Francis X. Conidi, M.D. from the Florida Center for Headache and Sports Neurology has issued a new study which examined retired NFL players for signs of traumatic brain injuries using Diffusion Tensor Imaging (DTI), and the results were fairly damning. The study found that over 40% of the retired NFL players had sustained a traumatic brain injury. Approximately 40 retired NFL players underwent the exam, which included a Compressive Neurological/Headache history, neurological examination, neurophysiological evaluation, Clinical Dementia Rating Scale, physiological evaluation and DTI MRI were performed. According to Dr. Conidi, this represents “one of the largest studies to date in living retired NFL players.”
The North America Brain Injury Society (NABIS) held its 29th Medical Legal Traumatic Brain Injury Seminar to educate attorneys and assist them in better representing their clients. Medical and legal experts from around the United States presented at this three day conference held in Tampa, Florida.
As one of the programs co-chairs, along with Ken Kolpan, Stewart Casper, and Simon Forgette, we put together what many considered to be the premier medical legal traumatic brain injury conference in the United States. I had the pleasure of presenting on the topic of the admissibility of diffusion tensor imaging, which is a sophistic neuroimaging technique that can detect traumatic brain injury where conventional MRI and CT cannot.
I look forward to seeing everyone next year (March 29-April 1, 2017) in New Orleans when NABIS will be hosting the 30th Medical Legal Traumatic Brain Injury Seminar in conjunction with the International Brain Injury Association’s 12th World Congress that will be held at the same time.
Brent Masel, M.D., medical director of the Brain Injury Association of America, authored a paper entitled “Brain Injury as a Chronic Disease” in which he presented the strong argument that traumatic brain injury should be thought of as a chronic disease. In the white paper he laid out the long term consequences of TBI, including increased mortality and the increased incidence of sequelae from TBI. Nevertheless, defense courtroom doctors continue to argue that mild traumatic injury is self limiting and does not result in long term problems.
A new study from the University of Toronto, titled “Risk of Suicide after a Concussion,” assessed the long-term risk of suicide after concussion. Dr. Michael Fralick and his colleagues performed a longitudinal cohort analysis of adults with the diagnosis of a concussion in Ontario, Canada from April 1, 1992 to March 31, 2012, a 20 year period. Severe cases that resulted in hospitalization were excluded.
A federal judge has once again upheld the introduction of diffusion tensor imagining (DTI) in an mTBI case, rejecting defendant’s motion to exclude the DTI findings. In White v. Deere and Co., plaintiff filed a product liability action arising out of an incident that occurred while plaintiff was operating her Deere Model 4600 compact utility tractor and Model 460 loader. Plaintiff asserted that she sustained a traumatic brain injury as a result of a hay bale falling onto her head while she was operating the tractor.
Plaintiff retained Randall Benson, M.D. a board-certified neurologist as one of her medical experts. According to the opinion, Dr. Benson opined plaintiff sustained a traumatic brain injury, basing his opinion, in part, on the results derived from a DTI. Defendants moved to exclude Dr. Benson’s DTI findings, arguing that the DTI finding was unreliable.
The court, after discussing the admissibility standard established by the US Supreme Court in Daubert, Joiner and Kumho Tire, performed an analysis to determine whether Dr. Benson’s use and reliance on DTI was permissible.
A Nevada District Court trial judge recently ruled that Michael Freeman, Ph.D., an epidemiologist, was qualified to testify in a medical malpractice case. Karosy v. Summerlin Hospital Medical Center, et al., Case No. A-12-660815-C (Clark County, Nevada D.C.). In this case, 16-month-old infant plaintiff was admitted to Summerlin Hospital with a diagnosis of pneumonia. When her condition worsened, she was ultimately intubated. During the course of care, plaintiff sustained severe brain damage. The defendants, through their experts, claimed that plaintiff’s severe brain damage was likely caused by plaintiff’s medical condition and not medical negligence.
Plaintiff retained Michael Freeman, Ph.D., an epidemiologist, who performed an expert analysis of defendants’ alternative theories of causation. Epidemiology is a particular branch of medicine which studies the patterns, causes, and effects of diseases and other factors relating to the health of the body. Dr. Freeman offered opinions in epidemiology and rebutted defendants’ expert’s opinions that the child’s brain damage was caused by plaintiff’s medical condition individually and/or in combination, rather than defendants’ alleged negligence.
Defendants filed a motion in limine to strike Dr. Freeman and argued that because Dr. Freeman was not a medical doctor, he was not qualified to give opinions as to breaches in the standard of care, medical causation, and life expectancy.
Researchers at the University of Pittsburgh Medical Center recently utilized Shannon entropy, which is a mathematical information theory model that looks at areas of entropy or disorder in the brain, to determine which concussion patients would go on to suffer migraine headaches following a traumatic brain injury.
Researchers have been using Diffusion Tensor Imaging to assess concussion-related damage to the brain’s signal-transmitting white matter to look for symptoms like headaches. Fractional anistropy (FA), which measures how easily water moves through the brain, represents an average. As a result, someone with a higher FA to begin with may lose white matter integrity from trauma, but still might average out to have a normal mean FA, according to the study’s author Lea M. Alhilali, M.D.
It is well known that headache is one of the most common debilitating chronic pain conditions in patients who sustain a mild traumatic brain injury (mTBI). No conventional pharmacological treatment has been shown to be effective in treating headaches related to traumatic brain injury (TBI). I recently read an interesting abstract published in Pain Physician; 19(2)(E 34754)- entitled rTMS in Alleviating Mild TBI Related Headaches – A Case Series.
In this study, the authors designed a perspective evaluation in patients with established diagnoses of mild traumatic brain injury related headaches who were treated with neuronavigational guided rTMS. The study was conducted at the Veterans Administration San Diego Health Care System, where over 400 patients with mTBI are evaluated annually.
The study included six men (average age of 50) with mTBI-HA. Constant headaches were rated at 4 on a 0-10 numerical rating pain scale (NRPS) and all patients were on stable headache medication regiments. Each of the patients received 4 sessions of rTMS over a 2 month period.
Following the treatment, the patients were again evaluated. The average post rTMS headache intensity was reduced by 53.05%. The average headache exacerbation frequency per week was reduced by approximately 79% with 2 patients reporting complete cessation of severe headache episodes.
The authors concluded that rTMS offered a “non-evasive” treatment option for MTBI-HA.
(Pain Physician. 2016 Feb;19(2):E347-54. rTMS in Alleviating Mild TBI Related Headaches – A Case Series)
In researching the admissibility of Diffusion Tensor Imaging, I came upon a Louisiana court decision upholding the use of Diffusion Tensor Imaging. Andrew v. Patterson Motor Freight, Inc., Civil Action No. 6:13cv814 (U.S.D.C., W.D. 2014).
Plaintiff was injured in a motor vehicle crash and was diagnosed as having sustained a traumatic brain injury to the frontal lobe resulting in residual deficits in the areas of emotion, impulsivity, personality, and short term memory. Plaintiff retained Dr. Eduardo Gonzalez-Toledo who administered Diffusion Tensor Imaging, which according to Dr. Gonzalez-Toledo demonstrated evidence of traumatic brain injury pathology.
Defendants moved to bar Dr. Gonzalez-Toledo, a neuro-radiologist, arguing that Diffusion Tensor Imaging was not widely accepted for the diagnosis of traumatic brain injury. In support of their argument, defendants relied upon a single article entitled “Guidelines for the Ethical Use of Neuroimages in Medical Testimony.”
The Court found:
Presently, chronic traumatic encephalopathy (CTE) can only be diagnosed pathologically. However, there are research efforts, such as the “Understanding Neurological Injury and Traumatic Encephalopathy (UNITE) Study” that are investigating ways to diagnose CTE during an individual’s life. A recent article published in JAMA Neurology on January 4, 2016 released a case report entitled “Pathologically confirmed chronic traumatic encephalopathy in a 25-year old former college football player” by Jesse Mez, MD, MS, Todd M. Solomon, PhD, Daniel H. Daneshvar, MA,Thor D. Stein, MD, PhD, and Ann C. McKee, MD.
The case report examined a 25-year-old man with congenital bicuspid aorta valve and a family history of addiction and depression who died of a cardiac arrest secondary to staphylococcus aureus endocarditis. He had played football for sixteen years, beginning at age 6. He also played three years of Division I college football as a linebacker and special teams player, before he stopped playing football in the beginning of his junior season due to ongoing post-concussive symptoms. He had experienced over ten concussions while playing football, the first occurring at the age of 8. He had problems with headaches, neck pain, blurry vision, tinnitus, insomnia, anxiety, and difficulty with memory and concentration. He had been an excellent student in high school (3.8 GPA) and in the beginning of college. He left school with a GPA of 1.9, just twelve credits short of earning his bachelor degree.
On Monday December 14, 2015, United States Representative Bill Pascrell, Jr. (D-NJ-09) sent a blistering letter to the president of ESPN, John Skipper, regarding ESPN analyst’s recent comments attacking the protocols in place for concussions and overall making light of the seriousness of concussions. Congressman Pascrell wrote:
Dear Mr. Skipper,
I am writing to express my concern about recent comments made by ESPN analysts about concussions. As the co-founder and co-chair of the Congressional Brain Injury Task Force, I urge you to help ensure that the individuals that your organization employs treat head injuries with the gravity that they deserve.
In the U.S. Congress, the Congressional Brain Injury Task Force works to increase awareness of brain injury in the United States, supports research initiatives for rehabilitation and potential cures, and strives to address the effects such injuries have on families, children, education, and the workforce.
According to the Centers for Disease Control and Prevention, as many as 3.8 million sports- and recreation-related traumatic brain injuries (TBI) are estimated to occur in the United States each year, ranging from relatively mild concussions to fatal head injuries. Though symptoms may appear minor, the injury can have life-long effects on an individual’s memory, behavior, learning, and/or emotions.
I appreciate the work that ESPN reporters have done to highlight the dangers of concussions, as well as quality programming that educates sports fans and raises awareness about the issue. For this reason, I find it surprising that your organization would fail to comment or discipline employees who make statements that significantly downplay the risks that football players and other athletes face as a result of head injuries.
In response to a New York Times op-ed by Dr. Bennet Omalu, the doctor who first discovered chronic traumatic encephalopathy (CTE), which raised questions about children playing contact sports due to concerns about brain injury, ESPN college football analyst Danny Kanell tweeted that “the war on football is real” and that “concussion alarmists are loving it.”
During an interview with Charlie Rose in October, ESPN analyst Ray Lewis dismissed concerns about concussions and accused the National Football League (NFL) and those pushing for improved health and safety measures of “diluting the game.” Additionally, he called new rules prohibiting targeting – when a player takes intentional aim at his opponent, especially his head or neck – “disgusting.”
One of the greatest challenges we face in combatting the concussion epidemic is changing people’s perceptions about the gravity of these injuries. We have made great strides in raising awareness and educating the public about the dangers of head injuries. However, unfortunately, a stigma still remains and athletes of all ages sometimes attempt to hide symptoms of concussions and continue playing out of fear that they will be viewed as weak or inferior. This is especially concerning in youth athletes.
In fact, the Centers for Disease Control and Prevention (CDC) recently issued a report, “Concussion at Play: Opportunities to Reshape the Culture Around Concussion,” which provides recommendations on building a culture in sports that helps encourage athletes to help lower their chances of sustaining a concussion, as well as take necessary steps and time to recover in the event of a concussion. Many of the strategies may seem simple, but they can be extremely impactful and rely on the adults in children’s lives to set a good example. Changing the way coaches and parents talk about head injuries and react to young people reporting concussion symptoms is the first step to changing a culture that can be downright dangerous for athletes. The CDC found that young athletes who are ridiculed or insulted by their coaches or their parents for expressing concerns about a concussion are more likely to continue playing despite a possible head injury. Additionally, when youth athletes are not encouraged to report concussion symptoms, it becomes easy for them to view concussions as non-serious, which is not the case.
Professional athletes and sports media networks must play a role as well. As an organization that employs many retired college and NFL athletes, I would hope that you recognize the influence that your network and its employees have. When your employees make comments that belittle protocols and measures that aim to make sports safer and discount the seriousness of head injury, your organization has a responsibility to admonish them.
Thank you in advance for your attention to this matter.
Congressman Pascrell should be applauded for his comments.
If you have suffered from a concussion or traumatic brain injury, it is strongly recommended that you seek experienced legal counsel immediately.