The Emotional Adjustment to Brain Injury

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Posted on 29th April 2008 by Gordon Johnson in Brain Injury

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EDITORS NOTE: Continuing with this week’s theme of the emotional impact of brain injury, I have another post from a TBI advocate/survivor I want to share. Kimberly was referenced on our blogs a few weeks ago with respect to seizure dogs and she started following our blogs at that time.

Hello, Mr. Johnson:

My name is Kimberly Carnevale, founder of Canine and Abled, Inc. You wrote about me and my program in a recent blog. I’ve since followed your blog, and was happy to learn that you are educating about the “invisible” nature of brain injury; something that I struggle with everyday.

When I first was injured, I would try to “hide” my impairments from others. I was confused at how to React to other’s reactions to my injury. To be honest, I think I was very surprised and disheartened at people’s lack of support/understanding of my deficits. I fed off of other’s discomfort at my differences. I felt guilty at the behavior I had trouble controlling, was embarrassed when I couldn’t remember things I knew that I knew, and was self-conscience living in a body that “looked” fine, but as it’s captain, I knew was anything but fine.

Everyone used to say, “you look wonderful!”…but that’s only because on the days that my cognition was impaired, I would retreat into my shell, not emerging again until I felt fairly “normal” again. I felt as though people only accepted me when I didn’t show signs of my disability, and were uncomfortable dealing with my cognitive issues; and so I locked them (and myself) away until they subsided. It was a very solitary and depressing way to live.

If you have a broken bone, folks are prone to be more compassionate because they can see the cast, or limp or other physical sign. If you are brain injured, no one but you experiences the overwhelming anxiety of trying to manually process the environment and deal with the wide spectrum of emotions that overtake you at any given moment.

It wasn’t until I gained much-needed support through TBI groups, that I started to feel differently about my disability. I found that I wasn’t alone, and didn’t need to be embarrassed by my deficits any longer. While I once was apologetic about my service dog (the ONLY thing that made my confusing and overwhelming life bearable), I now hold my head high and am proud to be accompanied by the noble friend who offers assistance, safety, and never-ending emotional support.

I would like to personally thank you for educating people about hidden disabilities, and thank you for telling my story in your posts. If I can ever be of assistance to you in any way, please do not hesitate to ask.

All my best,

Kimberly Carnevale
Author/Motivational Speaker/Disability Advocate
President, Canine and Abled, Inc.
“Taking The Dis Out Of Disabled”
www.canineandabled.com
www.KimberlyCarnevale.com
canineandabled@aol.com
Kimberly’s is a success story, but only because she was able to move past the emotional and adjustment issues that plagued her.  And my take is that her dog helped her make an emotional connection that greatly assisted in that process.  There is something special about the connection between the canine and the human.  Maybe it should be at the cornerstone of all brain injury rehab.


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Emotional Issues After TBI

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Posted on 28th April 2008 by Gordon Johnson in Brain Injury

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This week, we will focus on emotional issues after TBI.

I will begin with a contribution from an old TBI from entitled Hope For Anger by Stephanie St. Claire:

There is help and hope for out of control anger. I no longer put holes in doors trying to get through them to the person I am angry at, or kill animals in a rage. Rages used to flood me even when I was relaxed, comfortable, and walking down the hallway. Is this the type of out of control emotion you are talking about? (I hope your anger is MUCH less violent.)

What helped me was:

1. Tegretol. It took away the violence of the mood swings and gave me enough control to be able to get away and alone in a quiet place until the flood of anger passed, sometimes four or more hours later. When I made changes in my environment, lifestyle, and was able to become more conscious of my emotions as they began, I no longer needed to have Tegretol for emotional control. Some rages/anger are caused by temporal lobe seizures, which need a Doctor’s (as much as I despise them, present company excepted) care.

2. Stopped pushing myself so hard to be “normal.” I grieved deeply for the “self” I had lost and then could better accept where I was at. The result was when I was tired I rested and it was easier to do, and when I was overloaded I took time out and relaxed. My pace of life slowed down enough to accommodate my difficulties, which helped lessen the high stress I carried around inside, and helped my brain function better.

3. My senses are overwhelmed very easily so I now live in a rural area that is quiet. Overstimulation would (still does) overload me and increase the likelyhood that I would be enraged at little things. (Or cry at the drop of a hat, or laugh and not be able to stop.)

4. By paying attention to how tired, stressed, anxious, overactive, or overloaded I am I am better able to catch flashes of emotion before they flash and burn everyone in sight. Being aware of physical sensations that tell me when my brain isn’t functioning as well (such as headaches or nausea) helps too.

5. Feedback from others helped me know what I was feeling. If someone I could trust saw a strong emotion, or one quickly building, she or he would ask me if I was feeling “angry” or whatever emotion they saw. I could then check myself and began to understand that when my chest felt tight and I was energized that I was agitated. In time I began to be able to recognize it for myself, as it sounds like you are starting to.

6. When I was able to get out and interact with people it helped to limit my social contact to people who were generally positive and upbeat (no phony optimists) and who accepted me as a human being, not as a brain injury.

7. My underlying mental and emotional outlook is critical. After the TBI I no longer have the ability to keep on functioning, come what may. I look for things to laugh about, I look for and find love, and I live as relaxed and comfortable a life as I can. I haven’t been able to change the TBI, but I have found that it is in my power to chose how I am going to cope. Though there is very little I am able to do about what goes on in my external environment I have found that there IS something I can do about what goes on with my internal life. It has taken me years to learn that. Staying relaxed and laughing has helped a lot to enable me to regain control. It took me years of fighting, denying, angry at, and bargaining with this TBI for me to get to the place where I could accept it, even though it wasn’t in my game plan or something I ever wanted. When I got to where I could accept it then I was where I could better do something about it.

Some of these things don’t seem to be related to not having belches of anger and they aren’t directly related, but they do have a behind the scenes effect of calming the brain down.

After time, and these things I’ve listed, I am able to be aware when my irritability makes its appearance. I then check myself, usually I am tired and I need time out. I no longer put off taking that time out and resting my brain. Feedback from others is still helpful, but it is rare these days that I don’t see it for myself and can take action. There are occassional flare-ups of irritability that tell me I still need to take precautions but I have regained emotional control and I haven’t had a flash of rage in many years. If your anger doesn’t become rage, like I was being flooded with, you might find that your emotions become better settled down and predictable more quickly than mine.

It may take time, and more patience than you knew you had, but it is possible, I believe, that your anger will be under your control again. It might take working through your emotions about having a head injury to help you regain mastery of those emotions that your brain creates against your will. If you can deal with the normal emotions then the TBI ones are easier because then there is less emotional baggage to cope with. At least I have found that to be the case. Staying away from angry, agressive people, or people that trigger emotion is a good idea too, at least until you can get a good handle on your own.

I related very strongly to what you wrote. I hope my experience with working through this and coming out on the other side helps you. Yes, it is possible to get through this and make it better. And yes, there ARE people who relate to what you are experiencing!

Better days ahead,
Stephanie, TBI Survivor


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Patterns of Footprints of Brain Injury

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Posted on 18th April 2008 by Gordon Johnson in Brain Injury

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Diagnosing brain injury in absence of a continuing loss of consciousness, is a matter of triangulating behavioral observations, scientific test results and objective measuring tools for the change in function correlated with brain injury. The most important piece of the diagnostic puzzle is the clinical judgment of a doctor experienced with brain injured people. In today’s world, medical science has a severe prejudice in terms of basing a diagnosis on imaging studies, to the exclusion of all other things. But most non-coma brain damage is microscopic and ruling out a brain injury based primarily on absence of abnormal imaging, is wrong. Yet far too often, even though physicians will admit that in theory a negative scan doesn’t mean no brain injury, they will base their diagnostic judgments upon that alone.

Yet, as many as 50% of those in coma have normal CT scans. MRI’s, while they are getting better, still have significant false negatives even with comatose patients. Neuropsychological tests results can provide a major portion of the diagnostic process, but again, if only the tests themselves are read in a vacuum, wrong conclusions are virtually guaranteed. Only if all testing, imaging, neuropsychological, EEG results are interpreted with a clear understanding that someone can have a significant brain injury without clear cut evidence on any one of these tests, can a reliable rule out diagnosis be made.

The most troubling area of brain damage to diagnose relates to frontal lobe deficits. The reason is that these deficits manifest themselves in real world behavioral changes, not abnormal neuropsychological tests. While numerous neuropsychological test instruments address certain frontal lobe issues, such instruments only measure particular aspects of frontal lobe function, not the synergistic interplay of the various deficits. One of the most significant frontal lobe deficits -deficits in terms of initiating activity – is virtually unmeasurable thru neuropsychological testing, because it is the test administrator who directs activity. Only thru a detailed evaluation of the pattern of activity (or lack thereof) in the real world, can an assessment of this most disabling of symptoms be assessed.

Brain injury symptomotology scans all types of cognitive, emotional and behavioral aspects. Anything that can go wrong with the human body can start in the brain. Yet, traumatic injury will follow certain patterns. If the change in function, particularly function in the real world, fits those patterns, then the diagnosis needs to be made, and treatment and adaptive strategies implemented. No test or MRI can substitute for the subjective judgments of someone who has worked with brain injured survivors for years.


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Footprints of Invisible Brain Injury

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Posted on 14th April 2008 by Gordon Johnson in Brain Injury

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Last week, we talked about the term “invisible injury” as used by the Brain Injury Association, to describe brain injury and its application to discrimination against seizure dogs. That topic transitions to today’s blog about how we identify an “invisible injury”, such as brain injury.

So how do we see the invisible? Well if we are in Hollywood and we are talking about the invisible man, we wrap him in bandages, or look for the footprints. Footprints: remember the legendary story of the million posters of “Footprints in the Sand”? http://www.footprints-inthe-sand.com/ Well how are we to know from the footprints that the ghost of brain injury is lurking beneath the surface?

Identifying brain damage is a complex problem of looking thru skin, skull and normal tissue, to see what may be microscopic pathology, without peaking. This is the ultimate Xmas present-type guessing game to identify what is in the package, with no shaking allowed. Yesterday we discussed the discrimination of society in favor of the service dog for the blind versus the service dog for the brain injured, because of the visible evidence of that disability. But all we are seeing in a blind person is the footprint of pathology as well. We cannot see the blindness; what we see is the footprint of behavior changes because of the blindness.

With apologies to the blind: we might see the sunglasses, we might see the cane, we might see that the eyes don’t look directly at us or other things. We see the seeing-eye dog. While we can’t see the pathology, we see the evidence of the pathology in a pattern we almost instantly recognize as patterns of blindness. The pattern of the footprint tells us that someone is blind.

Why is that pattern so much harder to see in the brain injured? It isn’t always. Many brain injuries come with physical disabilities – problems with tone, with motor skills, with walking. While not as visually recognizable, many brain injuries come with speech deficits that are recognizable as soon as you hear the brain injured person try to communicate. Yet, profound brain injury can occur in a pattern that doesn’t fit either the physical or speech disability pattern. Frontal lobe deficits may become obvious over time, but it is thru the pattern of behavior that we can see these deficits, not just a quick sense of what our eyes and ears are telling us.

Next: Identification of Patterns in the Sand


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Service Dog Discrimination Issues

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Posted on 10th April 2008 by Gordon Johnson in Brain Injury

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EDITORS NOTE: Yesterday, we talked about the “invisible injury” nature of brain injury, specifically with respect to public recognition of the role of seizure dogs. I had intended to next write about seeing the invisible, thru following the patterns of the footprints, but have decided to wait for that until tomorrow. I received this comment on seizure dogs from one of my readers, and felt it should go next.

Most people do not know what the legal description of a Service Dog is. A service dog is any breed of dog which is trained to perform certain tasks to assist their owner with disabilities and have access to all public facilities under ADA 1990.

Whether that person be:

Physical Disabled – Guide, Hearing, Mobility, Medical Alert, etc.
Social/Emotional/Mental Disabled- Autism, Acute Issues (phobia to leave home, socialize, depression, etc.)

One of the sad notes in the discrimination against service dogs is the current move to enact breed specific legislation in many areas. Due to the large numbers of unwanted pit bull type dogs, many are being rehabilitated as service and therapy dogs, including impounded dogs from the Michael Vick case. Once placed in a home these highly trained dogs provide a quality of life which would be impossible otherwise. In some places, BSL allows law enforcement to physically remove and euthanize these service dogs, or, to require muzzles which inhibits the dog’s ability to perform tasks for their handlers. Many BSL laws require $1,000,000 in home owner’s insurance which is difficult for those disabled people who rely upon their service dogs.
Pit Bull type dogs are ideal for service dogs. Small and compact, they are still strong enough to pull a wheelchair and carry backpacks, their coats are easy to maintain. They have confidence to function in public but were also bred to be submissive to humans. Even Helen Keller owned a pit bull.

Because the ADA is a federal law, it should override any state or local legislation when dealing with service dogs, no matter what the breed. Restricting pit bull service dogs in some areas violates what the US Supreme court has deemed a fundamental right, the right to interstate travel. In theory, all service dogs are protected under federal law and in some states such as California, to harm a service dog is a felony. However, if you call the Department of Justice, you will receive varied responses on your inquiry as to the rights of your service dog in BSL states, or your right to travel with your service dog through areas which have BSL legislation. Legally, pit bull service dogs are protected federally, but it will be a case by case decision to decide the fate of handlers and their dogs.

According to the ADA:
BUSINESSES MAY NOT:

* Require special identification for the dog
* Ask about the person’s disabilitiy
* Charge additional fees because of the dog
* Refuse admittance, isolate, segregate, or treat this person less favorably than other patrons

The ADA defines a service animal as any guide dog, signal dog, or other animal individually trained to provide assistance to an individual with a disability. If they meet this definition, animals are considered service animals under the ADA regardless of whether they have been licensed or certified by a state or local government.


Thank you Becca for this fine contribution.  And of course, if other readers would like to add something in response to any of my blogs, I will consider posting their comments here as well.


Well it is a bit off topic, the lawyer and the dog person in me, can’t really resist jumping in on this topic.  I have been a poodle person for years, yet the best dog I know resembles a cross between a border collie and a lab.  She is sort of black, with just enough white on her face to look like she has a little border collie coming thru.  She has web feet and loves to retrieve.  She has the border collies energy and intelligence, with the goofy affectionate people bonding people you might expect to see in a good lab.  The so-called experts tell me this dog is a Pit Bull.  I know dogs and this is a good dog.

In law school I learned the principles of legislation and discrimination.  The lay person thinks that discrimination is a bad thing, because the term is usually applied to racial or religious issues.  But all laws discriminate.  The theory of a law is you define legal versus illegal conduct, based upon a definition of some type.  That definition is a discrimination.  Now the legal issue is whether that form of discrimination is legal or constitutional.  Unconstitutional discrimination primarily includes discrimination against race or religion, and certain other protected activities.  But a discrimination while appearing constitutional, can still be illegitimate if it serves no rational state interest.  

A law serves no legitimate state interest if the stated basis of the law is irrational as applied to the class against which the discrimination is aimed.  I would not argue that the state does not have an interest in controlling unsafe animals.  I would not advocate a law that allowed tigers to roam free.  A law that prohibited  predatory SPECIES of animals to be off leash in a dog park, is certainly legitimate.  I do not want my dog eaten by a mountain lion.

But all dogs are the same species – the DNA of different breeds are virtually indistinguishable. It is an old cliche: there are no bad dogs, only bad owners.  I wouldn’t go quite that far.  There are some bad dogs, just like there are some bad people.  But I can’t accept that there are any bad breeds.  But let  us assume that there was a particular breed, lets call them the Saber Dog breed, that was in fact a universally dangerous animal.  Now in my artificial world, all Saber Dogs would have fangs like a saber tooth tiger, and since no other dogs have such teeth, we would know they were dangerous animals on sight, and we would have a rational law that could be applied.

But the similarities between breeds are staggering.  As well as I know dogs, I am still not convinced that my favorite dog is really a Pit Bull.  If she is a Pit Bull, she is the second Pit Bull I have known well who was smart, playful and liked to run around until she dropped chasing and being chased by other dogs.  So based upon my experience, that makes her breed a good, pleasurable breed to own or just spectate.

I challenge anyone to define a law prohibiting Pit Bulls that can be enforced on a visual inspection that is not at risk for being overly broad and excluding “safer” breeds.  How much do you have to mix with a boxer, or a lab, or a rottweiler to make them look a little too much like a Pit Bull?

I do believe there are bad dogs, but I am convinced that 90% of the problems with dogs stems from the dogs not getting to run around freely at times and not getting to play with other dogs.  A dog park solves both of those problems.  Not allowing a breed which the regulators have identified as potentially being dangerous, to engage in the kind of activity which would reduce their danger, is totally irrational.  

In summary, dogs are wonderful animals.  Something about their DNA as a species gives them a special bond with human beings.  They will become your best friend, if you allow them.  But that trait is spec ies specific, not breed specific.  Breeding is almost entirely about looks, not temperment.  The best dogs are often mutts.  In fact, all dogs are essentially mutts. You only get into trouble breeding dogs when  you interbreed them.  No law can be defined to discriminate between the good dogs and the bad dogs.  To base a discrimination on whether this particular “regulator” thinks they look too much like a dangerous dog breed, is positively Un-American.  Especially when you consider the breed is named “American Pit Bull Terriers.”
And that is my humble opinion.


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Seizure Dogs and Brain Injury/Seizure Disorders

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Posted on 9th April 2008 by Gordon Johnson in Brain Injury

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I have never been a big fan of the politically correct terms when discussing brain injury, hence my own coining of the term ©Subtle Brain Injury in 1999. See http://subtlebraininjury.com Having served on several boards where all they did was argue about what were the appropriate 30 words to put in a mission statement or policy statement, I have had a resistance to many of the pronouncements to come out of brain injury groups. But today’s blog does plagiarize one of those catchwords for brain injury “the invisible injury”. Credit for this phrase probably belongs to the Brain Injury Association of America. While again, this was never my favorite phrase, as so many disabilities are invisible, with respect to issue with seizure dogs, it rings so true.

When I first began my online advocacy about brain injury, one of the first issues that came to the forefront was discrimination against seizure dogs. Wal-Mart’s and the like would of course never ban a seeing eye dog, but a seizure dog? That was just a pet. I may be misappropriating credit, but I am reasonably sure that Debbie Wilson, one of our original contributors to http://waiting.com was carrying this torch in 1996. For unrelated poems of Debbie Wilson, click here.

Not long I first heard these cries on some of the seminal web TBI lists, Kimberly Carnevale was injured in a horse accident. One of the consequences of that injury was a seizure disorder. The German Shepherd, Dewey, that she had at that time had an ability to sense those seizures and warn her of the approaching danger, to assure that she could avoid additional damage of an unexpected seizure. Kimberly took her Dewey to be certified service dog, under the Americans with Disabilities Act (ADA) regulations.

Yet like those with seizure dogs before her, Kimberly was denied access to some public areas with Dewey. This denial angered and motivated Kimberly enough to found an organization and establish a website to fight this ignorance and discrimination. The Organization is Canine and Abled, and the website is http://www.canineandabled.com/

Why does reading about that website and Kimberly at http://www.northeastcenter.com/website-of-the-month-april08.htm this morning make me think about the “invisible disability?” Because it is the invisible nature of brain injury and seizure disorders that accounts for that discrimination. No one would consider banning a seeing eye dog because the disability is so obvious to an observer. Likewise, no one would ban a wheelchair, for the same reasons. To deny someone a cane, is equally ridiculous. But, a dog, with a normal walking and talking person: that just seems like someone who wants to sneak their pet in.

I applaud Kimberly and her organization. Education is the key. In a sense, Dewey now makes Kimberly’s disability visible, if people are educated to understand his role. His role is as a prosthesis, an assistive device (not to inanimate Dewey) that will assist a disabled person, in a way not so dissimilar from a wheelchair, an artificial limb, to make their way in the world.

Later this week: Identifying and diagnosing the “invisible injury” and the need for other prosthetic aids for brain injury survivors.


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

The Need for Periodic Followups after a Concussion

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Posted on 4th April 2008 by Gordon Johnson in Brain Injury

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As I discussed yesterday, if the person is seen the day after the concussion, there is a fertile opportunity to actually test the injured person’s memory formation, to see if they are in an amnestic period. Yet, no where in the Facts for Physicians Toolkit, does it call for a return visit the next day.

In the sports situation, the athlete doesn’t get back into the game if he or she is symptomatic at 15 minutes. So what does that mean? They don’t determine that the person is able to go back into the game at two minutes, they wait fifteen minutes. If there are no symptoms at 15 minutes, they send them back in. If they are symptomatic at 15 minutes, they don’t get back into the game until their symptoms have cleared for a significant period of time.

If it is classified as a significant concussion, they don’t get back into the game until their symptoms have cleared for seven full days. Now here is what is significantly different about the way that average people who get head injuries, brain injuries in motor vehicle accidents or falls are treated different than an athlete.

With an athlete, let’s take an NFL quarterback, there are millions of dollars at stake as to whether or not and when, that person can play again. That means that every day that such person continues to be symptomatic it is a problem. Which of course means that every day some expert in the field of brain injury or at least in the field of sport concussion, is evaluating them to see if they are still symptomatic.

If we could take that model of daily evaluations to see if symptoms have cleared and apply that to injuries that happen in motor vehicle wrecks , I believe we would be able to sort out the accidents and brain injuries that are significant from those that are not.

What I would like to see is a change in two significant things in respect to people who have concussions in motor vehicle accidents and other accidents are treated. First, there has to be an analysis done of memory not confusion in the ER, as discussed previously on this blog. Second, we need to demand a 24 hour follow-up, preferably at the same facility.

Sorting out confusion from amnesia at the ER on the day of the event is only going to tell us what is going on in the first three or four hours. “Brain injury is a process, not an event. “ (T Gennarelli) It can take 72 hours for the full effect of brain injury to start impacting on the mind. So more important than asking better questions about amnesia on the day of the accident is to ask them something the next day.

I have two classes of concussion cases. Those where the people went to the ER on day two, and those where they didn’t. In almost every case where the loved ones of the injured person were concerned enough about injured person’s behaviors that they took them back to the hospital, I was able to prove a brain injury occurred. It wasn’t that the second day’s ER staff was so much more competent. It was that by day two, it had become so much more obvious that a concussion had occurred.

When you go to see the doctor 24 hours after your concussion and it is a significant concussion, even busy doctors in the emergency room will spot amnesia and even if they aren’t confused about what happened in the accident, they are confused about what they have been doing.

If we believe it is important to treat those with lasting effects of concussion, we must identify those who are the highest at risk. If we are really going to improve how we sort that out, the key is to make sure they go back to the doctor, preferably the same emergency room. If we change this protocol, we also need to change forms, like the ACE form from the CDC, to tell the doctors what to ask, like: “What did you do since you left here?”

If the patient can only remember a few things, they are probably having amnesia. If they can remember all of it, then they probably don’t. If they don’t remember anything, then it is a significant head injury.

We must change the way we look at the long term potential for a head injury, brain injury, in the 24 hours after the accident. We must start giving the accident victims the same type of care and concern we give athletes who are injured in sports.


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

CDC Acute Concussion Evaluation – Improved Process

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Posted on 3rd April 2008 by Gordon Johnson in Brain Injury

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Included in the CDC Facts for Physicians Toolkit, http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm but not as conspicuous as I believe it should be is the Acute Concussion Evaluation (“ACE”) Form. Click here to go directly to such form: http://www.cdc.gov/ncipc/tbi/ACE.pdf

This form is a major step forward and I wish that it was used comprehensively at every Emergency Room and clinic. However, I do have two major concerns with this form, things that could easily be corrected and which would make a tremendous difference in diagnosing and treating the concussions. My first concern is the Amnesia portion. The second, which we will discuss tomorrow, is the serial followup issue.

Amnesia Questions. Here is what the ACE Form asks re on Amnesia and related acute symptoms:

• 3. Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? __ Yes __No Duration
• 4. Amnesia After (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? __ Yes __No Duration
• 5. Loss of Consciousness: Did you/ person lose consciousness? __ Yes __No Duration
• 6. EARLY SIGNS: __Appears dazed or stunned __Is confused about events __Answers questions slowly __Repeats Questions __Forgetful (recent info)

Compared to what is routinely asked, this form is a major step forward. Perhaps the best question on the form is “Repeats Questions.”

Here is what the form’s instructions portion says with respect to its Amnesia questions:

3/4. Amnesia: Amnesia is defined as the failure to form new memories. Determine whether amnesia has occurred and attempt to determine length of time of memory dysfunction – before (retrograde) and after (anterograde) injury. Even seconds to minutes of memory loss can be predictive of outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute).1

The literature completely supports the statement about the significance of Amnesia. My problem with this form is it too narrowly defines the time focus for Amnesia. Amnesia can begin in the period of time after “just AFTER the injury”. Why not just add a few simple sample questions to the form? And make those questions open ended, not something that can be answered with a yes or no. Ask questions where the examiner actually has to listen to a detailed explanation of what the patient remembers. How about these additions:

What can you tell me about the observers at the scene before the ambulance got there?
What can you tell me about the ambulance ride?
Did you have to wait in the emergency room? Who else was waiting?
What questions did they ask you about your insurance, your billing?

All of these questions make sense on the day of the accident. Adreniline improves memory. But that effect is short lived. These questions test memory whether memories were encoded, for the period of time when the adrenaline has worn off. These questions test that critical time frame from 5 minutes post accident to two hours post accident. Questions like these may tell us far more whether the person is converting short term memory into long term memory (saving it to the hard drive of their brain) than questions about the accident itself.

Now if the patient is seen a day or two after the event, the questions should be focused on the time frame from 2 hours post accident, to the time of the evaluation. What have the done that day, what do they remember about the day before? A person who has significant memory gaps for the period of time from 6 hours post accident to 72 hours post accident, is someone at risk of significant long term problems. Sadly, this is a period where few people are actually seen by medical professionals and poor documentation of amnesia during that period occurs.

Tomorrow: The Solution: The Call for a Return Visit.


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Sport Concussion Guidelines have Migrated to Accidental Injuries

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Posted on 2nd April 2008 by Gordon Johnson in Brain Injury

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Most of the focus on changing definition of concussion has come out of concern about concussions in sport. Thru that work, beginning in the early 1990’s, it became standard practice that if an individual suffered a concussion in a sporting event, they should not be allowed to return to competition until certain objective criteria of recovery had occurred.

That research led to the Practice Parameters of Sports from the American Academy of Neurology and other Sports and Concussion guidelines. This insistence on continuous at first, then periodic monitoring before allowing a return to competition has been a near revolutionary change in the approach to concussion. While in practical reality they are not followed to the letter, at a minimum they create a structure for determining whether or not the concussion needs to be taken seriously.

All concussions should be taken seriously but if someone has a 15 minute recovery from a concussion, they are allowed to return to play on that day. Especially with young jocks if a recovery occurs in 15 minutes, it is overwhelmingly likely that they will have a good result.

That work that was done with concussion has helped to change the way in which concussions are defined and diagnosed in the real world. By saying real world concussions, I am talking about concussions that happen to average people in accidents, not sports, not military. While the Concussion in Sports guidelines are not definitionally extended to real world concussions, it has changed perspectives and has lead to the CDC publishing this kit, Heads Up Brain Injury in Your Practice. This is not just for athletes, but for concussed individuals across the board. Click here for the CDC booklet.

The CDC materials included Facts for Physicians about Mild Traumatic Brain. That definition does not limit the definition of concussion to what would be in these neurological treatises discussed earlier this week, such Principles of Neurology by Adams and Victor. It now is using the type of definition that is used for concussion in sports. That is the basic introduction as to where we stand and we look to the future of diagnosing Mild Brain Injury.

I have used the term concussion and the way I use it is synonymous with Mild Traumatic Brain Injury (“MTBI’) in essence a concussion is a Mild Traumatic Brain Injury and the two terms do really mean the same thing, but I it is arguable that a concussion does not become a Mild Traumatic Brain Injury until the symptoms from that persist at least as long as the 15 minute requirement under the Sports and Concussion guidelines.

A concussion does involve injury to the brain. The kind of concussion that does involve injury to the brain that we would be concerned about in my practice as a lawyer who primary represents people with a mild brain injury is the kind of concussion where the symptoms are there the next day, there the next week, there the next month. The problem in determining whether or not someone is going to have a disabling concussion on the day of their accident is that it is not the symptoms they have at the time of their accident, not even the symptoms they have 15 minutes later but primarily their symptoms 24 hours later.

Tomorrow – the failure of the medical community to adopt the serial follow-up evaluations that are required in sport concussions.


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney

Evolution of the Definition of Concussion

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Posted on 1st April 2008 by Gordon Johnson in Brain Injury

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My last blog focuses the acute symptom of amnesia, the symptom that is now believed to be the most significant predictor of outcome after concussion. However, that is the modern way of looking at concussion, and unfortunately, not even all treatises or commentators on brain injury, are even willing to look at amnesia in absence of a documented loss of consciousness at the time of concussion.

I have a fairly extensive library of brain injury treatises in my library, something many of you who have seen my websites or brain injury videos will recognize. If we were going to look at those books, you might be surprised as to how different the definition of concussion is in those books from what is the current thinking about concussion.

For example, one of the treatises that is on more neurologists shelf than almost any other, Adams and Victor, Principles of Neurology- that books says that you can not have a mild brain injury, you can not have a concussion, without a loss of consciousness.

That frankly is wrong.

But this book has been restating that basic principle since it was originally published in 1977. The copy on my shelf was printed in 1997, and the most recent version says the same thing. That is not the current thinking about concussion, not the thinking of the CDC, not the thinking of the American Academy of Neurology. But because it is content on one of the leading treatises in neurologist’s own libraries, it is the thinking of a far greater percentage of neurologists than should in fact be the case.

The definition of concussion really started to change about 1992, even though the research behind that change dates back at least as far as 1971. What happened in 1992 is that there was the American Congress of Rehabilitation Medicine’s (“ACRM”) published its definition of “mild traumatic brain injury.” In that definition, the ACRM abandoned the absolute requirement that you had to have a loss of consciousness to be diagnosed with a brain injury. The ACRM definition substituted this requirement with four different, alternative, what I describe on my website as acute events. Those events were Loss of Consciousness, a Change in Mental State, Amnesia, and Focal Neurological deficits. Source: Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine, published at J Head Trauma Rehabil 1993:8(3):86-87 For the full context of the ACRM definition, click here.

The only one of those that really adds a significant amount to the diagnostic picture is amnesia. But because amnesia is one of those things that doesn’t have a true objective measure and something that is not particularly sensitive to be identified in the emergency room, amnesia has not helped us define mild brain injury/ in the cases where people are long term disabled as much as it should. See the previous blog on Amnesia, and the blogs that will follow later this week.

The 1992 ACRM definition of concussion was ultimately followed by the American Academy of Neurology’s work with concussion in sports. Those two movements had a major impact on changing the definition of concussion. That has ultimately lead to the extremely important “Heads Up Brain Injury in Your Practice “ which is published and distributed by the CDC. For those materials, click here.

Tomorrow: Concussion in Sport and How Relevant that is to Other Concussions


Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney