The theory of neuroplasticity holds that the brain will change and adapt to different conditions including to childhood injuries. This theory is often challenged and sometimes referred to as a “myth.” However, a new study by Seena Fazel and colleagues from the Department of Psychiatry at University of Oxford in the United Kingdom delivered data that supports the claims of neuroplasticity theorists. Fazel’s conclusions reveal that the later a mild TBI is sustained, the worse the health and social outcome is for the patient. The study also found a causal effect between childhood Traumatic Brain Injuries (TBIs) and the risk of brain impairment and social dysfunction at later stages in life.
A new study published in the Journal of Head Trauma Rehabilitation calls into question whether acute cognitive and physical rest improves concussion recovery times. Thomas A. Buckley, EdD, ATC of the Department Kinesiology and Applied Physiology at the University of Delaware conducted a study to determine if rest after concussion would result in a shorter recovery time in a population of college-aged student-athletes.
This hypothesis was based on the 4th International Consensus Statement on Concussion in Sport which recommends rest after injury as “a corner stone for acute concussion treatment” and outcomes. The authors noted that “rest” was achieved by discontinuing “school attendance, academic work, electronics usage and [any] exercise.” Prescribing rest was also believed to reduce the risk of repeated concussion and the “rare, but potentially fatal, second-impact syndrome.”
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.
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)
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.
Despite study after study demonstrating long term effects from mild traumatic brain injury (concussions), it is astounding that defense courtroom doctors still maintain that there are no permanent residuals from mild traumatic brain injury. A new study, Imaging Correlates of Memory and Concussion History in Retired National Football League Athletes, published in JAMA Neurology once again debunks this myth that everyone gets better.
The objective of the study, according to the abstract was “to assess the relationship of hippocampal volume, memory performance, and the influence of concussion history in retired NFL athletes with and without mild cognitive impairment.” The design of the study was a retrospective cohort study assessing differences between groups, mean hippocampal volumes, and memory performance by computing age quintiles based on group-specific linear regression models corrected for multiple comparisons for both athletes and control participants. The study utilized 28 former NFL athletes who were compared with 27 control participants. The mean age was 58.1 for the former athletes and 59.0 for the control participants.
The study found that retired athletes with concussion history, but without cognitive impairment, had normal, but significantly lower, California Verbal Learning Test scores compared with control participants. However, those with a concussion history and mild cognitive impairment performed worse when compared with both control participants and athletes without memory impairment. Among the athletes, 17 had a G3 concussion and 11 did not. Older retired athletes with at least one G3 concussion had significantly smaller bilateral hippocampal volumes compared with control participants.
The authors concluded that “prior concussion that results in loss of consciousness is a risk factor for increased hippocampal atrophy and a development of mild cognitive impairment. In individuals with mild cognitive impairment, hippocampal volume loss appeared greater among those with a history of concussion.”
Neurological testing of the first cranial nerve, which carries the sensory information for the sense of smell, is rarely performed. A new study from the Walter Reed National Military Center provides proof that olfactory testing should be performed.
According to the abstract, the objective of this recent study was to determine whether a structured and quantitative assessment of differential olfactory performance – recognized between a blast-injured traumatic brain injury (TBI) group and a demographically comparable blast-injured control group can serve as a reliable antecedent marker for preclinical detection of inter cranial neuro trauma.
The researchers, at Walter Reed, performed a prospectively and consecutively enrolled evaluation of 231 polytrauma inpatients who were exposed to explosions during combat operations in either Afghanistan or Iraq. The study correlated olfactometric scores with both contemporaneous neuro imaging findings as well as the clinical diagnosis of TBI.
The study found that while “quantitative identification olfactometry had limited sensitivity, it had high specificity as a marker for detecting acute structural neuropathology from trauma.” The researchers found that central olfactory dysfunction identified patients with TBI who had intracranial radiologic abnormalities. While the test had a sensitivity of only 35%, it had a specificity of 100%.”
Neuro attorneys representing patients with suspected traumatic brain injury, should insist that the neurologic examination include a test of the first cranial nerve. If you have questions about these exams, you should speak with your legal counsel.
It is presently the standard of care to keep children who have sustained concussion/traumatic brain injuries off the field and not to return to play until they are cleared by a competent professional. Assemblywoman, Pamela R. Lampitt (D Burlington and Camden) has introduced a bill in the New Jersey Assembly, which would require any student who suffers a concussion to be evaluated by a doctor or other health care provider and to get written clearance before the child can go back to school. Under the bill, each school district that deals with students with disabilities would be responsible for enforcing any limits on a student’s activities that were determined by the health care provider.
The statement accompanying the bill states:
This bill provides that a student enrolled in a school district who sustains a concussion must receive an evaluation by a physician trained in the evaluation and management of concussions and written clearance from the physician to return to school. In the event that the physician provides notice that the student requires accommodations for learning, the school district must immediately implement the accommodations and notify all teachers and staff who have contact with the student of the accommodations. The school district’s child study team will promptly evaluate the student in order to identify the manner in which the accommodations will be provided to the student during recovery and the need for the continuation or adjustment of the accommodations, and to determine the duration of the accommodations.
The bill also provides that a student enrolled in a school district who sustains a concussion is prohibited from engaging in any physical activity at school including, but not limited to, recess, physical education, sports, or cheerleading. The student may not participate in any physical activity until he is evaluated by a physician and receives written clearance to participate.
The sponsor’s intent is to have the child study team use the physician’s diagnosis and recommendations to guide accommodations upon the student’s return to school for the period of time prescribed by the physician.
People, who have sustained a permanent injury which results in a permanent work disability, will earn less and will have a shortened work life expectancy, even where the individual has returned to full time employment. Thus, in every case, where a plaintiff has sustained a permanent injury resulting in a permanent work disability, a claim for loss of future earning capacity exists.
In Figurski vs. Trinity Health-Michigan, the Michigan Court of Appeals upheld a verdict in an obstetrical medical malpractice action. On appeal, defendants asserted that the trial court abused its discretion when it determined that Anthony Gamboa, Ph.D., MBA, could offer an opinion as to plaintiff’s future loss of earning capacity. Defendants attacked both Dr. Gamboa’s qualifications to testify as an expert and attacked his methodology as unreliable. The Michigan Court of Appeals disagreed.
The Court of Appeals found that the trial court clearly understood her role as gatekeeper. Dr. Gamboa was qualified as a vocational rehabilitation expert. He held a number of degrees, including a Master’s in vocational counseling and a Ph.D. in an area that included vocational counseling and education. Gamboa also received a MBA and testified that he liked to focus on statistics. Gamboa has been with Vocational Economics, Inc. in one capacity or another since 1977. His work there necessarily included offering expert opinions on the cost of future care and compensation loss. He was a prolific writer in the area of earning capacity loss and work life expectancy. The Court of Appeals also found that there was nothing unusual with regard to Dr. Gamboa’s methodology and that the trial court was correct in concluding that the different methods of calculating plaintiff’s damages was best left to the ultimate trier of fact.
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.”