10 Myths of Brain Injury

On Monday, September 26, 2016, I had the pleasure of giving a presentation entitled “Dispelling the Myths of a Mild Traumatic Brain Injury: All Traumatic Brain Injury is Serious.”

My presentation addressed 10 myths surrounding Mild Traumatic Brain Injury, such as concussions are not serious, everyone recovers from mild TBI, mild TBI is not permanently disabling, one does not need to lose consciousness, and conventional neuroimaging is sensitive to mild TBI. The three day event in Nashville brought together some of the country’s leading trial attorneys and medical experts who presented on a myriad of medical and legal issues surrounding the preparation of a TBI case.

The symposium was sponsored by the Brain Injury Association of Tennessee and the Tennessee Trial Lawyers Association.

In this video, Bruce Stern, Chair of Stark & Stark’s Traumatic Brain Injury Litigation Group, discusses the differences between mild, moderate and severe traumatic brain injuries. Mr. Stern also discusses several common myths associated with brain injuries, including the belief that you must strike your head in order to sustain a traumatic brain injury.

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Traumatic Brain Injury Litigation – Part 2 from Stark & Stark on Vimeo.

Myth 10: Mild TBI is not disabling.

This myth has been rejected by the National Institute of Health. In its consensus statement, NIH writes that the consequences of TBI include a dramatic change in the individual’s life course, profound disruption of family, enormous loss of income or earning potential and large expenses over a lifetime.

There are approximately 300,000 hospital admissions annually for persons with mild or moderate TBI and an additional unknown number of traumatic brain injuries that are not diagnosed but may result in long-term disability.

The social consequences of mild, moderate and severe TBI are many and serious, including increased risk of suicide, divorce, chronic unemployment, economic strain and substance abuse.

Graham Teasdale, writing in the British Medical Journal, examined the disability effects on young people and adults one year after head injury. When the study was conceived, the authors believed the research would show that persons with severe and moderate traumatic brain injury had greater and longer disability than patients with mild traumatic brain injury. They were surprised what the research told them. Survival with moderate or severe disability was common after mild head injury and similar to that after moderate or severe injury. The incidents of disability in young people and adults with a head injury were higher than expected.

At the World Congress of Traumatic Brain Injury in Melbourne, Australia in 2005, Dr. Teasdale reported on his follow-up research five years after his initial paper was published. He reported that patients with mild TBI are still symptomatic and still suffering long-term disability.

You can read my other posts on the 10 myths of traumatic brain injuries here.

Myth 9: Mild TBI is not permanent.

Over and over again defense doctors testify that everyone who sustains a mild traumatic brain injury gets better; that mild traumatic brain injury is not a permanent condition. This simply is untrue.

Dr. Michael Alexander has pointed out that at one year after injury, 10 percent to 15 percent of mild TBI patients have not recovered. Many are more symptomatic than even immediately after the injury. Some have had persistence of one particularly troubling symptom –usually headache, neck pain or dizziness. Most have persistence and even worsening of the entire symptom complex. Both groups are at high risk of permanent symptomatic persistent post-concussive syndrome.

Work to date shows that mild brain injury results in measurable deficits in speed of information, processing, attention and memory in the immediate post-injury period. Recovery from these deficits is the rule occurring over a variable period ranging from four to 12 weeks. For small group, recovery may occur much more slowly or remain incomplete.

As Silver and McAlister explain, a good recovery is not universal. They note that although the long-term prognosis is favorable for the majority of patients with a mild TBI, it is well recognized that there can be significant short-term behavioral, somatic and cognitive sequelae. Furthermore, a significant minority of patients develops a chronic, often-debilitating constellation of signs and symptoms known as the chronic post-concussive syndrome.

You can read my other posts on the 10 myths of traumatic brain injuries here.

Myth 8: All children with traumatic brain injury get better.

One of the greatest myths perpetrated is that children have better recoveries from traumatic brain injury than adults. This myth rests upon the refuted theory known as plasticity, which claims developing brain can better rebound from injury. This theory is untrue. In fact, because a child’s brain is undeveloped, it may take years to realize the impairments that the child faces as a result of a brain injury. In an excellent article on children and head injuries published in the Journal of Recovery, Dr. Ronal Savage, who for 35 years has treated children with traumatic brain injuries, examines the following children related myths and puts them to rest.

Myth: Younger children recover better than older children.
Fact: New research shows that younger children, especially between birth and five years may experience more long-term challenges.
Myth: Severe TBI means permanent disability. Mild TBI means few, if any, problems.
Fact: Measures commonly used to evaluate brain injury severity were developed for adults, no children. Children do not lose consciousness as easily as adults.
Myth: Physical recovery is a sign the child has recovered.
Fact: Motor function is not a direct indicator of cognitive or behavioral recovery.
Myth: Normal intelligence scores after TBI mean the child will have no problems in school.
Fact: Intelligence tests often are unreliable measures of a child’s learning ability after TBI. Most intelligence tests measure prior learning.
Myth: Most injuries happen to older children, especially teen-agers.
Fact: The majority of brain injuries occur to children under 10.

It was once thought that child maturation followed a step-up progression. Research done by Dr. Savage and others now clearly demonstrates the traumatic effect of a child’s brain maturation. Not only does the brain as a whole mature at different times and ages, but a child’s different brain lobes maturate at different periods of time. In examining the long-term effects of traumatic brain injury on children it is important to look as to whether the child has suffered a previous TBI, whether the child has any pre-existing learning disabilities, whether the child has any pre-existing neurological or psychiatric problems and whether there is a history of family problems. All these issues are factors for poor outcome for children who have suffered a traumatic brain injury.

You can read my other posts on the 10 myths of traumatic brain injuries here.

Myth 7: Cognitive impairments on neuropsychological testing must fit a predictable pattern.

It is not unusual that a neuropsychological evaluation report prepared by a defense neuropsychologist finds a specific patient is faking or suffering from some other problem other than a traumatic brain injury because the neuropsychological findings do not fit “a normal or predictable pattern.”

Dr. Muriel Lezak has debunked this myth. Dr. Lezack, author of Neuropsychological Assessment –the bible of neuropsychology –writes:
“However, the behavioral repercussions of brain damage varied with the nature,extent, location and duration of the lesion. With the age, sex, physical condition and psycho-social background and status of the patient and with individual neuroanatomical and  physiological differences, not only does the pattern of neuropsychological deficits differ with different lesion characteristics and locations but two persons with similar pathology and lesion cites may have distinctly different neuropsychological profiles.”

Myth 6: Neuropsychological testing is subjective.

Because standard and traditional neuroimaging such as MRI, CT scans, and EEGs normally are neither specific nor sensitive enough to detect the damage done to the axons and neurons of the brain, the only objective testing which may be sensitive enough to detect and diagnose mild traumatic brain injury is neuropsychological testing. Neuropsychological testing consists of numerous tests designed to measure brain function. Because this testing requires a patient give his or her best efforts, some defense- oriented doctors suggest neuropsychological testing is subjective, not objective. This viewpoint has been rejected by mainstream medicine.

Strubb and Black in their text, Mental Status Examination in Neurology, explain that the neuropsychological evaluation is a comprehensive objective assessment of a wide range of cognitive adaptive and emotional behaviors that reflect the adequacy or inadequacy of higher brain functions. In essence, the neuropsychological evaluation is a greatly expanded and objectified mental status examination. The objective and highly qualified nature of most neuropsychological tests aids in the detection of subtle changes in performance over time.

Because of the wide range of behaviors assessed and the depth to which they are evaluated, the neuropsychological evaluation may detect subtle deficits not apparent on the mental status examination.

Not long ago, the American Academy of Neurology assembled a subcommittee to examine and validate the use of neuropsychological testing. That committee found that neuropsychological assessment is accepted and appropriate by the practicing medical community.

In summary, they found that neuropsychological assessment is most useful in patients with more subtle deficits. It also is useful for detecting deficits in patients with particularly high pre-morbid intelligence levels in which bedside type clinical testing may be insensitive to mild alterations.

Neuropsychiatrists also use neuropsychological testing. Formal neuropsychological testing is an essential part of the neuropsychiatric evaluation of the TBI patient. In fact, it often is the single-most sensitive indicator of subtle brain disturbances that may be contributing to the cognitive, emotional and behavioral dysfunctions that bring TBI patients to the psychiatrist, especially those with a history of only mild to moderate brain injury.

Neuropsychological assessment of the patient with TBI is essential to document cognitive and intellectual deficits and strengths.

Myth 5: The effects of TBI are immediate.

James Smith was stopped at a red light when his car was struck in the rear. At the scene, he was dazed and told the rescue squad personnel that he had pain in the back of his neck. He was taken to the local emergency room where again he complained of neck pain. He was examined, evaluated and released a couple hours later. Over the next couple of days and weeks, James began to experience problems with his attention and concentration. He began having difficulty at work and his relationship with his family began to suffer. His doctors ultimately diagnosed a mild traumatic brain injury, though doctors retained and hired by the insurance company disagreed –arguing that because James did not complain of TBI symptoms immediately following the crash he could not be suffering from a traumatic brain injury.

Are these defense doctors correct or are they simply perpetuating a myth? In Greenfield’s Neuropathology, the authors write:

“Under conditions of mild to moderate TBI, it is now apparent that there is a process of delayed axonomy in which the actual disruption of some axons does not occur until some time after the original injury. Axonomy only becoming apparent between six and 12 hours after injury. Thereafter, the proximal segment continued to expand.”

This delay in recognizing the symptoms of traumatic brain injury also was discussed in the National Institute of Health’s consensus statement, writing that as individuals with TBI attempt to resume their usual daily activities, the environment places increasing demands on them uncovering additional psychosocial consequences. For example, executive dysfunction may become obvious only in the workplace.

You can read my other posts on the 10 myths of traumatic brain injuries here.

Myth 4: Negative MRIs, CT scans and EEGs rule out brain injury.

Another misconception is that if a person has sustained or suffered a traumatic brain injury, today’s sophisticated diagnostic tests will detect it. There is a belief that if those tests are negative or normal, no brain injury has been sustained. Unfortunately, this is another myth.

In a seminal piece titled “Mild Traumatic Brain Injury” in the journal Neurology, Dr. Alexander states: “By common clinical agreement, neuroimaging studies are negative.” Other leading professionals in the field of caring for persons with traumatic brain injury are agreement.

In the text Neuropsychiatry of Traumatic Brain Injury, the authors write: “In addition, many patients with a history of minor brain injury will not have abnormalities on even MRI yet can manifest clear evidence of functional impairment on neuropsychological measures.”

Dr. Zasler, in discussing MRIs, CT scans and the like, writes, “Many practicing physicians believe that a patient with a normal CT and normal electroencephalogram is in fact normal.” They should keep in mind, however, the old adage: Absence of proof is not proof of absence. Historically, the lack of positive neurodiagnostic tests in patients with mild TBI may have reflected a simple lack of sensitivity and/or specificity.

You can read my other posts on the 10 myths of traumatic brain injuries here.

Myth 3: One must strike one’s head in order to suffer a traumatic brain injury.

Through movies and television, we have all come to expect that in order to suffer a brain injury one must either strike their head or have their head struck by a foreign object. This is not so. The brain has the consistency of gelatin. Think of the brain and skull as being similar to a bowl of gelatin, except that unlike a bowl, the underside of the skull is rough with many bony protuberances. These ridges can result in injury to the temporal lobe of the brain during rapid acceleration.

When the head is struck or undergoes acceleration/deceleration forces, the impact causes the brain to bump the opposite side of the skull. Damage then occurs at the area of impact and on the opposite side of the brain. This is called coup contre coup.

You can read my other posts on the 10 myths of traumatic brain injuries here.