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.”

An evidence– based guideline from the AAN for evaluating and managing athletes with concussions recommends that athletes who are suspected of having a concussion be removed from the game immediately and not be returned until assessed by a licensed health care professional trained in diagnosing and managing concussion. The new guideline, which replaces a 1997 AAN guideline on the same topic, was published in Neurology® electronically ahead of print on March 18, 2013. It has been endorsed by several athletic, medical, and patient groups.  Click Here to read the guideline.

“Among the most important recommendations the Academy is making is that any athlete suspected of experiencing a concussion should immediately be removed from play,” said co– lead guideline author Christopher C. Giza, MD, with the David Geffen School of Medicine and Mattel Children’s Hospital at UCLA. “We’ve moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return to play be assessed in each athlete individually. There is no set timeline for safe return to play.”

The guideline also addresses sports with the highest risk of concussion, protection provided by helmets and headgear, increased risk after having a concussion, the relationship between multiple concussions and permanent or lasting impairments, and other issues.

Read the guideline, access clinician and patient resources, and download the new AAN Concussion Quick Check app. For more information, contact Julie Cox or (612) 928– 6069.

I recently read an abstract in the journal Radiology in which the researchers demonstrated structural changes to the brain one year after injury after a single concussive episode. According to an article published in Health Imaging, Yongxia Zhou, PhD, from the department of radiology at New York University (NYU) School of Medicine in New York City, and colleagues enrolled 28 MTBI patients with posttraumatic symptoms after injury and 22 matched control subjects in the study. Nineteen of the 28 MTBI patients were followed for up to one year. All participants underwent 3T MRI, neurocognitive testing and assessments for anxiety, depression and fatigue.
“’The average BSI [boundary shift integral] in patients with MTBI from the time of initial assessment to one-year follow-up showed a loss of 7.6 cm 3, larger than two times the changes seen in control subjects (3.7 cm3),’ wrote Zhou and colleagues. ‘This study confirms what we have long suspected,’ Yvonne W. Lui, MD, neuroradiology section chief at NYU Langone School of Medicine, said in a press release. ‘After MTBI, there is true structural injury to the brain, even though we don’t see much on routine clinical imaging. This means that patients who are symptomatic in the long-term after a concussion may have a biologic underpinning of their symptoms.’” To read more, click here.

Here is the abstract:

Purpose: To investigate longitudinal changes in global and regional brain volume in patients 1 year after mild traumatic brain injury (MTBI) and to correlate such changes with clinical and neurocognitive metrics.Materials and Methods: This institutional review board-approved study was HIPAA compliant. Twenty-eight patients with MTBI (with 19 followed up at 1 year) with posttraumatic symptoms after injury and 22 matched control subjects (with 12 followed up at 1 year) were enrolled. Automated segmentation of brain regions to compute regional gray matter (GM) and white matter (WM) volumes was performed by using three-dimensional T1-weighted 3.0-T magnetic resonance imaging, and results were correlated with clinical metrics. Pearson and Spearman rank correlation coefficients were computed between longitudinal brain volume and neurocognitive scores, as well as clinical metrics, over the course of the follow-up period. Results: One year after MTBI, there was measurable global brain atrophy, larger than that in control subjects. The anterior cingulate WM bilaterally and the left cingulate gyrus isthmus WM, as well as the right precuneal GM, showed significant decreases in regional volume in patients with MTBI over the 1st year after injury (corrected P < .05); this was confirmed by means of cross-sectional comparison with data in control subjects (corrected P < .05). Left and right rostral anterior cingulum WM volume loss correlated with changes in neurocognitive measures of memory (r = 0.65, P = .005) and attention (r = 0.60, P = .01). At 1-year follow-up, WM volume in the left cingulate gyrus isthmus correlated with clinical scores of anxiety (Spearman rank correlation r = -0.68, P = .007) and postconcussive symptoms (Spearman rank correlation r = -0.65, P = .01). Conclusion: These observations demonstrate structural changes to the brain 1 year after injury after a single concussive episode. Regional brain atrophy is not exclusive to moderate and severe traumatic brain injury but may be seen after mild injury. In particular, the anterior part of the cingulum and the cingulate gyrus isthmus, as well as the precuneal GM, may be distinctively vulnerable 1 year after MTBI.

A new paper published in the Annals of Neurology by trained pattern classifiers discriminated between patients with microbleeds and age-match controls with a high degree of accuracy, and outperformed other methods. “Individual prediction of white matter injury following traumatic brain injury,” Hellyer PJ, Leech R, Ham TE, Bonnelle V and Sharp DJ, Ann Neurol 2013.

In their article, the researchers note:

Traumatic brain injury often results in traumatic axonal injury (TAI). This can be difficult to identify using conventional imaging. Diffusion tensor imaging (DTI) offers a method of assessing axonal damage in vivo, but has previously mainly been used to investigate groups of patients. Machine learning techniques are increasingly used to improve diagnosis based on complex imaging measures. We investigated whether machine learning applied to DTI data can be used to diagnose white matter damage after TBI and to predict neuropsychological outcome in individual patients.
The researchers, “Trained pattern classifiers to predict the presence of white matter damage in twenty-five TBI patients with microbleed evidence of TAI compared to neurologically healthy age-match controls.” The researchers then applied these classifiers to, “Thirty-five additional patients with no conventional imaging evidence in TAI [mTBI patients]. Finally, using a regression analyses to predict indices of neuropsychological outcome for information processing speed, executive function and associative memory in a group of seventy heterogeneous patients.”

The study provides, “Proof of principal that multivariate techniques can be used with DTI to provide diagnostic information about clinically significant TAI.”

This is a very important study. While it was not exclusive to mTBI patients – about one half were, DTI clearly delineated a difference between controls and TBI subjects.

This study also debunks Larrabee (2013) in their response to Bigler (2013) in which Larrabee noted the inability of DTI to “diagnose” TBI.

This month’s issue of the American Journal of Psychiatry, the Aflagship@ journal of the American Psychiatric Association, includes a study entitled ARisk for Addiction-Related Disorders Following Mild Traumatic Brain Injury in a Large Cohort of Active-Duty U.S. Airmen,@ Miller SC, Baktash SH, Webb TS, Whitehead CR, Maynard C, Wells TS, Otte CN and Gore RK, Am J Psychiatry Miller, et al.; (2013).

The objective of the study was the acknowledgment that “military personnel are at increased risk for traumatic brain injury (TBI) from combat and non-combat exposures. The sequelae of moderate to severe TBI are well described, but little is known regarding long-term performance decrements associated with mild TBI (mTBI). Furthermore, while alcohol and drug use are well known to increase risks for TBI, little is known regarding the reverse pattern.” The authors sought to assess possible associations between mTBI and addiction-related disorders in active-duty U.S. military personnel.

The authors conducted a historical perspective study using electronically recorded demographic, medical and military data for more than a half-million active-duty U.S. Air Force service members. Cases were identified by ICD-9CM codes considered by an expert panel to be indicative of mTBI. Outcomes included ICD-9CM diagnoses of selected addiction-related disorders.

The study found that airmen with mTBI were at increased risk for certain addiction-related disorders compared with a similarly injured non-mTBI comparison group. Hazards for alcohol dependence, nicotine dependence and non-dependent abuse of drugs or alcohol were significantly elevated, with a consistent decrease over time.
 
In their discussion, the authors noted:

Mild TBI was associated with an increased risk for alcohol dependence, non-dependent abuse of drugs or alcohol and nicotine dependence in the first thirty days following mild TBI, with alcohol dependence being significant across all three independent time periods. Contrary to published observations of moderate to severe TBI, there was no period during which significant risk did not occur following mild TBI. Furthermore, whereas previous research indicated that mTBI sequelae resolved quickly, our findings suggest that alcohol dependence may be a long-lasting adverse health outcome following mild TBI.

Again, this study exposes the problem that Larrabee, Binder and Rohling have in that they want to use neuropsychology in the narrowest sense – to assess some cognitive metric in the neuropsychologist’s office and not the real world and dismiss everything else, subjective symptoms, onset of new psychiatric disorders, suicide, substance abuse, etc.
 

Neuro law attorneys are very familiar with the meta-analytic review of neurological studies that was authored by Binder, Rohling and Larrabee (Binder 1997). It is a study that is often cited by defense attorneys to support the myth that recovery after mild traumatic brain injury (mTBI) occurs within the first three months, with any subsequent changes in performance being of limited statistical and clinical significance. Binder, et al. found only a small overall effect size and concluded that the size of the overall effect was unimpressive and suggestive of clinical non-significance. That study was later updated by Frencham, Fox and Maybery (Frencham 2005). These meta-analyses are sometimes cited as evidence that mTBI has no lasting effect on neuropsychological status.

 

In 2009, Pertab JL, James KM and Bigler ED (Pertab 2009) conducted a study designed to clarify opposing conclusions in the mTBI literature by re-analyzing meta-analytic data sets. The study was conducted as there had not been, “A critical review of meta-analytic techniques in mTBI to help clarify discrepancies and conclusions that are drawn from the literature” (Pertab 2009). “Since Binder (1997), there had been a large volume of research published in the literature showing that a sub-set of those who sustained mTBI have long-term significant problems.” (Pertab 2009). Pertab “revisited the data combined in the meta-analysis of Binder and Frencham, specifically addressing four areas: (1) mechanism of injury, (2) diagnostic criteria employed, (3) type of neuropsychological assessment tool employed, and (4) whether symptomatic or non-symptomatic mTBI subjects were assessed separately.” Pertab concluded, after re-analyzing the data, “By using different mTBI characteristics as inclusion/exclusion criteria to re-examine the existing meta-analyses, the current results indicated significant statistical heterogeneity (a) the effect sizes of neuropsychological measures employed in the post-acute phase and marked qualitative heterogeneity in (b) the criteria used to define mTBI and mTBI severity, and (c) the populations and mechanisms of injury from which the mTBI samples were selected.”

 

Pertab concluded:

 

As indicated in the introduction, we are not disputing the overall conclusions in mTBI meta-analyses where it appears that the majority of individuals who sustain an mTBI suffer no significant neuropsychological residue after three months. In fact, the largest effect size in this re-characterization was moderate, with most being small to trivial. It is well known and widely understood that group inferential statistics can obscure important individual differences.

 

As indicated in the introduction, the Binder, et al. and Frencham, et al. studies have been cited to support the non-effect of any lasting sequelae of mTBI as a general principal for the outcome of all mTBI’s. From the total group standpoint, that likely remains a true statement, but not one that necessarily applies to an individual within that sample.

 

If small sub-samples of clinically symptomatic mTBI patients do exist within a broader sample of non-symptomatic subjects where the mechanism of injury differs between studies or the methods of assessment differ, etc., the averaging process of meta-analysis is likely to obscure, rather than highlight, clinically relevant features of any minority sample within an mTBI group that may have residual symptoms and/or deficits.

 

Following the publication of Pertab (2009), Binder, Rohling and Larrabee updated their meta-analysis to include studies through 2002, observing similar results to Binder, et al. (1997). Rohling, et al. (2011) have now critiqued the methods used by Pertab (2009) and performed even more meta-analytic comparisons on the original twenty-five studies, again concluding that there were no lasting cognitive effects of mTBI.

 

Now, Bigler (2013) and his colleagues have again reviewed Binder (1997), Frencham (2005) and Rohling (2011). In their new paper, Bigler responds to the Rohling (2011) critique, reaffirming the original findings of Pertab (2009), and providing additional details concerning the flaws in prior meta-analytic mTBI studies and the effects on neuropsychological studies. “Reaffirmed Limitations of Meta-Analytic Methods in the Study of mTBI: A Response to Rohling, et al.”, Bigler ED, Farrer TJ, Pertab JL, Kelly JM, Petrie JA and Hedges DW, The Clinical Neuropsychologists (2013).

 

Bigler (2013) again acknowledges that:

 

The majority of mTBI patients over time enjoy a full functional return to their pre-injury baseline and their recovery follows a quick and rather benign course. However, some mTBI patients do experience persisting neuro cognitive and neural behavioral deficits and symptoms, even after controlling for such factors as depression and potential response bias.

 

Bigler (2013) responds further:

 

While such a statement may apply to the majority of mTBI participants who experience a positive outcome, this perspective does not match contemporary animal-model neuropathological investigations and human neuroimaging and neuropathological studies of mTBI which do indicate that permanent changes may occur after mTBI.

 

A major point of Pertab (2009) was that meta-analytic technique as applied to group data will not detect embedded impaired performance by the few, because it becomes averaged and therefore hidden within the overall group mean.

 

The Rohling (2011) critique strongly disagrees with the idea that embedded effects may go undetected in a meta-analysis and in fact cite literature demonstrating, … in some cases, low-powered individual studies of various medical topics have failed to show differences, while meta-analytic studies of the same topics have revealed significant results.

 

Bigler (2013) also addresses some important issues in the field of mTBI. Discussing the sensitivity or lack of sensitivity of neuropsychological measures to persistent effects of mTBI, Bigler (2013) notes, “Regardless of the type of neurologic and/or psychiatric disorder, neuropsychological assessment faces its biggest challenge in detecting subtle impairment,” citing B. Johnson, et al. (2011).“An fMRI investigation showing persistent deficits in the brain’s default network in athletes with mTBI, explicitly state that: ‘Neuropsychological testing and conventional neuroimaging techniques are not sufficiently sensitive to detect’ neurological changes.”

 

On this point, Bigler (2013) includes:

 

All of this suggests that traditional neuropsychological techniques, including those used in the twenty-five source studies for meta-analyses discussed herein have inherent sensitivity problems after the acute recovery  time period; issues of sensitivity not discussed by Rohling, et al. in offering their conclusions. If the traditional neuropsychological measure is insensitive after the acute time frame, what should be used? The answer is likely to be found in the integration of functional neuroimaging with cognitive processing speed tasks that measure performance in milliseconds, a more direct representation of brain processing speed.

 

Bigler (2013) also criticizes Rohling’s failure to separate mTBI from complicated mTBI cases. Bigler (2013) finds:

 

Rohling and co-authors state that their conclusions were not necessarily applied to those with complicated mTBI. Is that conclusion not being made because in mild-complicated TBI there is objective indication (i.e., a bio-marker?) of neuro injury (see Green, Koshimori and Turner, 2010) and that mild-complicated TBI participants have been shown and even classified by some as having sustained a moderate TBI? As already stated, the distinction of whether mild-complicated TBI was present or not was not uniformly addressed whatsoever in the twenty-five source studies. In regards to technology, CT imaging – which was the basis for mild-complicated TBI classification for essentially all studies prior to the early 1990’s – is the least sensitive of the imaging technologies for detecting hemorrhage which is a typical marker for the mild-complicated TBI distinction. … Because current-day technology did not exist during any of the twenty-five source studies used to perform the meta-analyses, the issue of objective indications of neuro injury simply cannot be addressed, including the mild-complicated issue.

 

Rohling, et al.’s conclusions assume that neuropsychological measures represent the best approach for detecting impairment. However, as shown above, neuropsychological methods may simply be ineffective (i.e., lack of proper sensitivity) in detecting the subtleties of any type of residual impairment following mTBI from the sub-acute to chronic phase.

 

With regard to their initial evaluation of the twenty five source studies, Bigler (2013) write:

 

Given everything discussed to this point, the real mistake of Pertab et al. (2009) was that even after they demonstrated the various assumption violations and listed all of the limits of the Binder et al. (1997) and Frencham et al. (2005) meta-analyses, they went ahead and used some of the same studies in their metaanalysis. In fact Pertab et al. should have stopped and offered no additional analyses of the 25 mTBI articles because of the study quality issues and assumption violations. The real message of Pertab et al. is that past mTBI studies are problematic for all the reasons discussed herein, and if meta-analysis is to be used to address the mTBI problem, the highest quality of research and clinical standards need to be used.

 

Bigler (2013) concludes:

 

In conclusion, we show methodological violations, all of which were originally identified in Pertab (2009) that limit Rohling (2011) critique where their findings merely perpetuate type-II statistical errors. As already stated, it is an untenable and non-supportable position that neuron-based symptoms and deficits do not persist in some individuals who experience mTBI. (Citations omitted). Current neuroimaging and neuropathological findings indicate that mTBI results in permanent structural and physiological injury to the brain in some individuals. As such, neuropsychology’s goal should be to refine its methods, including its interface across disciplines to detect those individuals who have experienced an mTBI and in whom brain dysfunction and its symptoms persist, not to continue arguing that permanent deficits do not occur from mTBI.*

 

* It should be noted that Larrabee (2013) published a rebuttal to Bigler (2013) in an article entitled “Meta-Analytic Methods and the Importance of Non-TBI Factors Related to Outcome in Mild Traumatic Brain Injury: Response to Bigler, et al. (2013), Larrabee GJ, Binder LM, Rohling ML and Ploetz DM, The Clinical Neuropsychologist (2013).

New research published online in the December 2012 issue of the Journal of Neuroscience utilized diffusion tensor imaging (DTI) to examine the last affects of a traumatic brain injury in children. The Journal of Neuroscience, 12 December 2012, 32 (50):17961-17969. 

The researchers from Mind Research Network and the University of New Mexico examined fifteen semi-acute pediatric mild traumatic brain injuries as well as fifteen well-matched controls.  A region of interest and voxelwise Analyses indicated increased anisotropic diffusion for pediatric mild TBI patients with an elevated number of clusters with high anisotropy.  Researchers were able to objectively classify pediatric mild TBI patients from healthy controls with a 90% accuracy.  Researchers found little evidence of recovery in white matter abnormalities over a four month interval in returning patients, “indicating that physiological recovery may lack behind subjective reports of normality….  Current findings suggest that developing white matter may be more susceptible to initial mechanical injury forces and that anisotropic diffusion anisotropic diffusion provides a objective bio marker of pediatric mild TBI.” 

An abstract of the article by Mayer, et al. can be found here

An excellent review of the study can be found at the Education Week Spotlight

 

A recent systematic literature review of eight research studies has shown that the rate of traumatic brain injury (TBI) is higher amongst homeless people than the general population.  The results from this collection of information, which had never before been reviewed in a scientific study, will significantly affect those who are at risk of becoming, or who are, homeless.

Most case studies and data samples collected and analyzed in this research had many flaws, including small sample sizes of mostly men and poor qualitative studies and documentation.  However, the results from the studies showed that the rate of traumatic brain injury within the homeless cases ranged from 8% to 53%, far higher than the rate for the general population.  Regardless of the imperfect research parameters, the findings should still be taken seriously and reflect an absolute relationship between TBI and the homeless population.

Now that the correlation between the rate of TBI and homelessness is known, it is important for caregivers of homeless people, or people at risk of becoming homeless, to be trained on, and educated about, traumatic brain injury.  Additionally, those who are homeless, their families, and public policy workers should be aware of the risks of TBI.
 

Earlier this week I was contacted by a reader who discussed his recent experience with State Farm Insurance in an arbitration proceeding. You can read his comments, as well as another reader’s here. First, let me express my condolences for the bad outcome in your case. Please understand that it is difficult to respond specifically without having read your entire file. Dr. Lees-Haley and Dr. Fox are well known to me. I draw your attention to a recent article authored by Dorothy Sims, Esq. which was recently published in Brain Injury Professional, The Official Publication of the North American Brain Injury Society. In Ms. Sims article, quoting from a recent deposition of Dr. Lees-Haley, she quotes him as conceding:

1.His practice is “almost all defense.” His practice is so reliant upon defense referrals his template, or prewritten report, already indicates the defense hired him before he even receives the referral. 2.He treats no patients. 3.By the time the case in question comes to trial, his charges could exceed $25,000.00.

In a previous article I wrote some years ago entitled “Anticipating the Defense’s” I stressed the need for neurolawyers to be well versed concerning defense experts. As Ms. Sims points out, many of these defense experts come with preconceived biases and are hired because the insurance industry knows what it is getting before the referral is made. In your post, you indicate that Dr. Fox wrote a report without having ever evaluated you. I draw your attention to the ethics of the American Psychological Association which discusses this behavior. In retaining an attorney to represent someone who has an acquired traumatic brain injury, it is imperative to hire an attorney who has great experience in handling these types of cases. Finally, while you are correct that I do not practice law in the state of California, I am always happy to speak with individuals with acquired traumatic brain injury regardless of their location. If I cannot help them, I am more than willing to make an appropriate referral to an attorney who can. Thank you all for sharing you stories and questions. Please keep them coming!

I read a story in The Journal News which highlights a common occurrence in many personal injury cases, including those which involve a traumatic brain injury. After a debilitating injury, many people find themselves without pre-established provisions such as power of attorney designees or health care trustees. Injured individuals who are incapable of managing their healthcare or finances are then dependent on the courts to make that decision for them. One of my fellow shareholders, Steven Friedman dedicates his practice to assisting people in planning for their future. He is also an accredited estate planner. You can also read an earlier post regarding the need for estate planning for those who are currently the sole care provider for a younger person who has suffered a traumatic brain injury.