Brain Injury Resources & Links

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.

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).

I just received this month’s issue of the Brain Injury Professional, the official publication of the North American Brain Injury Society (NABIS). This month’s issue covers the post concussion disorder. 

The issue contains the following articles:

  1. Physiologic Post Concussion Disorder by Barry Willer, Ph.D. and John Leddy, M.D.
  2. Augmenting Neuro Cognitive Assessment in the Evaluation of Sports Concussion:  How the vestibular and ocular issues impact recovery. Anne Mucha, DPT, Michael Collins, Ph.D., and Jonathan French, Psy.D.
  3. Cervicogenic Post Concussion Disorder:  A pain in the neck.  John Leddy, M.D.
  4. Suggestions for Facilitating Return to Learn After Concussion.  Brian Rieger, Ph.D.
  5. Providing a Continuum of Care for Concussion Using Existing Educational Frameworks.  Karen McAvoy, Psy.D.
  6. Psychologists Working in Concussion Clinics.  John Baker, Ph.D.
  7. Concussion Legislation:  Variations on a theme.  Gene Rickerson.
  8. Sports Concussions.org:  A new resource for brain injury professionals and families.  Neal McGrath, Ph.D.

I recommend everyone joining NAIBIS.  The above link will send you to the society’s web page.  Please remember that NAIBIS will be holding its 25th medical legal conference and its 9th medical conference from September 12-15, 2012 in Miami, Florida.

Jason Mihalik, an assistant professor of Exercise and Sports Science in UNC’s College of Arts and Sciences, and Gerard Gioia, member of the UNC’s class of 1984 who currently works for the Children’s National Medical Center and George Washington University School of Medicine in Washington, D.C., co-authored a smartphone app which could help players, coaches and parents determine if someone has suffered a concussion.

The Concussion Recognition and Response App uses a checklist of symptoms like dizziness and memory problems, to guide the user through a series of questions in order to evaluate whether or not someone has suffered a concussion. The App does not provide a diagnosis, but rather provides feedback to the user to aid in the determination if the player should be removed from a game and seek additional medical attention. Removing concussed athletes from activity can be critical. A second impact after an initial head injury can often bring catastrophic consequences.
 

This month’s issue of Pediatrics, the official journal of the American Academy of Pediatrics contained an interesting article, Long-Term Intellectual Outcome of Traumatic Brain Injury in Children: Limits to Neuroplasticity of the Young Brain, by Harvey S. Levin.

Dr. Levin reports on two studies from the same children’s hospital with regard to the outcome of children who have sustained traumatic brain injury.  Dr. Levin states that “taken together, these studies challenge views long held by clinicians and researchers, including that young children are more resilient to the effects of TBI on intellectual development then older children because of the greater capacity for neuroplasticity.  The view that young children have greater capacity for cerebral reorganization of function may find support in early, focal vascular lesions, but not in severe diffused white matter injury.  The data reported by Anderson, et al. also challenge the contention that children who sustain early TBI ‘grow into their deficit,’ and extrapolation from experimental lesions in regions of motor cortex and prefrontal cortex in monkeys.  Instead, the trajectory of intellectual development after early moderate to severe TBI appears to reflect a consistent lag in comparison with health children.”