepsy within three years.48 More than 86% of patients suffering one seizure following a TBI will develop a second seizure within the next two years.49
Researchers have found individuals who have had bleeding within the brain or underwent craniotomies and other brain surgery are at increased the risk for the development of seizures.
Informational videos provide useful information on seizures, and how and why they develop following a traumatic brain injury.50
Individuals who have sustained a traumatic brain injury are at an increased risk for developing an ischemic stroke.51 Patients who developed increased intracranial pressure, shifting of the brain within the skull, and a carotid or vertebral dissection were at most risk.52
It is estimated the risk of experiencing a stroke after TBI is ten times greater compared with patients who never sustained a TBI. After one year, 4.6 percent remained at a higher risk for developing a stroke. After five years, traumatic brain injury victims were 2.3 times more likely to sustain a stroke.53
Traumatic brain injury is a risk factor for developing Parkinson’s Disease. Recent research examined the medical records of over 325,000 American veterans to determine the risk of developing Parkinson’s disease following head trauma.
Records of service members with brain injuries ranging from “mild” to “severe” were reviewed. The incidence of Parkinson disease was almost double (0.58%) for veterans who experienced a traumatic brain injury compared to those who never experienced brain trauma (0.31%).
The incidence of Parkinson’s disease was related to the severity of brain trauma, ranging from 0.47% following a “mild” brain injury to 0.75% following moderate to severe brain injury.54
Individuals who sustained a traumatic brain injury were 24% more likely to be diagnosed with dementia than those without a history of TBI
Traumatic brain injury (TBI) has been associated with increased risk of dementia. Individuals who sustained a traumatic brain injury were 24% more likely to be diagnosed with dementia than those without a history of TBI.
The risk of dementia increased with the number of TBIs and severity of injury. Following a concussion (mild TBI), victims have a 17% increased risk of dementia.55 Following moderate brain injury, the risk of dementia more than doubled, and those with severe head injury risk of developing dementia quadrupled.56
A growing body of evidence establishes long-term consequences from all degrees of brain injury.57 Based upon an initial assessment of a patient’s level of consciousness following an injury, brain injury has traditionally been classified as “mild”, “moderate”, or “severe” in accordance with the Glasgow Coma Scale.58 Using these terms has led to considerable confusion in assessing a patient’s long-term outcome. The after-effects are numerous and diverse, regardless of classification.
Nothing is “mild” about a mild traumatic brain injury. “[I]t is clear that the consequences of MTBI are often not mild.”59 The term “mild” describes only the initial insult relative to the degree of neurological severity. There may be no correlation with short or long-term impairment or functional disability.60
Brain injury is a chronic disease with long-term consequences.61 The effects of a traumatic brain injury are greatly different from those due to a broken bone. A brain injury can affect an individual’s long-term physical and mental health. It can cause sleep disorders, cognitive impairment, neurodegenerative diseases, neuroendocrine dysregulation, psychiatric illness, and reduced life expectancy.62
It is estimated that 10 to 15 percent of mild TBI patients don’t recover after one year and may continue to have chronic and often debilitating post-concussive signs and symptoms.63 Developers of the Glasgow Coma Scale found most head trauma survivors have persistent disability 12-14 years after injury, regardless of initial classification.64
For individuals who sustained a moderate to severe TBI risk of death was over two times greater than control groups.65 Even patients suffering from a mild TBI exhibited a small but statistically significant increase in mortality compared with the general population.66
A brain injury survivor can never take a vacation from a brain injury. Yet, amazingly and tragically, the epidemic of brain injury is still a secret to most Americans. With the tremendous cost to individuals, families and society, brain injury must be foremost on our minds as a true public health crisis.
Brain injury is neither genetic nor contagious. Most brain injury is preventable. But, the tragic consequences of brain injury-the emotional, cognitive, behavioral, and physical problems last a life-time with enormous costs to society. TBI is a significant cause of morbidity and mortality to all age groups, and sexes.67 According to the Brain Injury Association of America, “brain injury is not an event or an outcome. It is the start of a misdiagnosed, misunderstood, under-funded neurological disease.”68 TBI is a “chronic disease process.”69 A brain injury affects everyone in the victim’s social network. The individual, spouse, children, and the entire social circle are affected by a TBI. We have made incredible progress in saving lives, now we must expend and expand the same care and resources in repairing and rebuilding those lives. Our brain injury survivor’s needs must be addressed.
The brain injury law firm® of De Caro & Kaplen, LLP provides legal representation to victims of brain trauma caused by vehicle collisions, pedestrian knock downs, dangerous construction sites, unsafe buildings and premises, and medical malpractice. Our attorneys, Shana De Caro and Michael V. Kaplen, each have over 35 years of experience representing victims of traumatic brain injury. They believe individuals suffering the long-lasting consequences of brain injury must be treated with compassion and respect. Shana De Caro is an officer and member of the Board of Directors of the Brain Injury Association of America. Michael V. Kaplen is a three-term president of the Brain Injury Association of New York State, past chair and member of the New York State Traumatic Brain Injury Coordinating Council. They have both served as Chair of the American Association for Justice, Traumatic Brain Injury Litigation Group.