For over fifteen years, researchers at the University of Glasgow and the University of Edinburgh have been following a large population of adults admitted to hospital with traumatic brain injuries. Those readers familiar with this blog are familiar with my reporting of the various papers that have been published by these researchers.
I recently came across an interesting research paper published in the Journal of Neurology, NeuroSurgery and Psychiatry, which looked at the mortality and morbidity fifteen years after hospital admission for patients who sustained a mild traumatic brain injury.
Dr. Tom McMillan and his colleagues designed a prospective case control record linkage study investigating the mortality rate in a population of Scottish adults admitted to hospital with mild traumatic brain injuries fifteen years post injury.
The study included 2,428 adults with mild traumatic brain injury and an equal number of community controls who were case-matched for age, gender and social depravation. The researchers also included a further control group admitted with non-brain injury that was also matched for duration of hospital admission. Any control member with a history of head injury prior to the study was excluded.
The researchers found that mortality in the mTBI group was higher than in the control group and other injury control group. They found that age at injury was important as younger adults (15-54) with mild brain injury had a 4.2 greater risk of death than the control group. In adults age over 54 the risk of death was 1.4 times higher. Repeated brain injury was also a risk factor for death in the mild traumatic brain injury group.
The researchers concluded, “Adults hospitalized with [mild traumatic brain injuries] had a greater risk of death in the following fifteen years in matched controls. The extent to which lifestyle and potential chronic changes in neuro pathology explain these findings is unclear. Lifestyle factors do contribute to risk of death after MHI and this finding has implications for lifestyle management interventions.” (Source)
Despite study after study demonstrating long term effects from mild traumatic brain injury (concussions), it is astounding that defense courtroom doctors still maintain that there are no permanent residuals from mild traumatic brain injury. A new study, Imaging Correlates of Memory and Concussion History in Retired National Football League Athletes, published in JAMA Neurology once again debunks this myth that everyone gets better.
The objective of the study, according to the abstract was “to assess the relationship of hippocampal volume, memory performance, and the influence of concussion history in retired NFL athletes with and without mild cognitive impairment.” The design of the study was a retrospective cohort study assessing differences between groups, mean hippocampal volumes, and memory performance by computing age quintiles based on group-specific linear regression models corrected for multiple comparisons for both athletes and control participants. The study utilized 28 former NFL athletes who were compared with 27 control participants. The mean age was 58.1 for the former athletes and 59.0 for the control participants.
The study found that retired athletes with concussion history, but without cognitive impairment, had normal, but significantly lower, California Verbal Learning Test scores compared with control participants. However, those with a concussion history and mild cognitive impairment performed worse when compared with both control participants and athletes without memory impairment. Among the athletes, 17 had a G3 concussion and 11 did not. Older retired athletes with at least one G3 concussion had significantly smaller bilateral hippocampal volumes compared with control participants.
The authors concluded that “prior concussion that results in loss of consciousness is a risk factor for increased hippocampal atrophy and a development of mild cognitive impairment. In individuals with mild cognitive impairment, hippocampal volume loss appeared greater among those with a history of concussion.”
A new study published in the Annals of Neurology has found that TBI patients’ brains were estimated to be older than their chronological age, “suggesting that TBI accelerates the rate of brain atrophy.”
It is well accepted that with the use of neuro imaging, it is possible to predict age in healthy individuals. The study therefore looked to see what effect, if any, a traumatic brain injury would have on accelerated atrophy of the brain.
The researchers studied 99 patients with persistent neurological problems after traumatic brain injury and compared them with a group of a 113 healthy controls assessed on the same scanner to validate the accuracy of the age prediction model. All of the patients were scanned at least one month post injury with a range of 1 to 563 months. Of the 99 patients, 17% were classified as mild, and 83% being moderate to severe. The cause of injury was included to those injured in motor vehicle accidents, falls, assaults, sport related injuries as well as other causes.
Neurological testing of the first cranial nerve, which carries the sensory information for the sense of smell, is rarely performed. A new study from the Walter Reed National Military Center provides proof that olfactory testing should be performed.
According to the abstract, the objective of this recent study was to determine whether a structured and quantitative assessment of differential olfactory performance – recognized between a blast-injured traumatic brain injury (TBI) group and a demographically comparable blast-injured control group can serve as a reliable antecedent marker for preclinical detection of inter cranial neuro trauma.
The researchers, at Walter Reed, performed a prospectively and consecutively enrolled evaluation of 231 polytrauma inpatients who were exposed to explosions during combat operations in either Afghanistan or Iraq. The study correlated olfactometric scores with both contemporaneous neuro imaging findings as well as the clinical diagnosis of TBI.
The study found that while “quantitative identification olfactometry had limited sensitivity, it had high specificity as a marker for detecting acute structural neuropathology from trauma.” The researchers found that central olfactory dysfunction identified patients with TBI who had intracranial radiologic abnormalities. While the test had a sensitivity of only 35%, it had a specificity of 100%.”
Neuro attorneys representing patients with suspected traumatic brain injury, should insist that the neurologic examination include a test of the first cranial nerve. If you have questions about these exams, you should speak with your legal counsel.
It is presently the standard of care to keep children who have sustained concussion/traumatic brain injuries off the field and not to return to play until they are cleared by a competent professional. Assemblywoman, Pamela R. Lampitt (D Burlington and Camden) has introduced a bill in the New Jersey Assembly, which would require any student who suffers a concussion to be evaluated by a doctor or other health care provider and to get written clearance before the child can go back to school. Under the bill, each school district that deals with students with disabilities would be responsible for enforcing any limits on a student’s activities that were determined by the health care provider.
The statement accompanying the bill states:
This bill provides that a student enrolled in a school district who sustains a concussion must receive an evaluation by a physician trained in the evaluation and management of concussions and written clearance from the physician to return to school. In the event that the physician provides notice that the student requires accommodations for learning, the school district must immediately implement the accommodations and notify all teachers and staff who have contact with the student of the accommodations. The school district’s child study team will promptly evaluate the student in order to identify the manner in which the accommodations will be provided to the student during recovery and the need for the continuation or adjustment of the accommodations, and to determine the duration of the accommodations.
The bill also provides that a student enrolled in a school district who sustains a concussion is prohibited from engaging in any physical activity at school including, but not limited to, recess, physical education, sports, or cheerleading. The student may not participate in any physical activity until he is evaluated by a physician and receives written clearance to participate.
The sponsor’s intent is to have the child study team use the physician’s diagnosis and recommendations to guide accommodations upon the student’s return to school for the period of time prescribed by the physician.
A copy of the bill can be found here. You can read the story published in New Jersey Spotlight here.
People, who have sustained a permanent injury which results in a permanent work disability, will earn less and will have a shortened work life expectancy, even where the individual has returned to full time employment. Thus, in every case, where a plaintiff has sustained a permanent injury resulting in a permanent work disability, a claim for loss of future earning capacity exists.
In Figurski vs. Trinity Health-Michigan, the Michigan Court of Appeals upheld a verdict in an obstetrical medical malpractice action. On appeal, defendants asserted that the trial court abused its discretion when it determined that Anthony Gamboa, Ph.D., MBA, could offer an opinion as to plaintiff’s future loss of earning capacity. Defendants attacked both Dr. Gamboa’s qualifications to testify as an expert and attacked his methodology as unreliable. The Michigan Court of Appeals disagreed.
The Court of Appeals found that the trial court clearly understood her role as gatekeeper. Dr. Gamboa was qualified as a vocational rehabilitation expert. He held a number of degrees, including a Master’s in vocational counseling and a Ph.D. in an area that included vocational counseling and education. Gamboa also received a MBA and testified that he liked to focus on statistics. Gamboa has been with Vocational Economics, Inc. in one capacity or another since 1977. His work there necessarily included offering expert opinions on the cost of future care and compensation loss. He was a prolific writer in the area of earning capacity loss and work life expectancy. The Court of Appeals also found that there was nothing unusual with regard to Dr. Gamboa’s methodology and that the trial court was correct in concluding that the different methods of calculating plaintiff’s damages was best left to the ultimate trier of fact.
This past week, I attended the American Association for Justice’s mid-winter convention in Palm Desert, California. Besides my duties and responsibilities as Parliamentarian of AAJ, I was pleased to be invited to give a presentation at the Specialized Track: Concussion Crisis-Litigating Sports Injuries and TBI CLE program where I spoke on the topic of “Proving the Invisible: Arguing a Sports-Related Concussion Case without Neuroimaging.”
On returning to New Jersey this past Saturday, I co-chaired the New Jersey Association for Justice (NJAJ) Traumatic Brain Injury program. Besides co-chairing the event, I gave a presentation entitled “Identifying and Handling the Traumatic Brain Injury Case.”
I read a wonderful story by Amy Zellmer, a professional photographer and TBI survivor who published a firsthand account of her struggles with a mild traumatic brain injury. According to her story, Amy fell on a patch of ice and sustained a “mild” traumatic brain injury. Despite people telling her “it’s just a concussion,” a year later Amy is still struggling with the effects of her traumatic brain injury. I strongly recommend you read Amy’s story to understand what TBI survivors struggle with on a daily basis.
You can find the link to the story here.
If you have suffered form a traumatic brain in jury, contact Stark & Stark today for a free consultation.
A new study conducted by researchers from Boston University found that children who sustained a concussion/mild traumatic brain injury prior to the age of 12 had a greater risk of later-life cognitive impairment. Robert A. Stern, Ph.D. and colleagues at Boston University conducted a study to “determine the relationship between exposure to repeated head impacts through tackle football prior to age 12, during a key period of brain development and later-life executive function, memory, and estimated verbal IQ.” The study, published in Neurology, the official journal of the American Academy of Neurology studied 42 former NFL players ages 40-69, who were divided into two groups based on their age and first exposure to tackle football. The players were administered a neuropsychological test battery consisting of the Wisconsin Card Sort test, Neuropsychological Assessment Battery List Learning Test, and the Wide Range Achievement Test, 4th Edition (WRAT-4) reading subtest.
The researchers found that those NFL players who had sustained a brain injury prior to the age of 12 performed significantly worse on all measures after controlling for the total number of years of football played and age at time of evaluation, indicating executive dysfunction, memory impairment, and lower estimated verbal IQ.
According to the abstract conclusion, “there is an association between participation in tackle football prior to age 12 and greater later-life cognitive impairment measured using objective neuropsychological tests. These findings suggest that incurring repeated head impacts during a critical neuro developmental period may increase the risk of later-life cognitive impairment.”
From a neuro legal perspective, this study lends objective proof that children who sustained a traumatic brain injury have a greater risk of long term problems that their cohorts who sustained a concussion after the age of 12. Click here for the full article. If you or a loved one has been injured, contact Stark & Stark today for your free no obligation consultation.
It was recently reported that King-Devick Tests, Inc. has developed a quick and effective screening tool for the evaluation of concussion. The tests, to be called the King-Devick Test, according to the manufacturer, is a “quick‑accurate and objective concussion screening tool that can be administered on the sidelines by parents, coaches, athletic trainers, school nurses, and medical professionals.”
In the press release, Mayo Clinic neurologist and director of Mayo Clinic’s concussion program David Dodick, M.D. stated “most importantly, the test is affordable and can easily be used by any youth sports league, and administered by non‑medical personnel. And youth athletes are the higher risk for concussion and a longer recovery time than adults.”
It will be interesting to see whether the King-Devick test is adopted by rescue squad and emergency room doctors and nurses for the evaluation of concussion.