Shannon Entropy Analysis Helps Predict Likelihood of Migraines in Concussion Patients

Posted in Brain Injury News

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.

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rTMS in Alleviating Mild TBI Related Headaches – A Case Series

Posted in Brain Injury News, Brain Injury Resources & Links

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)

Federal Court in Louisiana Admits DTI into Evidence

Posted in Brain Injury Legal Cases

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:

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New Case Study Presented in JAMA Neurology

Posted in Brain Injuries in Sports

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.

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Congressman Pascrell Admonishes ESPN to Combat Concussion Stigma

Posted in Brain Injuries in Sports

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.

Concussions and the Courthouse

Posted in Brain Injuries in Sports, Brain Injury News

The American Association for Justice released a new report entitled concussions and the courthouse, which examines the role the civil justice system has played in encouraging sports leagues to not only take action to prevent concussion, but also change the way they respond to players who have suffered traumatic brain injuries.

Below are the highlights of the report:

  • We all know that football is an exciting, competitive, and violent sport. But for decades, the NFL and other professional and amateur sports organizations ignored and denied the science behind concussions and long-term health impacts.
  • Class action lawsuits on behalf of former NFL players finally forced a change in policies and a recognition that more should be done to protect professional and student athletes. Although the settlement reached between retired players and the NFL was not without controversy, it did force the league to acknowledge the toll that concussions have on long-term cognitive health.
  • While every state except Wyoming has some kind of concussion law in place, no state has a comprehensive law that includes important safeguards such as notifying parents when their child suffers a concussion, comprehensive training for all coaches, and clearance from a licensed physician or trained health professional before a student is allowed to return to play.
  • AAJ has done the research and is offering five points that all states must adopt to protect player safety:
    1. States must require students who have been concussed to be cleared by a licensed physician or health professional trained in traumatic brain injury (TBI) management.
    2. States must require TBI training for all coaches.
    3. States must require comprehensive athlete education on concussions.
    4. States must require schools notify parents of student-athletes who have suffered a concussion.
    5. States must require comprehensive parental education on concussions.
  • We encourage every state, school board, professional and amateur athletic program to review its policies and ensure these five protections for student, amateur, and professional athletes are in place.

Read the full report here.

The Chronic, Long-Term Consequences of Traumatic Brain Injury

Posted in About Brain Injuries, Brain Injury News

It is ironic that on the same day I receive a defense neuropsychological report stating, “Individuals who have sustained a mild traumatic brain injury typically recover from neuro cognitive deficits within 6-9 months after the time of injury” that I also receive the current issue of the Journal of Neuro Trauma. And in this current edition, they discuss “the chronic consequences of neuro trauma,” which was guest edited by Brent E. Masel and Douglas S. DeWitt.

As you might recall, Masel and DeWitt are the authors of the BIAA White Paper, “Traumatic Brain Injury: A Disease Process, Not an Event,” which was also published in the Journal of Neuro Trauma (27, 1529‑1540).

Included in is issue, there is an interesting article by Helen M. Bramlett and W. Dalton Dietrich entitled, “Long-Term Consequences of Traumatic Brain Injury: Current Status of Potential Mechanisms of Injury and Neurological Outcomes.” In this article, the authors write, “In models of mild, moderate, and severe TBI, histopathological and behavioral studies have emphasized the progressive nature of the initial traumatic insult and the involvement of multiple pathophysiological mechanisms, including sustained injury cascades leading to prolonged motor and cognitive deficits.”

It is now well established in current literature that persons with mild traumatic brain injury do not all recover within the narrow 6-9 month range listed in the defense neuropsychological report I recently received. Unfortunately, many go on to suffer long term chronic consequences of mild traumatic brain injury.

If you are suffering from a traumatic brain injury, it is strongly recommended that you seek experienced legal counsel immediately.

Massachusetts Trial Court Finds DTI to Be a Well-Established and Reliable Tool to Identify Traumatic Brain Injury

Posted in Brain Injury News

The use of diffusion tensor imaging, an advanced neuroimaging technique, has once again been found by a Massachusetts court, to be a reliable diagnostic tool in the diagnosis of a traumatic brain injury. In the case of Craffey v. Embree Construction Group, a Norfolk trial judge rejected defendant’s motion in limine to strike plaintiff’s expert, Randall Benson, M.D. and to preclude his testimony regarding his use and interpretation of diffusion tensor imaging. In denying the defendant’s motion, the trial court found:

DTI is a well-established and reliable tool to identify conditions in the brain. In line with the science, Dr. Benson may not testify that DTI proves brain injury, but may testify that DTI results are consistent with brain injury and, along with other medical evidence, is part of the puzzle leading to a diagnosis of brain injury. Without limitation, this expert will assist the jury, has sufficient qualifications, is based upon reliable principles and applying those principles in a reliable manner to the particular facts of this case.

This decision is in line with multiple decisions that have been rendered by trial and appellate courts throughout the United States, finding that diffusion tensor imaging is a valuable tool. While one cannot make a diagnosis of traumatic brain injury solely upon abnormalities seen on DTI, as this court found, DTI nevertheless is a valuable tool along with her medical records, history and physical examination in leading to and making a diagnosis of traumatic brain injury.

The Age and Sex Differences in Working Memory after Mild Traumatic Brain Injury: Functional MR Imaging Studies

Posted in Brain Injury News

A new study published in Radiology evaluated the age effect on working memory performance and functional activation after mild traumatic brain injury. According to the abstract, researchers at Taipei Medical University-Shuang-Ho Hospital in Taiwan compared a group of thirteen individuals between the ages of 21-30 (with a mean age of 26.2 years) to a group of thirteen older patients who had an age range between 51-68 years (with a mean age of 57.8 years). Both groups had sustained mild traumatic brain injuries (MTBI). The researchers compared these twenty-six patients with twenty-six age- and sex-match control subjects. Functional MR images were obtained within one month after injury and six weeks after the initial study. Researchers performed group comparison and regression analysis among post concussion symptoms, neuropsychological testing and working memory activity in both groups.

The results showed different manifestations of post concussion symptoms at functional MR imaging between younger and older patients, which confirmed the important role of age in activation, modulation and allocation of working memory processing resources after mild traumatic brain injuries. The researchers concluded that these findings also supported the observation that younger patients have a better neural plasticity and clinical recovery than older patients.

David Yen-Ting Chen, the lead author of the study, stated in a press release, “old age has been recognized as an independent predictor of worse outcome from concussion, but most previous studies were performed on younger adults.” Dr. Chen went on to state, “taken together these findings provide evidence for differential neural plasticity across different ages, with potential prognostic and therapeutic implications. The results suggested MTBI might cause a more profound and lasting effect in older patients.”

The researchers also looked at the differences between men and women. They found that female patients with MTBI had lower digit span scores than did female control subjects, and functional MR imaging depicted sex differences in working memory functional activation; hypoactivation with non recovery of activation change at follow-up studies may suggest a worse working memory outcome in female patients with MTBI.

Again, this is just another example that refutes defense allegations that mild TBI always goes on to uneventful healing and recovery with 3-6 months.  If you or your family was injured and sustained traumatic brain injuries, it is encouraged that you seek experienced legal counsel.

Mild TBI May Lead to Chronic Traumatic Encephalopathy (CTE)

Posted in Brain Injuries in Sports, Brain Injury News

In almost every case in which I represent a client who has sustained a mild traumatic brain injury (TBI), the defense courtroom doctors write that my clients have not, in fact, suffered permanent injuries as everyone who suffers a mild traumatic brain injury goes on to eventually and uneventfully recover. If that were true, then we would expect that people who sustain multiple concussion/mild traumatic brain injuries should have no long term effect, because, from this logic, each injury is self-limited and results in full recovery over a period of time.

However, a recent study, which was conducted by researchers with the Department of Veteran Affairs and Boston University, found that 96% of examined NFL players and 79% of all examined football players have suffered the degenerative disease known as chronic traumatic encephalopathy (CTE). CTE is known to be a progressive degenerative disease of the brain, which can be found in person’s suffering from repetitive brain trauma. This trauma includes both symptomatic concussions and asymptomatic subconcussive hits to the head.

Additionally, the study found that 40% of those who tested positive CTE were offensive and defensive lineman. “That finding supports past research suggesting that it’s the repeat, more minor head trauma that occurs regularly in football that may pose the greatest risk to players, as opposed to just the sometimes violent collisions that cause concussions.”

This recent study, which can be found here, should certainly put to rest the argument that everyone who suffers a concussion recovers.