Brain Injury Resources & Links

Following a concussion, patients are instructed to rest for twenty-four to forty-eight hours beginning any type of return to normal activities.  Many doctors recommend an even longer period of rest so as to reduce the risk of re-injury during recovery from the concussion.  Some clinicians even advocate “cocoon therapy” which “restricts patients to several days in a darkened room before slowly returning to activity.”

A new study out of the Department of Pediatrics at the Medical College of Wisconsin calls into question the efficacy of cocoon therapy.

Danny G. Thomas, M.D. and his colleagues conducted a study of patients aged between eleven  and twenty-two years who presented to a pediatric emergency department within twenty-four hours of having sustained a concussion.  Participants underwent neuro cognitive, balance and symptom assessment in the emergency room and were randomized to strict rest for five days versus the usual care of one-two days rest followed by stepwise return to activity.  Patients were asked to complete a diary to record physical and mental activity level, calculate energy exertion, and record daily post concussive symptoms.

Ninety-nine patients were enrolled and eighty-eight completed all study procedures.  Post discharge, both groups reported a 20% decrease in energy exertion and physical activity levels.  As expected, the intervention group reported less school and after-school attendance for days two to five post concussion.  However, “there was no clinically significant difference in neuro cognitive or balance outcomes.  However, the intervention group reported more daily post-concussive symptoms and slower symptom resolution.”  The conclusion of the researchers was “recommending strict rest for adolescents immediately after concussion offered no added benefit over the usual care.  Adolescents’ symptom reporting was influenced by recommending strict rest.”

This study can be downloaded from pediatrics.aappublications.org.  The study is entitled “Benefits of Strict Rest after Acute Concussion:  A randomized controlled trial, Thomas

Space, DG, APPS JN, Hoffman RG and McCrea M, and Hammeke T.  Pediatrics, Vol. 135, No. 2, February 2015.

If you or a loved one have suffered from a brain injury and have legal questions, contact Stark & Stark today.

At the annual meeting of the Radiological Society of North America (RSNA), Christopher C. Whitlow, M.D., Ph.D., M.H.A., an associate professor of radiology at Wake Forest School of Medicine and radiologist at Wake Forest Baptist Medical Center presented the findings from his research that some high school football players exhibit measurable brain changes after a single season of play, even in the absence of concussion

Dr. Whitlow and his fellow researchers studied twenty-four high school football players between the ages of sixteen and eighteen, none of whom had a history of having sustained a concussion.  During all games and practices, the twenty-four players were monitored with Head Impact Telemetry System (HITs) helmet-mounted accelerometers.

Utilizing this data, the players were divided into two groups “heavy hitters” and “light hitter.”  All twenty-four players underwent pre- and post- season evaluation with Diffusion Tensor Imaging (DTI).  Although none of the players suffered a concussion during the season “the results showed that both groups demonstrated global increases of FA over time, likely reflecting effects of brain development. However, the heavy-hitter group showed statistically significant areas of decreased FA post-season in specific areas of the brain, including the splenium of the corpus callosum and deep white matter tracts.”

“’Our study found that players experiencing greater levels of head impacts have more FA loss compared to players with lower impact exposure,” Dr. Whitlow said. ‘Similar brain MRI changes have been previously associated with mild traumatic brain injury. However, it is unclear whether or not these effects will be associated with any negative long-term consequences.’

Dr. Whitlow cautions that these findings are preliminary, and more study needs to be done.” If you or a loved one has been affected by a brain injury, contact Stark & Stark today.

Click here for the link to the RSNA press release.

There has been much research with regard to the long term effects of mild traumatic brain injury (MTBI) and post traumatic stress disorder (PTSD) as independent conditions.  However, there has been very little research studying the combined effect of MTBI and PTSD. 

This month’s Journal of Neurotrauma contains an article by Walter High, M.D. and his colleagues at the University of Kentucky, Department of Physical Medicine and Rehabilitation, Neurosurgery and Psychology.  Dr. High and his colleagues conducted a multi site study looking at the collective as well as the individual effects of MTBI and PTSD on an individual’s psychological, and cognitive functioning abilities.

The participants in the studies underwent a series of neuropsychological testing to measure their cognitive functioning.  The participants were classified as MTBI only, PTSD only, or both.  The results of the studies suggested that veterans suffering from both PTSD and MTBI have a poor cognitive and psychological outcome than those diagnosed with only one of the two conditions.  A link to the University of Kentucky press release can be found here.

This summer the Radiological Society of North America published an article summarizing the findings from Research conducted at Stanford University on the effects of concussive and sub-concussive head injuries.  There the Stanford researchers, headed by  Michael Zeineh, MD, Ph.D. concluded that even for young football players who didn’t experience a concussion, football and other contact sports can cause brain abnormalities that mimic mild traumatic brain injuries and which can lead to the frightening degenerative decease call CTE. More information can be found here.

Recently, the athletic administration at Ohio University has published on its website an infographic that highlights the impact CTE has had on sports.  Ohio University breaks down the number of cases of CTE per sport (76 Football players at the professional level, 47 amateur or professional boxers, two soccer players, and more). While the narrative surrounding concussions and CTE has been attached to the NFL, it is spreading to other sports, including soccer, which was once considered a safer alternative to football. The infographic also offers ways to make sports safer and the stories of many athletes diagnosed with CTE, including Pat Grange, the first soccer player diagnosed with CTE. Click here to read the full article. If you or a loved one has been affected by a brain injury, contact Stark & Stark today for a free consultation.

The Association for Scientific Advancement in Psychological Injury in the Law has published an official position regarding psychological assessment of symptom and performance validity, response bias, and malingering. Psychol. Inj. And Law (214) 7:197-205.  Bush, SS, Heilbronner and Ruff RM.  According to the abstract, the “purpose of this position statement is to promote ethical psychological practice in legal context by reviewing validity assessment issues and their ethical foundations.”  The authors find the position statement necessary as “no previously published document focuses specifically on symptom, performance, and response validity assessment that is pertinent for all psychological evaluation performed in forensic context.”

The authors make the following recommendations: Recommendations for Forensic Practitioners

  1. Strive to be familiar and practice consistent with relevant practice, ethical, and legal/legislative requirements pertaining to validity assessment, including the present statement and extant position statements (e.g., Bush et al. 2005a, 2005b; Heilbronner et al., 2009).
  2. Only validity measures having appropriate psychometric properties are used, selected based on the characteristics of the examinee and the circumstance(s) for which the examinee is referred.
  3. List all validity measures and psychometric indicators used but avoid describing them in detail.
  4. Interpretations of the results of assessment measures are based on consideration of all the relevant reliable assessment data, and then considered with the full data set (e.g., from examinee interview, collateral sources, records). These other data sets might contain substantial inconsistencies or discrepancies. The conclusions that best fit the full data set are offered in opinions and testimony, independent of the desires of the referral source.
  5. Be wary of inferring motivation, volition, intention, and consciousness when there is insufficient evidence. However, do not avoid making such judgments when sufficient evidence is available. Consistently using preferred inferences, such as feigning or a “cry for help,” can be unhelpful or misleading in individual cases unless the evidence overwhelmingly supports such a conclusion.
  6. Use of validity measures and indicators is maximized when practitioners understand the various items and definitions, and how to resolve inconsistencies therein in their conclusions. Understanding inconsistencies within and across relevant ethics codes, professional guidelines, practice regulations, legal/legislative frameworks, and position statements, enables practitioners to address them effectively in court.
  7. Repeatedly check for biases and incentives in one’s own practices and conclusions. Internal or external influences that detract from an unbiased approach to evaluations need to be considered and countered. It is the forensic practitioner’s responsibility to guard against biases and strive to maintain a balanced perspective.

Almost everyone involved in representing or treating persons with traumatic brain injury is aware of the history and story of Phineas Gage.  Mr. Gage, in 1848, was working as a railroad foreman for the Rutland & Burlington Railroad.  Although accounts differ as to how his accident occurred, needless to say, while tamping gunpowder with an iron rod an explosion occurred causing the 13 ¼ pound tamping iron to be propelled.  The iron entered Gage’s head point-first, striking below the left cheekbone.  It passed behind his left eye and tore into his brain’s left frontal lobe.  The incident has become a textbook lesson as it is claimed that Phineas Gage never lost consciousness despite having suffered a significant traumatic brain injury.  Accounts of his life depict that Phineas Gage’s behavior was significantly changed for the worse following this incident. 

I bring this story to everyone’s attention as a new article by Sam Kean entitled “Phineas Gage, Neuroscience’s Most Famous Patient” was recently published online in Slate.  A link to this interesting medical story can be found by clicking here.

Health Day News recently issued a story on a study published in NeuroRehabilitation in which the author Jhon Alexander Moreno, a neuropsychologist at the University of Miami, analyzed the results of fourteen studies that together included almost fifteen hundred patients, spouses, partners, and people without traumatic brain injury as well as rehabilitation professionals.  According to Health Day News, which reported on the study, “the study found that 50% to 60% of people with TBI have sexual difficulties, such as reduced interest in sex, erectile dysfunction, and pain during sex, difficulties in vagina lubrication, difficulties achieving orgasm or staying aroused, and a sense of diminished sex appeal.”  Both the research found that partners of those with TBI experience personality and emotional changes, and a modification of family roles that can lead to a crisis….  For the spouse, the survivor becomes a different person, a person they do not recognize as the one they fell in love with in the past.  The spouse becomes a caregiver and this imbalance in the relationship directly affects sexual desire.”  According to Dr. Moreno, marital separation rates can be as high as 78% among people with traumatic brain injury.” 

For more information, click here.


I just received the premier issue of “Brain Injury Journey, Hope, Help, Healing", a magazine for the brain injury community published by Lash and Associates Publishing/Training Inc. 

According to the mission’s statement, “Brain Injury Journey – Hope, Help, Healing” helps persons with brain injury, families, and providers successfully navigate challenges and live a full and satisfying life.  We offer empowering personal stories, interviews with experts, and clinical updates and research findings.  Above all, we provide a community to enhance hope and foster healing after brain trauma or disease.

I strongly recommend this journal not only for survivors and family members, but for providers and neuro law attorneys as well.

How can we, as trial attorneys, best understand the trials and tribulations that our clients experience after sustaining a traumatic brain injury than through the life stories of survivors and their families. 

Brain Injury Journal will be published six times a year.  Subscriptions can be ordered at www.lapublishing.com/brain-injury-magazine.  

I previously commented on an article authored by Grant Iverson, Ph.D. discussing the concept of “Good Old Days Bias” in which patients remember being healthier prior to their sustaining their traumatic injury.

More recently, clinicians at McGill University in Montreal interviewed parents of children five to twelve years old approximately one month after the children had sustained a concussion.  According to a report published in MedPage Today, the study, led by Basil Kadoura, a student at McGill, resulted in similar findings as reported by Dr. Iverson. In this recent study, parent interviews revealed that parents’ recollections of their children’s pre-injury symptoms, “as being much less severe than they indicated in the emergency department when the children were being evaluated.”  

From a neuro attorney standpoint, this again emphasizes the need to get a client’s prior medical records rather than simply relying on the memory of the client, or his or her parents or spouse.  

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.