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)
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:
- 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.
- States must require TBI training for all coaches.
- States must require comprehensive athlete education on concussions.
- States must require schools notify parents of student-athletes who have suffered a concussion.
- 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.
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.
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.