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Traumatic Brain Injury: Lessons Learned From Our Nation's Athletes and Military

The University of Missouri School of Law, where I teach, operates a Veterans Clinic. Under the supervision of faculty director Angela K. Drake, students help veterans and their families secure disability benefits before the Board of Veterans' Appeals and the Court of Appeals for Veterans' Claims.

Veterans Day

Each Veterans Day, the clinic's symposium explores a cutting-edge topic important to veterans' affairs. This month's day-long symposium will explore "Traumatic Brain Injury - Lessons Learned From Our Nation's Athletes and Military." The symposium begins at 8:00 am and is free and open to the public; advance registration is requested, but not required.  The symposium will be live streamed and also available afterwards.

Relevance for Youth Sports

I recommend the symposium to youth sports parents, coaches, and administrators for two reasons. The first reason concerns citizenship, and the second concerns safety.

First, expert panelists will discuss treatment of traumatic brain injury (TBI) in physically- and emotionally-wounded veterans. This discussion concerns all Americans, inside and outside the sports world. Veterans have earned service-related medical care and other promised benefits; providing what they are due is a solemn national obligation. Americans have debated war and peace throughout nearly every conflict the nation has fought, and debate has accompanied the Iraq and Afghanistan wars. But the national obligation to honor commitments made to service members should remain inviolate and beyond debate. 

I also commend the symposium to youth sports audiences because continued cross-pollination between athletic and military TBI medical research can help advance the effective treatment of injured athletes at all levels of competition, including youth leagues. Medical researchers report that the effects of TBI in injured athletes can resemble effects suffered by troops injured by bomb blasts and who suffer other head trauma in Iraq and Afghanistan. The upcoming law school symposium recognizes that athletic and military brain injuries are marked by both important differences and important similarities.

Athletes and Troops

The symposium's title, which recites athletes first and veterans second, initially surprised me, but the order makes good sense because the military can learn much from sports.  As a youth hockey coach for more than 40 years, I remain awed by the quality and quantity of recent medical research and commentary concerning traumatic brain injuries in adult and child athletes.

In its new Policy Statement, "Tackling in Youth Football," the American Academy of Pediatrics synthesizes competent studies whose conclusions frequently diverge. Because the pace of TBI research in football and other youth sports has accelerated in only the last decade or so, however, early lack of consensus will spur further research.

Youth leaguers and veterans alike are fortunate because the sheer magnitude of exposure to physical and emotional harm from TBI has already drawn careful attention from leading health and safety advocates, notably MomsTeam Institute of Youth Sports Safety. The Institute's Executive Director Brooke de Lench has written widely for years about concussions in football and other sports, which she correctly calls "the predominant youth sports safety issue of the 21st century."

A word search on www.MomsTeam.com produces a treasure trove of articles with valuable information, insights, and recommendations. The Institute's Youth Sports Concussions Safety Center now has more than 4,000 pages of information, videos, and other resources, and it is constantly being updated.   This summer the National Collegiate Athletic Association (NCAA) and the Department of Defense awarded the Institute a Mind Matters Challenge grant for its application, "Creating a Safe Concussion Reporting Environment: A Multi-Media Approach." 

Common Challenges

At the upcoming symposium, I will join Kansas City lawyer Paul Anderson and retired National Football League player Marvin Washington on a panel to discuss traumatic brain injury in athletics. I am not a physician, and I will speak as a citizen. I am concerned about fulfilling our national obligation to veterans, and also about responding effectively to what medical organizations call a public health crisis among the nation's youth athletes, who number in the millions each year. In the 20 minutes or so allotted to me, I will talk about two challenges shared by athletic and military TBI researchers:

1. We must continue learning and adapting.  In athletic and military research alike, strategies for treating traumatic brain injury have evolved over the years. This evolution must continue.

Let's turn back the clock for a few moments because, as historian David McCullough says, "History is who we are and why we are the way we are." In 1905, football was at a crossroads because 18 collegiate players were killed, and scores more were seriously injured, that year. Most of these casualties would likely be diagnosed today as multiple concussions, skull fractures, or other traumatic brain injury from game action. In 2015, even one on-the-field death among several thousand college football players would attract national attention. Far fewer collegians played football in 1905, so 18 deaths in a single season was an astounding percentage of all players.

With football facing possible extinction from public scorn late in 1905, President Theodore Roosevelt summoned officials from the Big Three teams - Harvard, Yale and Princeton - to the White House to hammer out rules changes and other safety measures that continued to evolve. Death on the college gridiron was serious business because, with a national professional league still more than a decade away, the collegiate game was the most prominent football played in America.

Change came slowly. As the White House conference convened, some intercollegiate football players wore skimpy protective equipment and soft leather helmets without face guards, but game photos show that most players went helmetless. Helmets did not become mandatory in NCAA play until 1939.

The effects of serious head injury have reached football's radar screen only recently. In 2004, for example, Michael McCambridge wrote America's Game: The Epic Story of How Pro Football Captured a Nation. It is a well-researched, 552-page history of professional football, but the book never mentions the word "concussions."

Former Tampa Bay Buccaneers president Gay Culverhouse reports that, as late as 2006, rushing a player back from a concussion was "standard operating procedure in the NFL.  Concussions were not taken seriously. . . . This was the culture of the time." The NFL's public concern about head injury did not begin until a few years later.

Over the years, the military has similarly learned much about traumatic brain injury, sometimes the hard way. A few years after President Roosevelt's 1905 football summit, World War I brought unprecedented carnage as the first mechanized total war. The United States and the rest of the world were unprepared for the battlefield horror, and for treating the emotional and physical devastation that it inflicted on so many returning troops. In a world accustomed to warfare that often took a greater toll from disease than from battlefield hostilities, medical science had to play catch up.

Many Americans today have undoubtedly flinched at haunting photographs of muddy World War I troops staring blankly ahead in their trenches. Their condition was called "shellshock" in those days, and that is about all anyone knew. A century later, medical science can better confront what was likely Post Traumatic Stress Syndrome (PTSD) in many of the affected troops.

Fast forward to the Vietnam War, when the nation shortchanged many veterans who returned home in emotional and physical distress. The abdication of responsibility stemmed partly from lack of national will after a long war that was unpopular to many Americans. But the frequently inadequate medical care in those earlier years also stems partly from the fact that the day's most advanced medical knowledge was not good enough, at least when compared with what medical science understands now.

The point is that in athletics and the military alike, what passed for TBI prevention and treatment even a few decades ago does not pass today. A decade and more from now, medical science will likely know more than it knows today. Even as many medical studies reach divergent conclusions, vigilance defines the essence of medical work in progress.

2. Younger troops suffering traumatic brain injury may have special vulnerability and special needs.  Some recent medical research suggests that concussions in children can be more serious than concussions in adults because children's brains are still developing. In various contexts, medical breakthroughs also suggest that children's brains continue developing past the general age of majority (18) until about the age of 24. These tentative findings may influence approaches to TBI prevention and treatment of thousands of veterans below this age.

Child and adolescent athletes may be more susceptible than adult athletes to concussion's after-effects, and to repeated sub-concussive blows to the head that occur over the span of one or more seasons.  Adolescent athletes may also be prone to "second-impact syndrome," which Lindsey Barton Straus explains is a rare but usually fatal condition caused by a second blow to head before the brain has healed from an initial concussion. Because concussed children may require longer recovery periods than concussed adults, continued hits during practice sessions or games can produce devastating physical and emotional consequences even if none by itself would cause injury. Military attention seems warranted, pending further studies.


"[T]he concussion problem in football and other contact sports is far more serious than any of us want to believe, and it is time to do something about it," writes former football player, professional wrestler, and Minnesota Governor Jesse Ventura. He writes in the Introduction to a book on sports concussions, but, as a Navy veteran during the Vietnam era, he could say the same thing about concussions in the military.


Am. Acad. of Pediatrics, Policy Statement, Tackling in Youth Football, http://pediatrics.aappublications.org/content/early/2015/10/20/peds.2015-3282.full.pdf+html?sid=12d9b3d5-b5d8-42f0-85c0-fd0eb9f062ce (Oct. 25, 2015)

Gay Culverhouse, Throwaway Players: The Concussion Crisis From Pee Wee Football to the NFL at p. 74 (2012)

Brooke de Lench, Praise For MomsTEAM Is Nice, But The Fight To Make Youth Sports Safer Isn't Over, http://www.momsteam.com/blog/brooke-de-lench/praise-momsteam-nice-but-fight-make-youth-sports-safer-not-yet-over#ixzz22VEOtiR9 (May 23, 2012)

Historian Addresses Wesleyan, N.Y. Times, June 4, 1984 (quoting David McCullough)

Lindsey Barton Straus (reviewed by William P. Meehan III), Second Impact Syndrome: A Rare But Usually Fatal Condition, http://momsteam.com/health-safety/concussion-safety/general/second-impact-syndrome-signs-and-symptoms#ixzz3pnUD8tAW

Jesse Ventura, Introduction, in Christopher Nowinski, Head Games: Football's Concussion Crisis from the NFL to Youth Leagues, p. ix (2007)

Douglas E. Abrams, Confronting the Youth Sports Concussions Crisis: A Central Role for Responsible Local Enforcement of Playing Rules, Mississippi Sports Law Review, vol. 2, p. 75 (2013).  

Thank you to Prof. Drake for reviewing this article in draft form.