The Doctor told you that your MRI of the brain, CT scan, and skull x-rays are normal. He said that you have just suffered a mild concussion. You did not suffer an extended loss of consciousness and you can not remember hitting your head on anything. You should be fine in a couple of days, right? Wrong! Weeks later you realize that you still have trouble with ringing in your ears, blurry vision, forgetfulness, tiredness, irritability, getting lost, nausea, or headaches. What was considered a mild concussion that should have been over in a few days, is now, post-concussion syndrome.

Mild traumatic brain injury is often not detected or diagnosed by emergency personnel because it is usually not visible on MRI, CT, or x-rays. The damage to the brain is microscopic and has occurred diffusely throughout the brain to nerve fibers or axons that can not be seen on diagnostic radiology films. Patients at the emergency room also usually complain of other symptoms that are more painful and those injuries receive more immediate attention and diagnoses. People who have suffered from a mild brain injury often look very normal. Therefore, the diagnosis of mild traumatic brain injury or post-concussion syndrome may not be made until weeks or months later when the patient returns to school or work and notices a decline in mental, emotional, or behavioral functioning. At the Traumatic Brain Injury Law Group, we make sure that every client is screened for mild brain injury and receives the appropriate diagnoses from qualified physicians.

DEFINITION OF MILD TRAUMATIC BRAIN INJURY

A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:

• Any period of loss of consciousness
• Any loss of memory for events immediately before or after the accident
• Any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused)
• Focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following:
  • Posttraumatic amnesia (PTA) not greater than 24 hours
  • After 30 minutes, an initial Glasgow Coma Scale (GCS) or 13-15
  • Loss of consciousness of approximately 30 minutes or less.

Published in the Journal of Head Trauma Rehabilitation 1993:8(3): 86-87

Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine.

DEFINITION OF CONCUSSION

The American Academy of Neurology defines concussion as any alteration in consciousness such as:

• Vacant stare
• Delayed verbal and motor response (slow to answer questions or follow instructions)
• Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities)
• Disorientation (walking in the wrong direction; unaware of time, date, and place)
• Slurred or incoherent speech (making disjointed or incomprehensible statements)
• Gross observable incoordination (stumbling, inability to walk straight)
• Emotions out of proportion to circumstances (crying for no apparent reason)
• Memory deficits (exhibited by the repetition of questions or inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes)
• Any period of LOC

(Neurology 1997:48-581-585)

SYMPTOMS OF A BRAIN INJURY/CLOSED HEAD INJURY

Whether the initial brain injury is mild, moderate, or severe, the various symptoms of a brain injury may or may not occur for shorter or longer lengths of time. Symptoms of brain injury generally fall into one of three categories: (1) Physical, (2) Cognitive, and (3) Emotional/Behavioral. They are described as follows:

1. The physical impact of a brain injury may include: decreased motor control, coordination, gait, balance, and posture. It may include paralysis, weakness, spasticity, contractures, seizures, taste, smell, or vision disturbances, fatigue, slurred speech, difficulty chewing, swallowing, or speaking, sleep disturbance, bowel changes, and temperature changes.

2. The cognitive impact of a brain injury may cause impairment to the following brain functions: attention, concentration (focusing, blocking out distractions), executive function (planning, initiating, organizing, problem-solving), memory (receiving, storing, and retrieving information), communication (understanding, recalling words and expressing them), abstraction and judgment (misapplication of specifics to generalities, non-comprehension of consequences, inability to differentiate subtle variances), learning, and lack of motivation or impulse control.

3. The behavioral/emotional impacts of a brain injury may include agitation, frustration, aggression, mood swings, depression, anger, lack of interest, crying, disinhibition, impulsiveness, and loss of self-esteem.

These symptoms can cause life-long impairments to a person’s physical, cognitive, or emotional function. Tragically they are sometimes not medically diagnosed in the case of mild brain injury. In fact, it may be the neuro-lawyer who first identifies the nature and extent of a brain injury. When the neuro-lawyer interviews the client in an in-depth manner and researches medical records and accident reports she is able to identify clues to the cause of a client’s current symptoms and poor function.

THE HEALTHY BRAIN

In order to understand the cause and effects of brain injury, one must first understand the brain. The brain controls all bodily functions through the central nervous system. This complex network originates in the brain and continues through the spinal cord and the nervous system. The brain controls conscious functions such as skipping, running, reaching, etc., and unconscious functions such as sweating, heart rate, and perception of pain. The brain also controls perception (such as visual or auditory), memory, learning, emotion, and the integration of speech, behavior, or other functions. Even microscopic damage to the brain can disrupt these functions.

The brain is an approximate three-pound miraculous bundle of more than 100 billion microscopic nerve cells. The neurons are very long nerve cell fibers that connect electrochemical impulses throughout the brain. Chemicals in the neurons, called neurotransmitters, help convey electrochemical messages from the body to the brain and vice versa. The neurons are composed of a long axon, which may reach three feet long, and a dendrite, which is a branching part on top of the axon (Similar to a tall tree). These neurons connect different areas of the brain to allow the integration of thought and brain function.

The brain has different physical regions or “lobes” which are distinct in function and structure. While the lobes are distinct they communicate with and depend on each other through the long neurons. These lobes are grossly responsible for certain individual brain functions. The frontal lobe is responsible for personality, character, and the highest functions of thinking like reasoning, planning, organizing, and problem-solving. The parietal lobe is related to language and spatial relationships. The occipital lobe is associated with visual recognition and the temporal lobe is related to memory function. Each lobe is paired with a corresponding mild brain injury or concussion on the opposite hemisphere of the brain. A neurolawyer must have a thorough understanding of normal brain function and structure in order to appreciate subtle brain dysfunction.

CAUSES OF BRAIN INJURY/CLOSED HEAD INJURY

The brain can be injured in many ways. It may be injured by disease (infections, tumors, stroke, etc.), direct blow to the skull (falls, gunshots, car accidents, abuse), or by a closed head injury (like shaken baby syndrome). The brain resides within the skull surrounded by a protective cushion of cerebrospinal fluid. This fluid usually protects the brain from the bony ridges within the skull. However, when the brain is suddenly accelerated and decelerated as in a car accident whiplash injury, the neurons connecting the different regions of the brain can be stretched and torn. This damage is usually microscopic and can not be seen on MRI or CT. Additionally, the brain can be damaged when sudden movements like whiplash cause it to strike against the rough bony inner surface of the skull.

Closed Head Injury is caused by the gravitational forces of acceleration/ deceleration movement within the skull that tears and stretches neurons diffusely throughout the brain. A Doctor may refer to this as a “shear” injury because the long axon is torn from this movement within the skull. The brain may also develop a “coup contra coup” type of closed head injury when the brain bruises at the front and the back after suddenly striking the interior of the skull. The head does not have to be struck for a closed head injury to occur! A Bio-mechanical Engineer can be helpful to the attorney in proving that the gravitational forces were sufficient on the head to cause this type of closed-head injury.

Damage to the brain may occur at the time of injury as just discussed or it may worsen due to secondary causes from the initial impact. Cerebral edema or brain swelling causes additional pressure within the skull that can squeeze healthy brain matter causing injury to it also. Bleeding or intracerebral hemorrhage also causes pressure within the skull and can cause damage to other healthy brain tissue.

Excitotoxicity injury is microscopic and can not be seen on CT or MRI. This type of damage occurs when the damaged nerve fibers release excessive concentrations of chemicals that were used to transmit messages. Other healthy neurons nearby may be damaged days after the initial injury as this degeneration continues. The effect of a closed head injury may actually worsen after the first few hours as nerve degeneration and blood pooling occurs.

Blunt head trauma is caused by a direct blow to the head. It may result in external skull fractures or may also cause internal brain damage. If the fracture is depressed the brain covering (dura) may be torn and cerebral spinal fluid may leak out. Subdural hematomas may develop after blunt head trauma. This bleeding and bruising within the brain can cause brain swelling, increased brain pressure, and coma.

Brain Injury occurs every 15 seconds in the U.S. and is the leading cause of death or disability to people under the age of 45. Young males are the most likely to sustain a TBI and long-term disability is often a consequence. People suffer brain injuries as a result of automobile accidents, falls, bicycle accidents, oil well accidents, train crossing collisions, carbon monoxide poisoning, drowning, domestic violence, child abuse, firearms, sports, and other causes.

A lawyer representing a person with a brain injury must not only be knowledgeable about the biomechanics of how brain injury is caused but, it is vital that she understand the neurologic, cognitive, behavioral, and emotional consequences of mild, moderate, and severe traumatic brain injury. This knowledge will affect your ability to obtain full damages from the person that negligently caused your injuries. A life-care plan for future treatment can run several million dollars and that does not reflect lost earnings, past medical care, or pain and suffering. Roberta Robinson is an experienced neurolawyer who understands the causes and consequences of brain injury and she advocates aggressively for recovery both physically and financially.

UNDERSTANDING COMA

Your child, husband, wife, or friend is rushed to the emergency room and has suffered a serious traumatic brain injury. You wait for days by their bedside, hoping and praying that they will just open their eyes and recognize you. But, they lie in bed in a sleep-like state for days. Evidence of wakefulness comes gradually first with a response to a painful stimulus. Moaning and groaning and withdrawing a limb are the first responses. Next, the command to blink the eyes is obeyed. Yet, there may still be confusion, agitation, fatigue, and even agitation. It may take considerable time before the patient in this prolonged period of unconsciousness following a brain injury begins to consciously process information.

Coma can be caused by injury to the brain stem where the normal central nervous system nerve pathways are interrupted causing a loss of consciousness. This could be caused by a direct blow to the brain stem such as when a head hits the back of a headrest. It may also be caused when the brain is violently rotated on its axis (brain stem) by gravitational forces or it may be caused by pressure on the brain stem from edema and bleeding.

Doctors in the emergency room measure the acute severity of a coma with the Glasgow Coma Score. Progression of the patient’s responsiveness and cognition is measured with the Ranchos Los Amigos Scale. The use of these tools is helpful in preparing for rehabilitation and future life care planning. While these tools do not predict the speed of recovery or ultimate level of recovery they do provide insight into the anticipated progression of recovery.

RANCHOS LOS AMIGOS SCALE

I. No Response
The patient appears to be in a deep sleep and is unresponsive to stimuli

II. Generalized Response
The patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. Reflexes are limited and often the same, regardless of the stimuli presented.

III. Localized Response
Patient responses are specific but inconsistent and are directly related to the type of stimulus presented, such as turning the head toward a sound or focusing on a presented object. He may follow simple commands in an inconsistent and delayed manner.

IV. Confused-Agitated
The patient is in a heightened state of activity and is severely confused, disoriented, and unaware of present events. His behavior is frequently bizarre and inappropriate to his immediate environment. He is unable to perform self-care. If not physically disabled, he may perform automatic motor activities such as sitting, reaching, and walking as part of his agitated state, but not necessarily as a purposeful act.

V. Confused-Inappropriate, Non-Agitated
The patient appears alert and responds to simple commands. More complex commands, however, produce responses that are non-purposeful and random. The patient may show some agitated behavior it is in response to external stimuli rather than internal confusion. The patient is highly distractible and generally has difficulty learning new information. He can manage self-care activities with assistance. His memory is impaired and verbalization is often inappropriate.

VI. Confused-appropriate
The patient shows goal-directed behavior but relies on cuing for direction. He can relearn old skills such as activities of daily living, but memory problems interfere with new learning. He has a beginning awareness of himself and others.

VII. Automatic-Appropriate

The patient goes through daily routine automatically but is robot-like with appropriate behavior and minimal confusion. He has a shallow recall of activities and superficial awareness of them but lacks insight into, his condition. He requires at least minimal supervision because his judgment, problem-solving, and planning skills are impaired.

VIII. Purposeful-Appropriate
The patient is alert and oriented and is able to recall and integrate past and recent events. He can learn new activities and continue in home and living skills, though deficits in stress tolerance, judgment, and abstract, social, emotional, and intellectual capacities may persist.

THE MEDICAL TEAM

The following is a partial list of the brain injury team professionals that you might find in the hospital or rehabilitation center.

1. Neurosurgeon: A physician who is trained to diagnose and treat brain or central nervous system injuries and disorders and perform surgery on the brain or within the central nervous system as needed. He evaluates the need for surgical intervention.

2. Neurologist: A physician who is trained to diagnose and treat brain or central nervous system disorders. He should request neuropsychological testing by a neuropsychologist to assess brain dysfunction.

3. Physiatrist: A physician who is trained to evaluate and treat cognitive and physical dysfunction as a result of traumatic brain injury. They are especially concerned with helping the patient overcome disability as a result of brain injury through rehabilitation and are a critical part of the acute care brain injury team by preventing contractures and controlling spasticity.

4. Neuropsychologist: Ph.D. trained psychologist usually with a clinical background and extra training in neurology who evaluates brain dysfunction through a variety of psychological tests and observation. He also is helpful in planning appropriate cognitive rehabilitation and vocational rehabilitation.

1. Physical Therapist: Trained to help the patient regain bodily function.

2. Occupational Therapist: Trained to help the patient with activities of daily living and regaining maximum independence.

3. Speech Therapist: Trained to help the patient regain speech and language function.

4. Case manager: This can be helpful in coordinating rehabilitation and future care.

NEUROIMAGING

Diagnoses of traumatic brain injury can be made by clinical evaluation of indirect evidence of pressure on the brain through monitoring loss of consciousness, drowsiness, vomiting, confusion, unequal pupil dilation, lessened reflexes, etc. Diagnoses can also be made by neuropsychological testing of brain dysfunction. Physicians routinely use neuroimaging though as a means of looking at the brain and surrounding structures to detect brain injury.

CT scan is helpful in looking at the skull for evidence of linear or depressed skull fractures. CT is less clear or sharp than an x-ray when viewing the skull, but, it is superior in its ability to detect brain bleeding, swelling, enlargement of ventricles, tumor growth, and brain compression due to excess pressure. While CT is useful in the emergency room it is limited in detecting mild brain injury involving diffuse axonal shear injury. CT done in the emergency room may also miss a slowly developing intra-cranial leak 2 to 3 days after the initial trauma.
MRI is a non-emergency technique that has higher clarity of fine brain matter detail. This is an excellent tool for viewing brain injuries and lesions that are gross or focal, however, it cannot show diffuse cellular brain “shear” injury. PET and SPECT can show functional disturbances of normal brain metabolism that do not show up on traditional structural imaging. Few hospitals however have the latter-mentioned types of equipment and a patient may have to be sent out of state for such a scan. Sometimes brain injuries do not show up on any type of neuroimaging technology because the damage was microscopic. The neurolawyer must have a good knowledge of the neuroimaging technology available and the reasons why brain injuries are not always documented by such technology.

RECOVERY AND REHABILITATION

The road to recovery is a long and hard process. A good neurolawyer can help you not only preserve early evidence and document your case, but they can advocate for you to get the best treatment available, find sources of funding for that treatment, and coordinate your care for the duration.

The severity of a brain injury is often difficult to determine immediately following a head trauma. Generally speaking, full recovery is not expected where the coma is prolonged, the serious physical injury occurred, GCS is poor and Ranchos Los Amigos Scale score remains low. However, each injury is unique and many variables exist, such as whether the injury is focal or diffuse, whether the brain stem is injured, and whether anoxia occurred. It may take several months or even a year to understand the severity of the injury and the residual deficits and disabilities. There is medical literature that suggests recovery can continue throughout a person’s life despite intermittent plateaus.

Brain injury rehabilitation programs do positively enhance the rate of recovery and the eventual recovery gained. Usually, the most rapid recovery occurs in the first six months after a person progresses from a coma to a conscious state. By the end of the first year, a patient generally undergoes a plateau in their recovery, however, this slow down in progress does not indicate that gains in function will not occur. The neurolawyer can play a vital role in advocating for her client to obtain appropriate rehabilitation, help find funding sources, coordinate medical treatment with providers who know brain injury, and make sure that documentation of the nature and extent of a person’s injury is thorough.

Roberta Robinson has prior experience as a hospital medical social worker, which facilitates her role as an advocate for her clients in their rehabilitation experience. Her experience as past president of the Oklahoma Brain Injury Association has enabled her to personally visit many different types of rehabilitation facilities. Finally, her role as chairman of several medical conferences has helped her to meet many physicians and specialists across the country in brain injury medicine and rehabilitation.

Various options exist for rehabilitation. It is recommended that before committing to any treatment options, the patient should thoroughly explore all available options in their region. The state brain injury association is a good resource as is an experienced neurolawyer. The following is a brief list of the types of medical care a patient might encounter.

1. Acute Hospital Care: Medical stabilization of one’s condition.

2. Acute Inpatient Rehabilitation:

a. Early therapeutic intervention which encourages self-participation and weans one from medical dependency.

b. Coma stimulation which encourages consistent responses and weans off of sedating medicines.

c. Early functional and cognitive retraining and physical restoration.

d. Examples are weaning a patient off the ventilator, feeding tube, etc.

3. Post-acute Inpatient Rehabilitation:

a. Rehabilitation which focuses on community, educational, vocational, and social reintegration and continued independent function.

4. Day treatment:

a. Hourly, half-day, and full-day programs which address specific needs.

5. Group Home/Residential Living

a. Supported living with supervision

6. Support Group:

a. Local chapters of a state brain injury association

7. Vocational Rehabilitation:

a. State agencies and private facilities that provide vocational evaluation, Retraining, and job coaching for work re-entry.

Many of these programs provide specialized care for certain clients such as behavioral management for aggressive clients, pediatric care focusing on educational re-entry, ventilator care and weaning, coma stimulation, substance abuse counseling, and programs tailored for mild brain injury cognitive rehab. Please remember, few programs are capable of meeting every client’s needs. Make sure that the program your Doctor refers you to is best for you!