Alaska Injury Law Blog

One of the difficulties faced by our clients who have suffered "mild" traumatic brain injury (TBI) is that there has been no objective means of establishing that brain injury exists even though the clinical signs of dysfunction are present. This has often resulted in clients not getting the medical care that would help them with their rehabilitation, or they have suffered the undeserved claims by defense practioners that they were "malingering" or "magnifying" their symptoms.

Two new studies support the early data on the efficacy of a new MRI tool--diffusion tensor imaging--in the diagnosis of traumatic brain injury (TBI). Diffusion tensor imaging allows the care provider to visualize the brain's white matter, which contains the fibers that connect nerve cells. Conventional MRI would commonly not reveal any differences between the patients with mild TBI and controls. DTI, however, is finding objective evidence on imaging that is consistent with a positive finding on neuropsychological testing.

One study at the University of New Mexico has found that diffusion tensor imaging can be used to reliably detect and track brain abnormalites in patients with mild TBI. The study compared patients with known mild TBI and found that conventional MRI did not reveal any differences between those with TBI and control subjects. The diffusion tensor imaging, however, demonstrated white matter abnormalities in the subjects known to have TBI. Thus, the technique was successful in finding objective evidence of injury when conventional MRI failed to do so. Another important finding was that, when the patients found to have such abnormalities were evaluted with diffusion tensor imaging 3-5 months later, a period by which recovery is expected, the diffusion tensor imaging was able to track these white matter changes, as well. The study concluded that diffusion tensor imaging can provide an objective biomarker that can assist in the classification and tracking of mild TBI injuries and their effects.

With this kind of literature developing about the effectiveness of diffusion tensor imaging, we expect this imaging technique to provide patients with better diagnosis and treatment. The reader may also be interested in our previous reports about this literature, here, and here.

Sources:

Mayer, AR et al. “A Prospective Diffusion Tensor Imaging Study in Mild Traumatic Brain Injury.” Neurology, February 23, 2010, Vol. 74, pp. 643-650.

Bigler, ED and Bazarian, JJ. “Diffusion Tensor Imaging: A Biomarker for Mild Traumatic Brain Injury?” Neurology, February 23, 2010, Vol. 74, pp. 626-627.

There has long been a debate in medicine, and consequently one in the law, about whether a concussion caused by trauma can lead to structural brain tissue damage and functional deficits. While many recover from such injuries without lasting deficits, it is estimated that over 30 percent suffer from the traditional hallmarks of traumatic brain injury, such as personality changes, deficits in short-term memory, or deficits in executive functions involved in the ability to make decisions, organize, or plan.

As recently reported in the journal Radiology, researchers at the Albert Einstein College of Medicine have now demonstrated objectively the areas of the brain injured when concussion occurs. The study subjected patients who had sustained concussions to tradition MRI and CT scans, which routinely demonstrated that no structural injury had occurred. When neuropsychological testing showed effects upon their executive functions, however, the patients were then given a more sophisticated type of MRI scan known as diffusion tensor imaging (DTI). DTI can detect subtle changes in the brain by measuring the diffusion of water in the brain's white matter. The DTI studies in these patients showed the presence of major areas of structural damage located mainly in the brain's prefrontal cortex, a part of the brain essential for normal executive function. It is this area of the brain that is susceptible to injury in concussion, and such structures are involved in the cognitive processes that cause the functional deficits the patients were experiencing.

It is unfortunately the case that many people suffering mild traumatic brain injury are not properly advised about the possibility of functional deficit by either their medical or legal practioners. It is often the case that problems do not disclose themselves until a patient returns to more full function after orthopedic injuries have healed. It is when they try to reengage life at their former level of function that deficits begin to take shape. Using DTI as an adjunct to clinical evaluation will likely help identify those patients who should receive rehabilitation earlier when it is more useful to the patient.

We previously wrote about the advances DTI brings to this field, and that entry may also be of interest, January 22, 2008 entry.

Source:

Diffusion-Tensor Imaging Implicates Prefrontal Axonal Injury in Executive Function Impairment Following Very Mild Traumatic Brain Injury, Radiology

The Alaska Personal Injury Law Group recently posted an article about how the FDA and other federal agencies have systematically attempted to use preemption to make manufacturers immune from suit for injuries caused by their defective products. One point of discussion was how the FDA has weakened regulatory protection of consumers from dangerous, defective drugs. Now, just a few days later, an independent group of objective scientists has issued a new report chastising the FDA for its approval of bisphenol A, commonly referred to as BPA.

The new report was issued by the Science Board, a group of independent scientists that provides advice to the Commissioner of the FDA. The Science Board provided peer review of the FDA’s draft assessment of use of BPA in food contact applications. The Science Board concluded that the FDA position was seriously flawed.

BPA is an industrial chemical used to make polycarbonate plastic and an epoxy resin used in many consumer products. The FDA approved it for use in baby bottles and as a liner in food containers like baby formula cans. It is also used extensively in other food containers, in sport bottles such as Nalgene bottles, and as a liner in soda cans. In mid-2008, the National Toxicology Center issued an extensive report addressing the health risks resulting from exposure to BPA, including effects on brain and behavioral development in infants and small children, and the potential to cause cancer. In response, the FDA steadfastly maintained its position that BPA was safe.

The Science Board has now found multiple flaws in the FDA assessment. First and foremost, the FDA assessment failed to provide ``reasonable and appropriate scientific support'' for its finding that the public wasn't at risk from BPA. Second, the FDA ignored many peer reviewed studies that found BPA presents serious health hazards. Instead, the FDA relied upon two studies funded by the chemical manufacturers’ association, only one of which was peer reviewed. The studies ignored by FDA show multiple risks, including impaired neural development, developmental changes in children, impaired reproductive tract development and diabetes. Third, the FDA assessment improperly analyzed the margin of safety (MOS) provided by the FDA standard for BPA exposure. The Science Board found extensive evidence that the FDA standard for allowable exposure levels was at least an order of magnitude too high, particularly for children.

Continue reading " Independent Scientists Find FDA Report on BPA Defective " »

Most readers know that PTSD can be caused by intense trauma from accidents and injuries, but the question whether medical intervention itself can cause PTSD has not been extensively studied. Dr. Dimitry Davydow of the University of Washington's School of Medicine reports in the Sept.-Oct. issue of General Hospital Psychiatry that as many as 22% of ICU patients will later suffer PTSD. This conclusion arose from the review of 15 medical studies and 1,745 ICU patients. The symptoms of PTSD include nightmares, sleep problems, flashbacks, irritability and anger, as well as emotional numbness. The risk of suffering PTSD increased if the patient had underlying mental illness, such as anxiety or depression, or was treated with certain sedatives that cause disorientation, confusion, or psychotic experiences.

Sources:

General Hospital Psychiatry, Vol. 30, at 421-34, Sept. Oct. 2008

If the march of history has shown us anything, it is that technological advances are often the result of armed conflict. We have seen that in striking detail in the Iraq and Afghanistan conflicts. One of the most unfortunate consequences of these conflicts is that they have dramatically highlighted the armed services’ inability to effectively screen and treat traumatic brain injury (TBI) and post traumatic stress disorder (PTSD) in returning soldiers. Another consequence is that the fact that soldiers have suffered TBI and PTSD in ever increasing numbers has forced research forward concerning these intractable disorders. In recent weeks, several articles of note crossed our desks here at the Alaska Personal Injury Law Group.

The Government Accounting Office (GAO) just released a report that underscored the Dept. of Veteran’s Affairs’ (VA) continuing inability to identify and provide services to affected veterans. This is true despite a pledge by the VA Secretary, Jim Nicholson, last April to promote new screenings for brain injury and a personal promise to see the changes through. The GAO reviewed nine VA medical centers, and found that there were problems in securing follow-up appointments after the veterans initially tested positive under the VA’s TBI screening tool. Two of the medical centers did not follow the screening tools protocol because they failed to use the symptom checklist, which they said was because they didn’t know the checklist existed or because they had inadequate staffing. The GAO also identified poor rural access to services resulting in a 50% decrease in the ability to provide care. It is estimated that as many as 20% of US combat troops who fought in Iraq and Afghanistan are believed to leave with signs of TBI.

At the end of January, the New England Journal of Medicine published a study submitted by specialists at the Walter Reed Army Institute of Research that added further to the controversy about how veterans should be screened and treated upon their return. Studying outcomes for over 2500 soldiers, the researchers found that soldiers with mild traumatic brain injury, particularly those who had suffered loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and post-concussive symptoms than were soldiers with other injuries. After the data was adjusted, the researchers concluded that mild traumatic brain injury with loss of consciousness was strongly associated with PTSD and depression. Over 43% of soldiers reporting TBI with loss of consciousness met criteria for PTSD, compared with 27% of those with the lesser brain injury from an altered mental status following their injury. TBI with loss of consciousness was also significantly associated with major depression. The difficulties the soldiers faced may therefore be more attributable to the result of intense psychiatric reactions to battlefield events, rather than a structural injury to the brain. This may be good news in that there are treatments for PTSD and depression, and very few medical treatments available to those who have suffered a structural injury to the brain.

Finally, the February issue of the Journal of Nervous and Mental Disease published research concerning the link between PTSD and chronic inflammation and early death. Studying veterans diagnosed with PTSD after the Vietnam conflict, the researchers found high erythrocyte sedimentation rates (ESR), white cell counts (WBC), and cortisol/dehydroepiandrosterone sulfate ratios (DHEA-s). Death rates between the comparison groups was 13.6% among those suffering from PTSD and 5% for those without the diagnosis. In addition to PTSD predicting an increased all-cause mortality rate, PTSD and a high erythrocyte sedimentation rate were also associated with increased death rates from cardiovascular conditions. Thus, having PTSD, a high ESR, a high WBC count, and a high cortisol/DHEA-s ratio were associated with all-cause disease mortality. These study results suggest that physicians treating veterans should routinely screen for PTSD and these associated increased risks. The article provided further scientific explanation as to why the archaic mind-body duality relied upon by the law is medically unsupportable. This is simply because, if one’s mind (PTSD) is affected, one body will surely suffer consequence, as well.

Source:

VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain, GAO-08-276 February 8, 2008; http://www.gao.gov/docsearch/abstract.php?rptno=GAO-08-276.

Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq, New England Journal of Medicine, Volume 358:453-463 January 31, 2008 Number 5; http://content.nejm.org/cgi/content/full/358/5/453.

Psychobiologic Predictors of Disease Mortality After Psychological Trauma: Implications for Research and Clinical Surveillance,
Journal of Nervous & Mental Disease. 196(2):100-107, February 2008.

We have handled a number of cases at the Alaska Personal Injury Law Group where clients have developed balance and dizziness complaints after suffering a traumatic brain injury (TBI) in automobile crashes or similar assaults to the brain. It is not commonly known that these disorders flow from TBI, and attorneys often miss the connection. These disorders can develop in several ways, but a common mechanism is benign paroxysmal positional vertigo (BPPV). BPPV is a balance and dizziness disorder caused by a problem in the vestibular system of the inner ear which forms part of the body’s balance system. Small particles, or crystals, of the inner ear are dislodged with the trauma and this interferes with the normal function of the inner ear. This can cause episodic vertigo that can be quite disturbing to the client. If untreated, the episodes can recur for years and become part of the lasting and unfortunate legacy of TBI.

There are treatments for BPPV through a series of scripted movements by trained therapists designed to put these crystals back in their normal position. This is called a canalith repositioning maneuver, and significant improvement has been experienced by some clients.

To properly diagnose a patient regarding the many potential causes of balance and dizziness problems, a client often undergoes vestibular testing, but it has traditionally been aimed at finding a localized problem, a “site of lesion”. The major limitation of these site-of-lesion tests is that they assess structural and physiological changes within individual sensory or motor components in isolation, rather than in the functional context of balance control. A new type of testing has been developed called the Neurocom Balance Manager, which is designed to provide a comprehensive differential diagnosis of sensory, motor, and central functional impairments of balance control. Developed using methods created by NASA to study balance in astronauts, Neurocom uses a computerized dynamic posturography (CDP) system that professes to offer a more comprehensive means of diagnosing the patient, which hopefully will lead to more specific and helpful treatment.

Source: Mayo Clinic Vertigo Rehabilitation; Mayo Clinic Vestibular Lab; Neurocom International, Inc.

Depression is often one of the difficult conditions clients of the Alaska Personal Injury Law Group face following traumatic brain injury (TBI). Depression is suffered by about 5% of the general population, but over 40% of those recoverying from head trauma can suffer from depression. Until now, it has been difficult to understand how depression and TBI are linked, although that association has long been known.

Studying athletes who suffered concussions, the researchers at the Montreal Neurological Institute of McGill University have shown the neurological basis for depression in a study published this week in the Archives of General Psychiatry. They studied 40 concussion victims against healthy subjects and found through the use of functional magnetic resonance imaging (fMRI) that the same areas of the brain were affected in both the athletes and those patients with major depression. Abnormal neural activity was found in the dorsolateral prefrontal cortex and striatum, as well as attenuated deactivation in the medial and temporal regions. Gray matter loss was also confirmed using Voxel based morphometry (VBM), a neuroimaging analysis technique that analyzes focal differences in brain volume.

This type of medical advance in imaging will help clients and care providers better understand why depressed mood is occurring after someone has had a traumatic brain injury. Ultimately, it is hoped that such imaging will lead to better diagnosis and treatment for those who suffer the devastating consequences of traumatic brain injury.

Source: Neural Substrates of Symptoms of Depression Following Concussion in Male Athletes With Persisting Postconcussion Symptoms, Arch Gen Psychiatry. 2008;65(1):81-89. http://archpsyc.ama-assn.org/cgi/content/abstract/65/1/81

The Alaska Personal Injury Law Group often handles cases involving traumatic brain injuries(TBI). With severe brain injuries, the impairments suffered by the client are usually unmistakable to the client's care providers and neurological experts testifying on their behalf. With “mild” brain injuries—although there is no such thing as a “mild” brain injury when it happens to you—the impairments are more nuanced and difficult to determine with standard neuroimaging or routine neurological and neuropsychological testing. Often clinicians have concluded that no impairments have occurred simply because there was minimal or no loss of consciousness reported when the brain injury was sustained. Now, advances in neurological imaging are establishing what we have already found to be true in our practice—cognitive impairments can occur even with minimal or no loss of consciousness.

In a study published in the October issue of the journal Brain, researchers at the University of Illinois’ Chicago College of Medicine report that diffusion tensor imaging (DTI) can identify structural changes in the brain’s white matter—which is particularly vulnerable to injury—even in patients identified as having minimal or no loss of consciousness. They studied 37 TBI patients with both diffusion tensor imaging and neuropsychological testing to evaluate memory, attention, and executive function. All the patients were at least six months post-injury, and most were highly functioning, i.e., in school or working at the time of evaluation. The structural white matter changes found by DTI correlated to cognitive deficits that were observable.

The researchers were also able to determine axonal damage—a tearing of the axons that allow one neuron to communicate with another—occurring the brain’s white matter. This differs from injury to the myelin, which is the protective sheath around the axons. Injury to the myelin can interrupt the signals between the brain and other parts of the body. The study showed that all severities of brain injury, even those typically viewed as “mild,” caused some degree of axonal damage, while myelin damage was only apparent in moderate to severe TBI.

These findings help us explain why TBI victims can often experience cognitive deficits that one would not expect when their MRI and CT films show no focal lesions. There is now objective evidence that can explain why clients suffer from cognitive impairments even when little or no loss of consciousness has occurred.

Source: White Matter Integrity and Cognition in Chronic Traumatic Brain Injury: A Diffusion Tensor Imaging Study, http://brain.oxfordjournals.org/cgi/content/abstract/awm216v1

One of the unfortunate consequences of the current conflicts in Iraq and Afghanistan is that veterans are returning with traumatic brain injuries and psychological injuries in such numbers that it is forcing the military and America to learn more about the devastating consequences of these injuries.

The New York Times today reported that PTSD has been linked to more than 120 murders committed by returning veterans. The study was conducted based on examining news reports, and is not a study based on scientific data. The New York Times’ study showed an 89% increase in such episodes, from 184 cases to 349 cases, since the conflict in Afghanistan began in 2001. While the Pentagon questioned the methodology of the study, the newspaper said its study was conservative. “This reporting most likely uncovered only the minimum number of such cases, given that not all killings, especially in big cities and on military bases, are reported publicly or in detail.” The Pentagon does not track this type of data regarding its veterans.

The victims were mostly known to the veterans involved, including spouses, girlfiiends, children and family members, but their victims were also strangers. Unfortunately, the soldiers themselves became victims. Thirteen of the veterans took their own lives after the killings, and two more were fatally shot by the police. Several more attempted suicide or expressed a death wish.

The New York Times’ study showed that few of the veterans received anything other than a cursory mental health screening following their return from active duty. Many displayed symptoms of combat trauma in the interviews, but they were not evaluated for and did not receive a diagnosis of post-traumatic stress disorder until after their arrests.

While there may be a debate about methodology, there can be no debate about the fact that America is now returning home in increasing numbers veterans who have survived these conflicts to face the life-ravaging consequences of traumatic brain injury, PTSD, and emotional trauma. America’s battlefield medicine has advanced to save many who would otherwise have perished. By the sheer numbers of those afflicted and greater cognizance of the disorders, more attention is being paid to the problem. To date, however, the military has demonstrated its inability to adequately identify and treat those affected. America’s soldiers should not have to face these conditions alone, as they are treatable conditions that can be ameliorated with rehabilitation, medications, and therapy. America failed its returning soldiers in the Vietnam era. Let us hope that she will not fail the soldiers who serve her now.

Source: New York Times, January 13, 2008.