For decades we have had the consequences of brain damage on display in news items and in competitive sports, but in most cases the viewing public is left on its own to figure out what actually happened to the affected individuals and what the longterm consequences will be. Two of the most commonly occurring and highly visible medical problems that remain largely unexplained to the general public are blunt head injuries and strokes. Head trauma is a routine outcome in boxing and other sports that allow blows to the head. Strokes have made the headlines most recently in discussions of the Pennsylvania Congressional Senate Race.

Blunt trauma to the head may cause bleeding into or around the brain, fractures of the neck (cervical spine), fractures of the skull, and concussions. With regards concussions, Americans are concerned with the “concussions” that occur during a football game but encourage efforts to inflict “concussions” in boxing matches. A concussion is a temporary disturbance of brain function caused by a blow to the head or an abrupt acceleration-deceleration of the brain. A blow to the head sufficiently powerful to cause a concussion might occur with a Mike Tyson punch or with a quarter-back being thrown backwards to the ground as he tries to launch a football.

A few decades ago, the term was reserved for incidents that produced a loss of consciousness without evidence of permanent, structural brain damage. More recently, physicians have abandoned the need for a loss of consciousness and have adopted a more liberal interpretation of “permanent” brain injury.  Football players and boxers may have no objective changes to the brain on imaging studies obtained just after a knock-out but may still have regions of their brains that look like swiss cheese years after their careers have ended.

Head trauma is allowed in many sports. In boxing, it is a major element of the exchange between participants. In other competitive sports, some broken bones, lacerations, and organ damage are accepted as part of the game. No sport can claim that head trauma is without consequences. Even highly skilled boxers, like Mohammed Ali, could not escape the potential brain damage that develops with repeated blows to the head.

Ali developed post-traumatic parkinsonism, a movement disorder that deprived him of the agility and speed of movements for which he was famous. Other professional boxers have developed problems with speech and memory after years of blunt head trauma in the ring. Some lawmakers have suggested that boxing be ruled illegal or at least more limited in its tolerance of head injuries, but in the United States this sport is likely to remain a popular entertainment spectacle for decades to come. The ex-heavy-weight boxing champion George Foreman was asked if he believed boxing caused brain damage. He jokingly replied, “You have to be brain-damaged to become a boxer.”

In football, the trend is toward limiting concussions. Intentional helmet-to-helmet collisions are no longer deemed “legal.” Taking players out of the competition if they exhibit any signs of a concussion is increasingly enforced. That the player claims to be fine cannot be the basis for his continued participation in the game. The player who has obvious confusion, who stumbles after getting off the ground, or who has involuntary posturing of his limbs after head trauma is not fine.  He needs medical attention and imaging studies of the brain to rule out a bruise in (contusion) or bleeding around (hematoma) the brain. The development of either of these problems may have fatal consequences.

American spectators have witnessed the consequences of violence in boxing, football, and other high-energy-impact sports and deemed them worth the risks. We encourage our children to participate in potentially violent sporting activities to foster competitive or cooperative behavior. We describe the children and adults who are active in a variety of sports as “well-rounded.” We are tolerant of activities that pose a risk to our fellow citizens and their children and describe them as heroic if they are injured and struggle to recover from the sports injury, especially if that injury is to the brain.

People who suffer non-traumatic injuries to the brain are viewed very differently. This is evident in the Senate contest between John Fetterman and Mehmet Oz. Fetterman recently had a stroke and is being portrayed by supporters of Mehmet Oz as unable to serve as a senator by virtue of his recently acquired disability.  Fetterman had damage caused by disturbed blood flow to a part of his brain involved in spoken word recognition. This means that when he is spoken to he may not fully or readily recognize some of the words he is hearing. To compensate for this injury, he has employed a computer transcription of what is being said to him to be sure he accurately and quickly construes what he is being asked or told.

What he exhibits is neither rare nor disabling. Problems with word recognition are common in people as they age. Most of those affected are presumed to have a hearing problem, rather than a processing problem. Making the speaker’s voice louder with a hearing aid does not improve the accuracy of what the listener perceives. A simultaneous computer transcription of a discussion or inquiry avoids any misunderstandings. One might well argue that this would be an appropriate innovation in all public hearings or political forums. 

Given that the average age of members of the U.S. Senate is more than 64 years old and the oldest member, Diane Feinstein, is 89 years old, we must assume that many of our Senators have the same word recognition problem as Fetterman. That they cannot follow what they are being asked is routinely evident in the answers they offer to simple questions. That they have problems finding the correct words to explain their positions is especially evident when they go “off-script.”

Many of our Senators have obvious disabilities, some of which are a consequence of trauma. Those without disabilities are not necessarily doing a better job than those with disabilities. As voters we are obliged to assess candidates on the basis of what they can do and are likely to do, rather than on the basis of disabilities they have acquired or may acquire. Unlike the situation in boxing or football, we get to decide who stays in the game.

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan. He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

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