Traumatic Brain Injury in the United States: An Epidemiologic Overview
Abstract
A basic description of severity and frequency is needed for planning healthcare delivery for any disease process. In the case of traumatic brain injury, severity is typically categorized into mild, moderate, and severe with information from a combination of clinical observation and self-report methodologies. Recent US civilian epidemiological findings measuring the frequency of mortality and morbidity of traumatic brain injury are presented, including demographic and etiological breakdowns of the data. Falls, motor vehicle accidents, and being struck by objects are the major etiologies of traumatic brain injury. US civilian and Army hospitalization trends are discussed and compared. Features of traumatic brain injuries from Operation Iraqi Freedom and Operation Enduring Freedom are discussed.
MOUNT SINAI JOURNAL OF MEDICINE 76:105–110, 2009 105
Traumatic Brain Injury in the United
States: An Epidemiologic Overview
Carl R. Summers, PhD, Brian Ivins, MS, and Karen A. Schwab, PhD
Defense and Veterans Brain Injury Center, Washington, DC
ABSTRACT
A basic description of severity and frequency is
needed for planning healthcare delivery for any
disease process. In the case of traumatic brain
injury, severity is typically categorized into mild,
moderate, and severe with information from a
combination of clinical observation and self-report
methodologies. Recent US civilian epidemiological
findings measuring the frequency of mortality and
morbidity of traumatic brain injury are presented,
including demographic and etiological breakdowns
of the data. Falls, motor vehicle accidents, and
being struck by objects are the major etiologies
of traumatic brain injury. US civilian and Army
hospitalization trends are discussed and compared.
Features of traumatic brain injuries from Operation
Iraqi Freedom and Operation Enduring Freedom
are discussed. Mt Sinai J Med 76:105–110,
2009. 2009 Mount Sinai School of Medicine
Key Words: epidemiology, head injury, traumatic
brain injury.
A Centers for Disease Control and Prevention analysis
of hospital, emergency department (ED), and vital
statistics databases estimated that about 1.4 million
people presented for medical care for a traumatic
brain injury (TBI) each year in the United States
from 1995 through 2001.
1
The analysis also found
that approximately 50,000 (3.6%) of them died from
their injuries, 235,000 (17%) were hospitalized, and
1.1 million (80%) were treated and released from
the ED.
1
A separate study using data about people
hospitalized with TBI estimated that at the beginning
Address Correspondence to:
Carl R. Summers
Defense and Veterans Brain
Injury Center
Washington, DC
Email: Carl.Summers@amedd.army.mil
of 2005, 3.17 million people in the United States
(1.1% of the total population) were living with
long-term disability that resulted from TBI.
2
The
number of people with TBI who present in outpatient
settings other than EDs, such as physicians’ offices,
is currently unknown as is the number of those with
TBI who do not seek medial attention. However,
the proportions of those with TBI who seek medical
attention outside the ED or who do not seek any
medical attention may be sizable. A study of data
obtained from the 1991 National Health Interview
Survey estimated that 25% of individuals with a self-
reported TBI that resulted in loss of consciousness
did not seek medical attention and that 14% were
evaluated in clinics or offices.
3
These findings reveal 2 important features of
TBI. One is that it is a common injury. The
other is that TBI outcomes vary greatly. They also
indicate that many people who have milder forms
of TBI are not identified in current databases.
Studying the epidemiology of TBI is challenging for
a number of reasons, including limited data sources
and different methods for classifying TBI severity.
However, despite these challenges, enough research
has been performed about the epidemiology of TBI
to identify the most common mechanisms of injury
and to characterize TBI risk in various segments of
the population. This article summarizes findings from
epidemiological studies of TBI in the United States
that provide national-level data and briefly discusses
some methodological considerations that can help
readers of TBI epidemiology papers understand why
particular methodologies were used. A brief review of
recent research findings about TBI in the US military
is included.
METHODS
We searched PubMed and Medline for articles
published in the last 10 years that report national-
level data about the epidemiology of TBI in the
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI:10.1002/msj.20100
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106 C. R. SUMMERS ET AL.: TRAUMATIC BRAIN INJURY IN THE UNITED STATES
United States. Search terms included ‘‘traumatic brain
injury’’ paired with each of the following:
• Epidemiology incidence trends (124 citations
found).
• Severity classification (487 citations found).
• Symptom prevalence (78 citations found).
• Military (566 citations found).
The abstracts of publications that appeared to
be relevant were then reviewed. A total of 30
publications were found and reviewed. In addition,
several seminal articles from outside this timeframe
were included because they established current
definitions used for TBI severity
4,5
or reported
seminal evidence on specific topics.
3
INCIDENCE OF
TRAUMATIC BRAIN INJURY
Overall, falls were the leading cause of TBI in the
United States each year from 1995 through 2001.
1
Falls accounted for an annual average of 398,000
(28%) TBI cases during that period. Automobile
crashes were the second leading cause of TBI,
accounting for an average of 280,000 (20%) cases
per year.
1
Being struck by or against something was
the third leading cause, accounting for 19% of TBI
cases annually.
1
Another common cause of TBI is
assault, which accounted for 156,000 TBI cases per
year.
1
A number of TBI cases do not have a known
cause. These amounted to an average of 9% of all
TBI cases per year from 1995 through 2001.
1
The incidence of TBI among males is higher
than it is among females. Males account for 60%
of TBI cases that occur each year. Young children,
older adolescents, and the elderly have the highest
TBI rates.
1
Fall-related TBI among the elderly is
particularly problematic. TBI accounts for 50.3% of
unintentional fall deaths and 8.0% of nonfatal fall-
related hospitalizations among adults over 65 in the
United States.
6
CIVILIAN TRENDS
The published literature has shown that the incidence
of TBI mortality and hospitalization rates in the
United States decreased in the 1980s and 1990s. TBI-
related mortality in the United States, for example,
declined 22.6% (from 24.6/100,000 to 19.3/100,000)
from 1979 to 1992; there was an 11.4% decline
(from 21.9/100,000 to 19.4/100,000) from 1989 to
1998.
7
Probable causes cited in the literature for
these decreases include injury prevention efforts,
compulsory safety laws (eg, seatbelt, helmet, and
drunk driving laws), engineered solutions (eg, air
bags), and improved treatment for alcohol and drug
problems.
8
An analysis of data from the National Hospital
Discharge Survey, Thurman and Guerrero
9
found
that the incidence of hospitalization associated with
civilian TBI decreased 51% from 1980 to 1995
(from 199/100,00 to 98/100,000). However, most
of this was due to a decrease in the incidence
of hospitalizations for mild TBI. They found that
hospitalizations for mild TBI decreased 61% (from
130/100,000 to 51/100,000) during that period,
whereas the incidence of hospitalization associated
with moderate TBI decreased 19% (from 26/100,000
to 21/100,000). The incidence of hospitalization for
severe TBI increased 90% during that period (from
10/100,000 to 19/100,000).
Possible reasons for changes in TBI hospitaliza-
tion rates include the following:
• Changes in hospital admission practices for mild
TBI due in part to changes in health insurance
coverage.
9
• Increased survivability after severe TBI: With
improved availability and quality of TBI treatment,
an increasing proportion of potentially fatal TBI
incidents are survivable. This is a reasonable
explanation for the downward trend of TBI
mortality rates with a concurrent increase in severe
TBI hospitalization rates.
• Improved safety and prevention programs: Part of
the decrease in both mortality and morbidity in the
1980s and 1990s may be due to injury prevention
measures, especially those associated with motor
vehicles
9
and motorcycle helmet laws.
However, more recent research suggests that the
incidence of death due to TBI is no longer decreasing
at those rates. Rutland-Brown and colleagues
10
found
that the TBI mortality rate was 18.1/100,000 in 1998
and 17.9/100,000 in 2003. Data from the latest report
from the Center for Disease Control also indicate that
the rate of decrease in TBI hospitalizations has also
leveled off.
10
MILITARY TRENDS
The incidence of TBI-related hospitalization rates
in the active-duty US Army decreased during the
1990s. The overall incidence decreased 75% (from
247.7/100,000 to 62.3/100,000) from 1990 to 1999.
11
The hospitalization rate for mild TBI in the Army
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 107
Table 1. Glasgow Coma Scale Scoring Rubric.
Best Response Score
Test123456
Adults
Eyes Does not open
eyes
Opens eyes in
response to
painful stimuli
Opens eyes in
response to voice
Opens eyes
spontaneously
N/A N/A
Verbal Makes no
sounds
Incomprehensible
sounds
Utters inappropriate
words
Confused,
disoriented
Oriented, converses
normally
N/A
Motor Makes no
movements
Extension to
painful stimuli
Abnormal flexion to
painful stimuli
Flexion/withdrawal
to painful stimuli
Localizes painful
stimuli
Obeys commands
Children
Eyes No eye
opening
Eyes opening to
pain
Eyes opening to
speech
Eyes opening
spontaneously
N/A N/A
Verbal No verbal
response
Inconsolable,
agitated
Inconsistently
inconsolable,
moaning
Cries but consolable,
inappropriate
interactions
Smiles, orients to
sounds, follows
objects, interacts
N/A
Motor No motor
response
Extension to pain
(decerebrate
response)
Abnormal flexion to
pain for an infant
Infant withdraws
from pain
Infant withdraws
from touch
Infant moves
spontaneously
or purposefully
NOTE: This table was adapted from Teasdale and Jennett
4
and Camey et al.
25
Abbreviation: N/A, not applicable.
DOI:10.1002/MSJ
108 C. R. SUMMERS ET AL.: TRAUMATIC BRAIN INJURY IN THE UNITED STATES
decreased 78.6% (from 159/100,000 to 34.0/100,000),
whereas the rate for moderate TBI decreased 57.1%
(from 14.3/100,000 to 6.1/100,000), and the rate for
severe TBI decreased 53.7% (from 22.8/100,000 to
10.6/100,000). A likely reason for the decrease in the
Army’s TBI-related hospitalization rates is a change
in admission practices for mild TBI similar to those
that occurred in civilian hospitals. Another possible
reason is an increased emphasis on injury prevention
during the 1990s.
12
Studies from the 1990s indicated
that accident-related injuries in the Army decreased
to record lows.
13
A new TBI-related concern for both the military
and civilian medical establishment is the influx of
TBI cases due to the military involvement in the
Iraq [Operation Iraqi Freedom (OIF)] and Afghanistan
[Operation Enduring Freedom (OEF)] theaters of
operation. These cases, including members of the
National Guard and Reserve, are handled initially
through the Department of Defense and Department
of Veterans Affairs; however, some war-related TBI
patients are likely to be seen by civilian providers.
Civilian providers in some localities might see
nontrivial increases in TBI cases from Reserve and
National Guard combat units returning from OEF/OIF
as well as OEF/OIF combat veterans who have been
released from active duty and choose to be treated
by private healthcare providers.
As a group, OEF/OIF TBI patients are likely
to present with 2 common characteristics. The first
characteristic is that the etiology of their injuries is
likely to involve a blast (explosion). Gondusky and
Reiter
14
reported that in their sample of a returning
combat battalion, 97% of the 188 injuries sustained
by 120 Marines were from improvised explosive
devices (65%) or mines (32%). Using a survey of 2525
soldiers 3 to 4 months after deployment, Hoge et al.
15
reported that 79% of injuries reported in their survey
of returned OEF/OIF veterans were from blasts.
Although there is evidence that a large percentage
of service members who have experienced combat-
related TBI have done so because of blast wounds
(frequently in combination with other causes of injury
such as vehicle crashes or falls), it is not known if the
TBI blast sequelae are materially different from TBI
resulting only from noncombat causes such as falls
and vehicle crashes. In many cases, multiple injury
mechanisms are involved, and it is not possible to
determine the exact cause of the TBI.
The second characteristic is that service members
whoareinjuredincombatwithaTBIalsohave
a high occurrence of posttraumatic stress disorder
(PTSD) and depression. Hoge and colleagues,
15
using a sample of US Army soldiers who served in
Iraq, found that 43.9% of service members that had
experienced loss of consciousness (LOC) screened
positive for PTSD and 24.8% screened positive for
depression. Civilians with TBI have similar psychiatric
comorbidities. Silver and colleagues
16
found that
11.1% of adults who screened positive for self-
reported TBI also had a history of depression, but the
prevalence among OIF/OEF veterans may be higher.
METHODOLOGICAL
CONSIDERATIONS THAT INFLUENCE
RESULTS OF TRAUMATIC BRAIN
INJURY EPIDEMIOLOGY STUDIES
A variety of methods have been used to perform TBI
epidemiology studies. Perhaps the most important
methodological consideration faced in any type of
TBI research is how to classify severity. Although
TBIs are generally classified as being mild, moderate,
or severe, different methods can be used to determine
severity. The severity classification method that is
used depends largely on the source of the data for
the study. This section of the article provides a brief
overview of different ways in which TBI severity can
be classified and when they are likely to be used.
One commonly used method is to base severity
on the Glasgow Coma Scale (GCS) score (Table 1).
4,25
The GCS score is a measure of an individual’s level of
consciousness. It assesses 3 domains: eye opening,
motor response, and verbal response. Patients can
receive a score of 1 to 4 for eye opening, 1 to 6
for motor response, and 1 to 5 for verbal response.
The scores from each domain are summed to obtain
the GCS score, which ranges from 3 to 15. TBI
patients with a GCS score of 3 to 8 are considered
to have severe TBI, those with a score of 9 to 12 are
considered to have moderate TBI, and those with a
score of 13 to 15 are considered to have mild TBI.
Another method is to base severity on the dura-
tion of LOC and/or posttraumatic amnesia (PTA).
TBIs that result in LOC lasting 30 minutes or less
and/or PTA lasting less than 24 hours are defined
as mild by the American Congress of Rehabilitation,
the Centers for Disease Control and Prevention, and
the World Health Organization.
5,17,18
TBIs that result
in LOC or PTA of longer duration are considered
moderate or severe.
TBI severity can also be determined with
Abbreviated Injury Scale (AIS) scores.
19
The AIS
classifies injury severity into 1 of 6 categories: 1, mild;
2, moderate; 3, serious; 4, severe; 5, critical; and 6,
maximal (injuries that cannot be treated). Researchers
who have used AIS scores to determine TBI severity
have collapsed these into the mild, moderate, and
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 109
Table 2. Key Concepts.
Approximately 1.4 million Americans are treated for traumatic brain injury annually.
Traumatic brain injury is typically categorized as mild, moderate, or severe with clinical observation (which may include
imaging) and self-report methodologies.
Traumatic brain injury is a common injury that occurs most frequently in young males. Its most common etiologies are
falls, motor vehicle accidents, and being struck by or against an object.
The rate of traumatic brain injury mortality and hospitalizations generally fell in the 1980s and 1990s but has leveled off
since. Most of the drop in hospitalizations is in the mild traumatic brain injury range and is believed to be due, at least
in part, to changes in hospital admission practices.
A developing concern for traumatic brain injury treatment is a nontrivial number of wounded Iraq/Afghanistan war
veterans returning with traumatic brain injury. Members of this group are likely to have been wounded by a blast and
have an elevated chance of experiencing posttraumatic stress disorder and/or depression.
severe designations that are generally used to classify
TBI. When this is done, TBIs with AIS scores of 1 or
2 are considered mild, those with an AIS score of 3
are considered moderate, and those with AIS scores
of 4 to 6 are considered severe.
The method used to determine TBI severity in a
study is usually dictated by the source of data being
used. When a researcher has access to full medical
records, GCS can often be used to determine severity.
When large administrative databases are used, such
as the National Hospital Discharge Survey, severity
can be determined with AIS scores. When data are
obtained from self-report questionnaires, severity can
be determined from the reported duration of LOC or
PTA.
LIMITATIONS
Epidemiological research in TBI is fraught with
well-documented limitations.
20 – 24
Definitional incon-
sistency, limited data, practical data collection con-
straints, limited resources, nontrivial numbers of
injured people who do not seek treatment (resulting
in an undercount), and cases of TBI being overlooked
or not properly documented are the major limitations.
Thus, any inferences made from these data should
be made with these considerations in mind.
CONCLUSIONS
Overall TBI mortality rates in the US civilian
population declined in the 1980 and 1990s but
have since stabilized. TBI hospitalization rates in
the US civilian population followed the same basic
trajectory as mortality for the same period; however,
analysis by severity shows that severe TBI incidence
rates rose, moderate TBI rates were level, and mild
TBI hospitalizations dropped dramatically. These
trends are consistent with 3 possible scenarios:
changes in admission practices for mild TBI,
improvements in the delivery and care of treatment
to very severe patients (who previously would have
died), and improvements in safety and prevention
(Table 2).
Overall US Army TBI hospitalizations dropped
during the 1990s; however, unlike their civilian coun-
terparts, a substantial decrease in TBI hospitalization
was reported for all severity levels. Ivins et al.
11
sug-
gested that possible reasons for the decrease were
changes in hospital admission policies for mild TBI
and injury prevention programs. However, it is likely
that TBI hospitalizations in the Army have increased
because of the wars in Iraq and Afghanistan.
The influx of troops with TBI returning from
the Iraqi and Afghanistan conflicts has created a new
concern for the US medical system. A large percent-
age of returning service members with TBI have been
exposed to blasts, often in combination with other
causes of injury. It is not known if there are specific
sequelae caused by TBI blast exposure or if they are
substantially similar to TBI sequelae resulting from
noncombat causes such as falls and vehicle accidents.
Additional considerations for this population include
elevated rates of PTSD and depression.
ACKNOWLEDGMENT
The views expressed in the article are those of the
authors and do not reflect the official policy or
position of the Department of Defense or the US
Government.
DISCLOSURES
Potential conflict of interest: None.
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- CitationsCitations62
- ReferencesReferences34
- "Other medical causes of TBI include stroke, cerebral hypoxia (resulting from heart attack or near drowning), hypoglycemia, carbon monoxide poisoning, cerebral infections such as meningitis or encephalitis, or subarachnoid hemorrhage, usually due to an aneurysm (Joseph & Linley, 2008 ). Among military personnel, a staggering 79- 98% (Hoge et al., 2008; Summers et al., 2009) of TBIs are due to concussive blast waves from an improvised explosive device (IED) blast (Slone & Friedman, 2008). The second highest rates of TBI are from penetrating head injuries resulting from bullets and shrapnel (Slone & Friedman, 2008). "
[Show abstract] [Hide abstract] ABSTRACT: Alterations in personality and behavior following traumatic brain injury (TBI) are examined in a review of the literature. Research suggests that changes in personality and behavior could be caused by the injury at an organic level, as well as the patient’s response to the injury and the subsequent deficits that are experienced. Currently, various treatment options are available and practitioners would serve patients best by sampling from many areas of psychological and medical interventions in order to create custom rehabilitation programs to suit the individual patient’s needs. Future research into the level of permanency of the personality changes, compensatory skill building for affect deficits, and increased involvement of social supports in treatment are suggested.- "It is estimated that each year, TBI affects 1.7 million people resulting in 235,000 hospitalizations. In the United States alone, 50,000 deaths occur per year and currently over 3 million people are living with permanent disabilities due to TBI (Summers et al., 2009). The economic burden of TBI in US is estimated to be US$60 billion annually in total lifetime direct medical costs and indirect productivity losses (Langlois et al., 2006; Rockhill et al., 2012). "
- "Traumatic brain injury is an important public health problem in both civilian and military populations [1]. While brain injury spans the spectrum of mild to severe and can occur in military personnel both on deployment and in garrison, it is deployment-related mild traumatic brain injury (mTBI) that has garnered considerable recent attention [2]. "
[Show abstract] [Hide abstract] ABSTRACT: Background Up to 20% of US military personnel deployed to Iraq or Afghanistan experience mild traumatic brain injury (mTBI) while deployed; up to one-third will experience persistent post-concussive symptoms (PCS). The objective of this study was to examine the epidemiology of deployment-related mTBI and its relationship to PCS and mental health problems (MHPs) in Canadian Armed Forces (CAF) personnel.Methods Participants were 16153 personnel who underwent post-deployment screening (median =136 days after return) following deployment in support of the mission in Afghanistan from 2009 ¿ 2012. The screening questionnaire assessed mTBI and other injuries while deployed, using the Brief Traumatic Brain Injury Screening Tool. Current MHPs and PCS were assessed using items from the Patient Health Questionnaire, the Patient Checklist for PTSD, and the Cognitive Failures Questionnaire. Log-binomial regression explored the association of mTBI, other injuries, and MHPs with PCS, using the presence of 3 or more of 7 PCS as the outcome. Results are expressed as adjusted prevalence ratios (PR).ResultsmTBI while deployed was reported in 843 respondents (5.2%). Less severe forms of mTBI (associated only with having been dazed or confused or having ¿seen stars¿) predominated. Blast was reported as a mechanism of injury in half of those with mTBI. Multiple PCS were present in 21% of those with less severe forms of mTBI and in 27% of those with more severe forms of mTBI (i.e., mTBI associated with loss of consciousness or post-traumatic amnesia). After adjustment for confounding, mTBI had no statistically significant association with PCS relative to non-TBI injury. In contrast, MHPs had a strong association with reporting 3 or more PCS (adjusted prevalence ratio (PR) =7.77).Conclusion Deployment-related mTBI prevalence was lower than in many US reports; most of those who had had mTBI were free of multiple PCS. PCS was strongly associated with MHPs but not with mTBI. Careful assessment of MHPs is essential in personnel with a history of combat-related mTBI and PCS.
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