The 10 Myths Of Traumatic Brain Injury - Bruce Stern

PRINCETON PHILADELPHIA CHERRY HILL NEW YORK www.stark-stark.com

The 10 Myths Of Traumatic Brain Injury

by Bruce H. Stern, Esq.

Myth 1

Mild Traumatic Brain InjuryIs Not Serious

MILD TRAUMATIC INJURY

WHAT DOES MILD MEAN?

NIB CONSENSUS STATEMENT

Rehabilitation of Persons withTraumatic Brain Injury

MILD TRAUMATIC BRAIN INJURYWHAT IS IT?

American Congress of Rehabilitation Medicine

A patient with mildtraumatic brain injury isa person who has had atraumatically inducedphysiological disruption of brainfunction, as manifested by atleast one of the following :any alteration in mental state atthe time of the accident(feeling dazed, disoriented orconfused).

LOSS OF CONSCIOUSNESS (LOC)

IS IT NECESSARY?

MILD TRAUMATIC BRAIN INJURYWHAT IS IT?

This definition includes:1) the head being struck:2) the head striking an object: and3) the brain undergoing acceleration/deceleration movement without direct external trauma to the head..

Mild TBI Symptoms Physical Symptoms

Nausea Vomiting Dizziness Headache Blurred visionFatigue

Mild TBI Symptoms Cognitive Deficits

attentionconcentrationperceptionmemoryspeech/languageexecutive functions

Mild TBI SymptomsBehavioral Changes

IrritabilityQuickness to angerEmotional labilityDisinhibition

Myth 2

Loss Of Consciousness IsNecessary To Sustain A TBI

LOSS OF CONSCIOUSNESS(LOC)

IS IT NECESSARY?

More than 30 years ago, the Congressof Neurological Surgeons concludedthat head injury leading to mentalstatus alterations without loss ofconsciousness is also a form ofconcussion.


IS IT NECESSARY?

Certain facts underscore the needto educate physicians and othermental health care professionalsabout the effects of mild braininjury. There is a commonmisconception that forcessufficient to produce LOC arenecessary to cause concussion.

LOSS OF CONSCIOUSNESS ITIS IT NECESSARY?

Mild TBI is characterized by thefollowing:

(1) Head trauma may bedue tocontact forces or toacceleration/deceleration trauma.

(2) The duration ofunconsciousnessis brief, usuallyseconds to minutes, and in somecasses there is no loss ofconsciousness (LOC), but simply abrief period of dazed consciousness.


IS IT NECESSARY?

For future studies, reasonable criteria forthe definition of mild closed head injurywould include (1) a duration of loss ofconsciousness of 30 minutes or less orbeing dazed without loss of consciousness.


IS IT NECESSARY?

Patients with mild TBI may presentwith somatic, perceptual, cognitive andemotional symptoms that have beencharacterized as the postconcussivesyndrome. By definition, mild TBI isassociated with a brief duration of lossof consciousness (less that 20 minutes)or no loss of consciousness.


IS IT NECESSARY?

On the basis of the aboveoverview, we believe there issufficient clinical and researchevidence to suggest that clearlyunconsciousness is the sine quanon for brain injury.

Duration of loss of consciousness

None to 20 minutes


IS IT NECESSARY?

A concussion is a mild traumaticbrain injury (MTBI), induced bymechanical forces thatimmediately and temporarilydisrupt the normal functioningof the brain.

Myth 3

One Must Strike One’s Head InOrder To Suffer A TBI

Interior Skull Surface

Bony ridges

Injury fromcontact with skull

The base of the skull isrough, with many bonyprotuberances.

These ridges can result ininjury to the temporal lobeof the brain during rapidacceleration.

Coup/Contre-coup InjuryA French phrase thatdescribes bruises thatoccur at two sites in thebrain.

When the head is struck,the impact causes thebrain to bump theopposite side of the skull.Damage occurs at thearea of impact and on theopposite side of the brain.

Myth 4

Negative MRIs, CT Scans & EEGsRule Out Brain Injury

MRIs, CAT SCANS, & EEGs

Do They Detect Mild TBI?

By common clinical agreement,neuroimaging studies arenegative.



In addition many patients with a history of“minor” brain injury will not haveabnormalities on even MRI, yet can manifestclear evidence of functional impairment onneuropsychological measures.



Many practicing physicians believe thata patient with a normal CT scan andnormal electroencephalogram is in factnormal. The should keep in mind,however, the old adage, “Absence ofproof is not proof of absence.Historically, the lack of positiveneurodiagnostic tests in patients withMTBI may have reflected a simple lackof sensitivity and/or specificity.

Myth 5

Effects of TBI AreImmediate

Greenfield’s Neuropathology

Under conditions of mild to moderateTBI it is now apparentThat there is a process of delayedaxotomy in which the actual disruptiondoes not occur until some time after theoriginal injury….axotomy onlybecoming apparent between 6 and 12hours after injury.

NIH CONSENSUS STATEMENT

What Are The Consequences ofTraumatic Brain Injury?

Myth 6

Neuropsychological Testing IsSubjective

The neuropsychologic evaluation is a comprehensive,objective assessment of a wide range of cognitive,adaptive, and emotional behaviors that reflect theadequacy (or inadequacy) of higher brain functions.In essence, the neuropsychologic evaluation is agreatly expanded and objectified mental statusexamination.

The objective and highly quantified nature of mostneuropsychologic tests aids in the detection of subtlechanges in performance over time.

Because of the wide range of behaviors assessed andthe depth to which they are evaluated, theneuropsychologic evaluation may detect subtle deficitsnot apparent on the mental status examination.

NEUROPSYCHOLOGICAL TESTING

IS IT OBJECTIVE AND VALID?

NEUROPSYCHOLOGICALTESTING


Rating. Established. Neuropsychologicalassessment is accepted as appropriate bythe practicing medical community for theindications and under the conditionsdescribed herein.



Summary. In general neuropsychologicalassessment is most useful in patientswith more subtle deficits. It is also usefulfor detecting deficits in patients withparticularly high pre morbid intelligencelevels in which bed-side type clinicaltesting may be insensitive to mildalterations.



Formal neuropsychological testing is anessential part of the neuropsychiatricevaluation of the TBI patient. In fact, it isoften the single most sensitive indicator ofsubtle brain disturbances that may becontributing to the cognitive, emotional andbehavioral dysfunctions that bring TBIpatients to the psychiatrist, especially thosewho have a history of only mild to moderatebrain injury.

Neuropsychological assessment of the patientwith TBI is essential to document cognitiveand intellectual deficits and strengths.





Neuropsychological assessmentof the patient with traumatic braininjury is essential to documentcognitive and intellectual deficitsand strengths.

Myth 7

Cognitive Impairments OnNeuropsychological Testing Must

Fit A Predictable Pattern

Myth 8

Children Get Better

Fact or Fiction

Ronald C. Savage, Ed.D.

Neuroplasticity

“While children are resilient to manythings, TBI is not one of them.Children just don’t bounce back after aTBI. The concept of neuroplasticity ismuch more complicated than wepreviously thought.”

(Dr. William Singer. M.D.)

Fact or FictionMyth

Younger children recoverbetter than older children

Fact

New research shows that younger

children, especially between birth and 5 years, may experience more long term challenges.

Fact or FictionMyth

Severe TBI means permanent disability

Mild TBI means few, if any problemsFact

Measures commonly used to evaluate brain injury severity were developed for adults not children.

Children do not lose consciousness as easily as adults.

Fact or FictionMyth

Physical recovery is a sign that the child hasrecovered.

Fact

Motor function is not a direct indicator of cognitive or behavioral recovery.

Fact or FictionMyth

Normal intelligence scores after TBI mean the child will have no problems in school.Fact

Intelligence tests are often unreliable measures of a child’s learning ability after TBI.

Most intelligence tests measure prior learning.

Fact or Fiction

Myth

Most injuries happen to older children, especially teenagers.

Fact

The majority of brain injuries occur to children under 10.

Persisting Problemsin Pediatric Mild TBI

♦Previous TBI

♦Pre-existing learning disabilities

♦Pre-existing neurological or psychiatric

♦Family difficulties

Myth 9

Mild TBI Is Not Permanent

PERMANENT DEFICITS

IS MILD TBI PERMANENT?

After 1 year, 10 to 15% of mild TBI patientshave not recovered. Many are moreSymptomatic than even immediately after theinjury. Some have had persistence of oneParticularly troubling symptom, usuallyheadache, neck pain or dizziness. MostHave persistence and even worsening of theentire symptom complex. Both groups are athigh risk of permanent persistentpostconcussive syndrome (PPCS).

Long-Term Effects

PERMANENT DEFICITS


The impression from the work to date isthat mild brain injury results in measurabledeficits in speed of information processing,attention and memory in the immediatepost injury period. Recovery from thesedeficits is the rule, occurring over avariable period ranging from 4 to 12 weeks.For a minority, recovery may occur muchmore slowly or remain incomplete.

Unfortunately, a good recovery is notuniversal.

PERMANENT DEFICITS


PERMANENT DEFICITS


Although the long-term prognosis isfavorable for the majority of patientswith a mild TBI, it is well recognizedthat there can be significant short-termbehavioral, somatic and cognitivesequelae. Furthermore, a significantminority of patients develop chronic,often debilitating constellation of signsand symptoms known as the chronicpost concussive syndrome.

Myth 10

Mild TBI Is Not Disabling

NIH CONSENSUS STATEMENTRehabilitation of Persons with

Traumatic Brain Injury

NIH CONSENSUS STATEMENT

What Are The Consequences of

Traumatic Brain Injury?

Disability & Mild TBIHow Disabling Is It?

British Medical Journal Vol.320 June 17,2000British Medical Journal Vol.320 June 17,2000ThornhillThornhill, Teasdale, et al., Teasdale, et al.

Survival with moderate or severedisability was common aftermild head injury and similar tothat after moderate or severeinjury. The incidence ofdisability in young people andadults with a head injury ishigher than expected.

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The 10 Myths Of Traumatic Brain Injury - Bruce Stern