Head injuries due to sports have been studied since the late 19th century, and it is now widely accepted that multiple concussions sustained by boxers, hockey players and football players can result in permanent brain damage and increase the risk of conditions such as Alzheimer’s, Parkinson’s, and chronic traumatic encephalopathy (CTE).
In May, the Public and Environmental Health Committee learned about another population of patients who suffer multiple episodes of traumatic brain injuries and concussions and who are also at risk for permanent damage: victims of domestic or intimate partner violence.
Dr. Edie Zusman is a trauma neurosurgeon who has conducted clinical research on brain injury resulting from domestic and family violence. Dr. Zusman has been selected to file an amicus brief to the U.S. Supreme Court to develop case law for emergency care of strangulation survivors and currently serves on the board of directors for the Family Violence Appellate Project in California. She also started Safe Living Space, an educational philanthropy to address the large gap in brain injury evaluation and care for survivors of domestic violence and human trafficking.
“While the impact of concussion/TBI on athletes has led to their immediate evaluation and care, the same level of care is rarely provided to victims of domestic violence/intimate partner violence,” the safelivingspace.org website notes. “The symptoms of unrecognized concussion have been attributed to ‘Battered Women's/Person's Syndrome,’ which is classified as a psychiatric disorder, further delaying access to appropriate medical attention and treatment. It is a matter of social justice that we mandate screening for and treatment of concussion/TBI for those who have experienced DV/IVP.”
While the impact of concussion/TBI on athletes has led to their immediate evaluation and care, the same level of care is rarely provided to victims of domestic violence/intimate partner violence.
In Dr. Zusman's presentation to the committee, we learned that an estimated 25% of women and 10% of men in the U.S., which translates to 60 million people, have experienced domestic violence. A retrospective review of prior studies of domestic violence victims showed that 58.8% of domestic violence victims have sustained a concussion and of those who have one concussion, 79% have had three or more.
Victims of domestic and family violence frequently suffer blows to the head and strangulation. There is no difference between concussions from domestic violence and other causes, but unlike in sports, where most of those who suffer concussions are male, it is mostly women who suffer concussions from domestic violence. In addition, they suffer more episodes of brain injury than athletes do and the time to referral for medical evaluation is longer for victims of domestic violence.
Guidelines for return to sports play after concussion include keeping someone out of a game or practice until all symptoms are resolved and preventing a second impact. After two concussions in a single season, traumatic brain injury experts will remove the player for the remainder of that season. After three to four concussions, the player is counseled about retiring from contact sports.
In the case of domestic violence survivors, since brain injury may be unrecognized, victims may sustain a second impact before they have recovered from the first. When they are medically evaluated, domestic violence survivors often describe six to 15 concussions; some say that there were so many episodes including sexual assault with strangulation that they lost count.
Strangulation is an important cause of brain injury for survivors of domestic violence. Dr. Zusman said surveys show 38% of people who have experienced domestic violence have been strangled and 43% of intimate partner homicides had a history of prior strangulation episodes.
Survivors may say that they passed out, blacked out or lost consciousness, and may exhibit amnesia for events following the trauma. Usually, they will remember up to the injury event and after that they will not be able to make new memories; they have anterograde amnesia, considered loss of consciousness by TBI experts. If someone is evaluated while actively brain injured, they may have no memory for seconds, minutes or hours. It is important to recognize this because survivors with amnesia may be accused of lying, covering up or changing their story if interviewed for law enforcement purposes.
Another thing to remember is that after an acute injury, such as strangulation or blows to the head, it may take 48-72 hours for signs of the trauma to show up. Bruising may become visible two to three days later and symptoms such as dizziness, blurred vision and balance problems may increase after the first few days. Education on the timeline for signs and symptoms after trauma is important so that survivors aren’t accused of making up their symptoms or trying to get attention.
Significant brain injuries from abuse and strangulation are often present without visible signs of bruising or petechia on the neck. For health care providers it is important to take a history of what the patient remembers with gaps in the timeline being concerning for loss of consciousness, what symptoms they are describing, and perform the key elements of a neurologic exam: memory/recall, following three step commands, near point convergence, vestibulo-ocular reflex, balance, and orthostasis.
Dr. Zusman and her associates have developed a short concussion screening tool that first responders can use to assess the risk of brain injury in the field. It has 10 questions and is easily scored. Two or more incorrect answers should lead to medical evaluation.
Dr. Zusman has also collaborated with Volunteers of America to introduce brain injury screening as part of the routine intake process for seven domestic violence shelters in the Greater New York area. The goal, like we do with sports, is to prevent a second injury while the first heals, protect from further brain injury and get brain injuries evaluated and treated.
Recognizing a brain injury may help with legal issues such as obtaining a restraining order, increase compassion for survivors and help them access resources such as SSI and victim-of-felony funds.
Another population at risk for brain trauma are victims of human trafficking, who also experience the highest rates of brain injury from physical violence.
After Dr. Zusman’s presentation, the committee discussed what actions SSVMS could take to improve the chance that domestic violence survivors are adequately evaluated and treated for any brain injury that they may have sustained.
We agreed on the following:
Increase awareness in the medical community about brain injury and domestic violence, including through articles such as this one.
Reach out to the SSVMS emergency services committee to ask for their help in educating first responders and law enforcement about this issue.
Develop an educational program for primary care and emergency physicians to learn to evaluate and treat brain injury in domestic violence victims.
Reach out to domestic violence shelters with education and awareness of possible brain injury in their clients.
Support legislation that would improve care for survivors of domestic violence.
For more information on brain trauma related to domestic violence along with information on initiatives to understand the diverse and unique implications of repetitive brain injury, visit safelivingspace.org.
Email Glennah Trochet, MD
Glennah Trochet, MD is chair of the SSVMS Public and Environmental Health committee.
