young people under 45 years of age. This makes it the single most common cause of death and disability for individuals under the age of 45 (Faul 2015).
The most common causes of TBI/concussion include road traffic incidents or accidents (RTI), falls, sporting injuries, and interpersonal violence.
What is interesting about TBI/concussion is that the causes have evolved over time in keeping with our changing lifestyles, human interactions, world order, and technology. A major study on the incidence and occurrence of TBI worldwide reported on the Global Burden of Disease Study in 2016 revealed that the two leading causes of TBI were road traffic accidents and falls. The increase in the incidence of TBI between 1990 and 2016 can be attributed to the increase in population density, population aging, and the increased use of motor vehicles, motorcycles, and bicycles (GBD 2016).
Road traffic accidents increasingly affect the youth in low–middle-income countries, and this ties in with the male preponderance of the condition (Maas 2008). Developing nations are more significantly affected by this condition due to defective roads, the lack of or limited enforcement of laws that promote safety, and defective equipment.
Alcohol and substance abuse also play an important role in such cases. The highest rates of TBI in Latin America and the Caribbean result from road traffic incidents (RTI) and violence (Murry 1996). RTIs are the most significant contributor to the economic costs associated with TBI in Latin America (Hijar 1999). Further, violence is the second largest cause of intracranial injury in the Latin American region as well as a principal cause of death in Brazil, Columbia, Venezuela, El Salvador, and Mexico (Briceno-Leon 2005).
A study covering a quarter of a million people in Ontario, Canada, showed that the long-term risk of individuals who have a concussion committing suicide is three times the general incidence. When the concussion occurs over a weekend, the risk is even higher (Frallick 2016).
While motor vehicle accidents remain the major cause of TBI in high-income countries (HICs), there has been a relative increase in age-related TBI due to falls in HICs. This has been evidenced by the growth in the oldest segment of the elderly population and in the pediatric age group. Falls in the elderly are the major cause of TBI due to aging factors resulting in the loss of balance and motor control and the medical conditions of the elderly (Brazinova 2016, CDC 2015, Peters 2015, CDC 2010).
The increased incidence of injury related to sports has been noted and this in part is due to better education and higher self-reporting (CDC 2011, Hootman 2007, Lincoln 2011).
Military conflicts being a major cause of injuries have placed war-torn Syria as the country with the highest incidence of TBI in recent times (GBD 2018).
The direct costs incurred due to TBI in the USA have been estimated at $13.1 billion per year. An additional $64.7 billion is lost because of missed work and lost productivity. The total medical costs range from $63.4 to $79.1 billion (Salassie 2008, Coronado 2011).
These cost estimates mostly cover direct costs, such as that spent on acute care, hospitalization, acute, and sub-acute rehabilitation. However, these numbers are believed to be an underestimation because they do not cover certain indirect long-term costs such as neurobehavioral management and the impact on families and social order. Worldwide, direct and indirect costs related to TBI borne by the global economy are estimated at approximately $400 billion per year.
Concepts and terms that better define TBI/concussion in the context of the BHET Method
OVER THE YEARS, the pressure to implement well-defined research methodologies combined with our misunderstanding of how the brain works, is injured, and how it recovers has forced us to standardize what many experts believe to be unsound definitions of what a concussion and/or a Traumatic Brain Injury (TBI) is. In fact, we now know that some of our conclusions regarding a brain injury and its impact have been sometimes wrong or misleading. These unsound definitions have caused us to have generations of people with missed cases of concussion and TBI. Imagine playing American Football in the 1960s, 1970s, 1980s, 1990s and even in early 2000. In many cases, you would not be considered to have suffered a concussion or TBI without loss of consciousness (LOC). LOC was a key part of defining a concussion, and this remained the case for many years. While LOC continues to be a factor in the definition, one needn’t have experienced LOC to have suffered concussion or TBI. We now know that most persons who suffer a concussion do not in fact experience LOC. I have seen patients with gunshot wounds to the head with a bullet traversing the frontal lobe of the brain with what we know to be a severe TBI requiring major neurosurgical intervention and yet not have experienced LOC. In a study performed with 343 individuals with concussion, more than 80% did not experience LOC and 95.6% had Glasgow Coma Scale (GCS) scores of 15/15 on presentation to the Emergency Department (ED). A score of 15 represents the best possible score following an injury (Pensford 2019).
A study published by the University of Pittsburgh Medical Center for Sports Medicine determined that only 2 out of 107 athletes with concussion suffered LOC, indicating that approximately 98% of persons with concussion in their program did not suffer LOC. According to Kenzie et al. (2017), LOC during concussion has been evidenced at 14%.
Even today, I hear some of my colleagues in neuroscience say that you must have LOC to be considered as having a concussion or TBI. How sad and uninformed! Several ex-football players who participated in hitting exercises whom I see as patients today tell me that if they did not experience dizziness, spinning sensation, feeling of being in a fog, or daze, they were considered “a softy.” What they did not know at the time is that every time they experienced these symptoms, yet another cerebral concussion was heralded. What we now know is that repeated hits to the head as that witnessed in American Football can lead to long-term consequences, including conditions such as chronic traumatic encephalopathy (also known as (CTE), a form of Dementia commonly seen in athletes with repeated hits to the head (McCrory 2017). Increasingly, data shows that even players with multiple hits to the head who are not considered to have suffered concussion (sub-concussive hits) can suffer long-term consequences such as CTE, a degenerative disorder of the brain caused by TBI and concussion (Moore 2017, McAlister 2017, Gardner 2015, Washington 2016).
Concussion occurs when mechanical forces affect the brain in such a manner that the physiological hierarchical organization and the associated functioning of the brain are disrupted to the extent that the patient experiences signs and symptoms which we now know are characteristics of concussion. These signs and symptoms include the following:
• Physical: fatigue, sleep disturbance, dizziness, spinning sensation, headaches
• Cognitive: mental fog, memory and attentional impairment, word-finding problems, communication problems
• Neurobehavioral: anxiety, depression, panic attacks, low self-esteem, fear, racing thoughts, short fuse, obsessive-compulsive tendencies
At its core, concussion have much to do with an imbalance between energy availability and its utilization throughout the brain or in certain parts of the brain (Giza 2001).
Following concussion/TBI, the delicate hierarchically organized structure of nerve cells or neurons working in an array becomes impaired and disorganized. These structures are responsible for the orderly production of energy to ensure the proper function of the brain. After injury, the brain remains impaired until there is recovery or reorganization of these neurons.
Applying the GCS criteria, approximately 80% of all TBI/concussion cases are classified as mild head injuries (Bazarian 2005, Rutland 2006). Data from various studies have shown that
