If you think wearing a bicycle helmet is for wimps, think again. Joey Harrington, a 33 year old former National Football League quarterback, was struck from behind by a driver of an SUV while riding a bike. On Sunday, July 31st, 2011, Harrington was hospitalized with non-life threatening injuries including a broken collarbone, a punctured lung, and a cut on his head. The crash caused Harrington to land on the vehicle. He was upside down when he skidded off and landed on his head and shoulder. Harrington was wearing a bicycle helmet which prevented much more serious injury. Harrington is expected to be released from the hospital on Tuesday, August 02, 2011. “>
Beaten Baseball Fan Suffered Traumatic Brain Injury
Bryan Stow, 42, a San Francisco paramedic, who was attacked by two suspects on March 31st at Dodger Stadium in Los Angeles, last week has been upgraded from ‘critical’ to ‘serious’ condition but his doctors say they remain “extremely cautious about interpreting his progress”. Stow is able to open his eyes and respond to basic commands. Doctors said Stow suffered a 30-second seizure recently and underwent surgery to relieve fluid built up in this head. http://www.thirdage.com/news/bryan-stow-injured-giants-fan-undergoes-more-surgery_07-22-2011
New details of the attack, that has spurred nation-wide public outrage, were released at a bond reduction hearing on August 1st. Stow was punched on the side of his head from behind. As fellow paramedics witnessed, Stow become unconscious before he fell to the asphalt covered parking lot. Stow was unable to impede his fall. Witnesses further heard his head hit the asphalt and observed his head bounce upon hitting the ground. Once on the ground, one of the two beating suspects kicked Stow numerous times in the head. The other suspect also kicked Stow in the head. http://www.washingtonpost.com/national/court-documents-describe-attack-on-giants-fan-at-dodger-stadium/2011/08/01/gIQAuwWlnI_story.html
Battlefield Soldiers and Football Players with TBI have Higher Risk to get Dementia, Studies Show
A new study introduced at the Alzheimer’s Association’s International Conference in July, suggest a strong link between head injuries in veterans and dementia. Soldiers who had suffered brain injury were two times more likely to develop the brain disorder.
http://today.msnbc.msn.com/id/43797462
Another study indicates an even more ominous prognosis for another group of veterans: retired football players. The research shows that by almost three times the normal rate, 35% of former NFL gridiron warriors studied had signs of dementia, compared to 13% in the general population.
Other detailed studies done by research scientists at various universities including Loyola University in Chicago, UCLA and at the University of Pennsylvania, research indicates a Traumatic Brain Injury (TBI) and the development of ‘brain clogging plaque and tangles’ that are known to cause Alzheimer’s and dementia.
The new research on combat veterans is especially worrisome to Dr. Douglas Smith, of the Penn Center for Brain Injury and Repair. He suggested that these injuries and long term effects to the brain may make the “Agent Orange” concerns of a generation ago “pale by comparison”.
Brain Injury and Malingering – A Dangerous Deceit
I hope you read past the title, because that was meant as a double entendre. The “Dangerous Deceit” is not that of the brain damaged person, but the deceit of the neuropsychologist who claims to be able to tell if someone is committing a fraud. At its core, to claim someone is a malingerer is to claim that they are lying. In most states, an expert is not able to testify that someone is lying. That is felt to be the province of the jury. Far too many plaintiff lawyers accept such claim at face value and do not challenge this claim with a pre-trial motion.
The more clever defense doctor will not go so far as to outright claim that a plaintiff has malingered, but suggest it, and then to base such suggestion on what the doctor deems to be inconsistent effort throughout the battery of tests. I discussed in my previous blog the problem that fatigue creates in interpreting neuropsychological results, especially claims that someone did not give best effort. If you progressively tire, you invariably will do worse on tests given later in a battery than earlier.
But a progressive decline in test performance is not the only pattern that can be expected in a brain injured person. In my way of looking at it, a significantly brain injured person can be expected to be inconsistent, because virtually every symptom of brain injury can affect how a person feels, thinks and reacts at any given moment. And that symptom can ebb and flow, both within a given test, across a test battery or from one day of testing to another.
Another common problem with malingering tests is that they are based upon the theory that such test is so easy that even a severely brain injured person would pass it. Well that has some superficial merit, but when they are talking about severely brain injured individuals, they are talking about someone who in most cases, had a focal injury that resulted in an increase in intracranial pressure, resulting in a coma. Such people often have a different set of problems, more severe in the focal area of their injury, but with not as severe of problems in other areas. One cannot assume, despite the logic of it, that a person with a severe brain injury will have a worse outcome than someone with a significant concussion. I have written for years about the Miracles and Tragedies of Brain Injury.
The third problem with malingering claims, is that they only look at the few tests in the battery that are considered malingering or effort tests, and ignore the dozens of other tests in the battery that require considerably more effort than the “effort” test. If properly designed, an effort test should look just like all of the others. So if a person was truly malingering, wouldn’t they do poorly on all the tests, not just the “effort” tests. Yet in every single case I have every heard a defense neuropsychologist raise the malingering specter, there were subtests by my client, and usually many, many subtests, where my client did extremely well. If they were malingering, why did they do well on these tests?
Bottom line, all malingering tests are fatally flawed because there is no actual research on people who actually malingered. The research that is done is done on experimental subjects who are told to pretend to be malingered. In my favorite malingering study, the instruction to exaggerate your claims, but in a way not to get caught, was given to an equal number of brain injured persons and non-brain injured persons. In this study, it was only the brain injured persons got caught. In all other studies, the pretend malingerers were instructed to “act” like a malingerer. But a true malingerer would not want to get caught. The realities are that the only time a malingering test is ever likely to catch someone for true exaggeration, it is likely to catch a brain injured person, because they lack the judgment to do it in a way they won’t get caught.
The more clever defense doctor will not go so far as to outright claim that a plaintiff has malingered, but suggest it, and then to base such suggestion on what the doctor deems to be inconsistent effort throughout the battery of tests. I discussed in my previous blog the problem that fatigue creates in interpreting neuropsychological results, especially claims that someone did not give best effort. If you progressively tire, you invariably will do worse on tests given later in a battery than earlier.
But a progressive decline in test performance is not the only pattern that can be expected in a brain injured person. In my way of looking at it, a significantly brain injured person can be expected to be inconsistent, because virtually every symptom of brain injury can affect how a person feels, thinks and reacts at any given moment. And that symptom can ebb and flow, both within a given test, across a test battery or from one day of testing to another.
Another common problem with malingering tests is that they are based upon the theory that such test is so easy that even a severely brain injured person would pass it. Well that has some superficial merit, but when they are talking about severely brain injured individuals, they are talking about someone who in most cases, had a focal injury that resulted in an increase in intracranial pressure, resulting in a coma. Such people often have a different set of problems, more severe in the focal area of their injury, but with not as severe of problems in other areas. One cannot assume, despite the logic of it, that a person with a severe brain injury will have a worse outcome than someone with a significant concussion. I have written for years about the Miracles and Tragedies of Brain Injury.
The third problem with malingering claims, is that they only look at the few tests in the battery that are considered malingering or effort tests, and ignore the dozens of other tests in the battery that require considerably more effort than the “effort” test. If properly designed, an effort test should look just like all of the others. So if a person was truly malingering, wouldn’t they do poorly on all the tests, not just the “effort” tests. Yet in every single case I have every heard a defense neuropsychologist raise the malingering specter, there were subtests by my client, and usually many, many subtests, where my client did extremely well. If they were malingering, why did they do well on these tests?
Bottom line, all malingering tests are fatally flawed because there is no actual research on people who actually malingered. The research that is done is done on experimental subjects who are told to pretend to be malingered. In my favorite malingering study, the instruction to exaggerate your claims, but in a way not to get caught, was given to an equal number of brain injured persons and non-brain injured persons. In this study, it was only the brain injured persons got caught. In all other studies, the pretend malingerers were instructed to “act” like a malingerer. But a true malingerer would not want to get caught. The realities are that the only time a malingering test is ever likely to catch someone for true exaggeration, it is likely to catch a brain injured person, because they lack the judgment to do it in a way they won’t get caught.
Brain Damage Not Malingering
Yesterday’s blog about my frustrations with the refusal of the Wikipedia editor to add my two cents on the interaction between organic injury and emotional problems is symptomatic of a problem that is persuasive throughout neuropsychology: the insurance companies and their alter ego, the defense bar, are polluting the science of brain injury. The toxic words in this equation are malingering, conversion disorder and somatoform disorder. Huge sums of money are being funneled into what is being passed off as neuropsychological research from the insurance industry. The goal: to create peer reviewed literature that says that those with mild brain injury symptomotology are either faking their symptoms or are having an emotional reaction to what they experienced.
This topic is one worthy of several blogs. But essentially, more effort is being put into effort testing research, than almost all of the research that is going into the rest of the field brain injury. And the insurance industry has made it so profitable for neuropsychologists to work on the defense side of forensic cases, that neuropsychologists who went into the field with some sense of a calling, have convinced themselves that the doctrines of malingering, conversion disorder and malingering are real.
What does that have to do with a PTSD issue discussed in Wikipedia? It is a mild version of the same equation. The defense bar has what is correctly identified as a dog bite defense to brain injury cases. A dog bite defense is a multi-layered basis of denial, that each time something is proven, then retreat to the next defense.
You weren’t bitten by a dog; if you were, it wasn’t my dog; it you were bitten by my dog, it was your fault the dog bit you; if it was my dog’s fault you weren’t hurt.
Well in brain injury cases the dog bite defense is this:
There are no deficits, the plaintiff is normal; if there are deficits, then the plaintiff is malingering those deficits; if the plaintiff isn’t malingering, then the deficits are being caused by emotional problems, that the plaintiff had before the injury; if the plaintiff’s deficits didn’t exist before the injury, they are still just an exaggerated case of a somatoform or conversion disorder that a normal person wouldn’t have. If none of those other things don’t work, then call it PTSD (post traumatic stress disorder.)
If you work for the defense, NEVER, NEVER, NEVER, admit that the plaintiff had any permanent organic (meaning actual physical) damage or injury to the brain.
The ways in which these “research” studies are structured, they evaluate the plaintiff’s effort. They claim that their research validates that they can tell whether someone is malingering. That is just so much lying with statistics. No study can possibly tell that. It is impossible to tell what is in the mind of an individual. Neuropsychologists are not mind readers. In a court of law, they are most often not even allowed to comment on the credibility of a plaintiff. When you strip the cover off this claim, what they are really saying is that their super secret methodology (that no plaintiff could ever guess at) is telling them that a plaintiff didn’t give consistent “best effort” throughout the test.
I will blog on this particular topic more in the coming days, but such logic is incredibly flawed for a myriad of reasons. But one simple issue invalidates all effort testing claims: no person with brain damage could be expected to give consistent “best effort” over any battery of tests that last for hours and hours. Every single symptom of brain injury, makes it virtually impossible to maintain consistent effort for hours upon hours. I will later itemize how many of those symptoms effect consistent effort, but one common denominator has such a profound impact on effort that it alone makes effort testing a fraud: FATIGUE. Virtually everyone with brain damage, has fatigue. Fatigue makes you work slower, and progressively slower, the longer you are tested. Fatigue makes you make more mistakes. If you are working progressively slower and with progressively more mistakes, you will not be able to give consistent “best effort.”
Our next blog will examine these effort testing issues in more depth.
This topic is one worthy of several blogs. But essentially, more effort is being put into effort testing research, than almost all of the research that is going into the rest of the field brain injury. And the insurance industry has made it so profitable for neuropsychologists to work on the defense side of forensic cases, that neuropsychologists who went into the field with some sense of a calling, have convinced themselves that the doctrines of malingering, conversion disorder and malingering are real.
What does that have to do with a PTSD issue discussed in Wikipedia? It is a mild version of the same equation. The defense bar has what is correctly identified as a dog bite defense to brain injury cases. A dog bite defense is a multi-layered basis of denial, that each time something is proven, then retreat to the next defense.
You weren’t bitten by a dog; if you were, it wasn’t my dog; it you were bitten by my dog, it was your fault the dog bit you; if it was my dog’s fault you weren’t hurt.
Well in brain injury cases the dog bite defense is this:
There are no deficits, the plaintiff is normal; if there are deficits, then the plaintiff is malingering those deficits; if the plaintiff isn’t malingering, then the deficits are being caused by emotional problems, that the plaintiff had before the injury; if the plaintiff’s deficits didn’t exist before the injury, they are still just an exaggerated case of a somatoform or conversion disorder that a normal person wouldn’t have. If none of those other things don’t work, then call it PTSD (post traumatic stress disorder.)
If you work for the defense, NEVER, NEVER, NEVER, admit that the plaintiff had any permanent organic (meaning actual physical) damage or injury to the brain.
The ways in which these “research” studies are structured, they evaluate the plaintiff’s effort. They claim that their research validates that they can tell whether someone is malingering. That is just so much lying with statistics. No study can possibly tell that. It is impossible to tell what is in the mind of an individual. Neuropsychologists are not mind readers. In a court of law, they are most often not even allowed to comment on the credibility of a plaintiff. When you strip the cover off this claim, what they are really saying is that their super secret methodology (that no plaintiff could ever guess at) is telling them that a plaintiff didn’t give consistent “best effort” throughout the test.
I will blog on this particular topic more in the coming days, but such logic is incredibly flawed for a myriad of reasons. But one simple issue invalidates all effort testing claims: no person with brain damage could be expected to give consistent “best effort” over any battery of tests that last for hours and hours. Every single symptom of brain injury, makes it virtually impossible to maintain consistent effort for hours upon hours. I will later itemize how many of those symptoms effect consistent effort, but one common denominator has such a profound impact on effort that it alone makes effort testing a fraud: FATIGUE. Virtually everyone with brain damage, has fatigue. Fatigue makes you work slower, and progressively slower, the longer you are tested. Fatigue makes you make more mistakes. If you are working progressively slower and with progressively more mistakes, you will not be able to give consistent “best effort.”
Our next blog will examine these effort testing issues in more depth.
Wikipedia and Concussion
I am a lawyer, not a doctor. I carry no academic credentials as an author on brain damage. Yet, brain damage is all I do. All of my cases involve brain damage, and I interact with doctors on both side of the forensic bar, day after day. I can’t prove that it is true, but my guess is that more words of mine are read about brain damage and brain injury worldwide, than any other author. We get 50,000 visitors a month to our websites and our pages are linked on more than 6,000 other places on the internet. http://tbilaw.com is 4176 days old.
Yet, because I am a lawyer, my words only mean anything formally, when I am the one asking the questions, not doing the teaching. Despite this, years ago, I got involved in the definition of concussion on Wikipedia and was delighted that my non-scholarly words were allowed to guide people. If you have been reading this blog, you are well aware at the severe deficiencies in our medical approach to concussion, both from a treatment and a research standpoint. At least on the web, things could be better.
Well today I went back to Wikipedia, because a traffic report indicated that my page on concussion, http://subtlebraininjury.com was no longer linked there. What I found was a technically improved definition, with more than 40 references to scholarly treatment on Mild Traumatic Brain Injury. But alas, we now have a definition that is written by a committee, and a committee that has been too greatly influenced by insurance companies and doctors in their care, who are trying to fight the tide of growing understanding about brain damage following a concussion. Click here for Wikipedia’s definition of concussion.
I found these words there: “Diagnosis of concussion can be complicated because it shares symptoms with other conditions. For example, post-concussion symptoms such as cognitive problems may be misattributed to brain injury when they are in fact due to post-traumatic stress disorder (PTSD).[54] Injured people may suffer PTSD due to emotional trauma from the event, and cognitive effects of MTBI may impair a person’s ability to deal effectively with a traumatic event, potentially increasing the risk of PTSD.[54]“
This reads an awful lot like a defense neuropsychological report, and I can almost guarantee you was authored by someone who makes his living charging insurance companies $500 an hour to write 50 page reports, blaming every legitimate brain damage symptom on pre-injury psychological problems. So, I added my thoughts to the role of PTSD in brain injury diagnosis. It went up, and a minute later it came down. Someone named LeadSongDog, cut my additions, because he said it was unreferenced. Here is what was left:
I cut the following new para by User:Whipesq, as it was unreferenced:
However, PTSD is frequently over diagnosed in Post Concussion situations. Too many medical providers are using PTSD as a grab bag diagnosis to cover symptoms that appear to be more severe than the medical provider concludes they should be, based upon the verified evidence of concussion on the day of the event. Historically, PTSD is a syndrome that grew out of combat type stressors. Few, if any civilian injuries involve the same level of emotional shock (and hypervigilance) which accounts for the combat diagnosis. If, as discussed above, the concussion was under diagnosed on the day of the event, the symptoms may be consistent with a more severe injury than originally believed. The intersection of organic brain damage and emotional issue post concussion is a synergistic battleground within the mind, with both areas at risk for more severe symptoms, because of the interplay between the two. An area of study still in it’s infancy is whether brain plasticity, which has for generations been credited with positive gains in brain recovery, may be partially responsible for the poor recovery from PCS. The hypothesis here would be that during the early PCS period, the combination of cognitive difficulties, synergistically interacting with the stress and frustration of adapting to the trauma, rewires the brain in destructive ways.
The account had just been registered and I wouldn’t want to discourage a new editor. If someone can back it up with cites, some of it might be worth keeping. LeadSongDog (talk) 19:45, 7 March 2008 (UTC)
LeadSongDog is a physicist. I wonder where they taught about amnesia/PTSD/PCS in his education? I wonder if I could bring references from depositions of defense doctors?
I suppose it is fair. Wikipedia is supposed to be the people’s encyclopedia. I wonder how he got elected chair of one of the most important pieces of information on the internet?
Yet, because I am a lawyer, my words only mean anything formally, when I am the one asking the questions, not doing the teaching. Despite this, years ago, I got involved in the definition of concussion on Wikipedia and was delighted that my non-scholarly words were allowed to guide people. If you have been reading this blog, you are well aware at the severe deficiencies in our medical approach to concussion, both from a treatment and a research standpoint. At least on the web, things could be better.
Well today I went back to Wikipedia, because a traffic report indicated that my page on concussion, http://subtlebraininjury.com was no longer linked there. What I found was a technically improved definition, with more than 40 references to scholarly treatment on Mild Traumatic Brain Injury. But alas, we now have a definition that is written by a committee, and a committee that has been too greatly influenced by insurance companies and doctors in their care, who are trying to fight the tide of growing understanding about brain damage following a concussion. Click here for Wikipedia’s definition of concussion.
I found these words there: “Diagnosis of concussion can be complicated because it shares symptoms with other conditions. For example, post-concussion symptoms such as cognitive problems may be misattributed to brain injury when they are in fact due to post-traumatic stress disorder (PTSD).[54] Injured people may suffer PTSD due to emotional trauma from the event, and cognitive effects of MTBI may impair a person’s ability to deal effectively with a traumatic event, potentially increasing the risk of PTSD.[54]“
This reads an awful lot like a defense neuropsychological report, and I can almost guarantee you was authored by someone who makes his living charging insurance companies $500 an hour to write 50 page reports, blaming every legitimate brain damage symptom on pre-injury psychological problems. So, I added my thoughts to the role of PTSD in brain injury diagnosis. It went up, and a minute later it came down. Someone named LeadSongDog, cut my additions, because he said it was unreferenced. Here is what was left:
I cut the following new para by User:Whipesq, as it was unreferenced:
However, PTSD is frequently over diagnosed in Post Concussion situations. Too many medical providers are using PTSD as a grab bag diagnosis to cover symptoms that appear to be more severe than the medical provider concludes they should be, based upon the verified evidence of concussion on the day of the event. Historically, PTSD is a syndrome that grew out of combat type stressors. Few, if any civilian injuries involve the same level of emotional shock (and hypervigilance) which accounts for the combat diagnosis. If, as discussed above, the concussion was under diagnosed on the day of the event, the symptoms may be consistent with a more severe injury than originally believed. The intersection of organic brain damage and emotional issue post concussion is a synergistic battleground within the mind, with both areas at risk for more severe symptoms, because of the interplay between the two. An area of study still in it’s infancy is whether brain plasticity, which has for generations been credited with positive gains in brain recovery, may be partially responsible for the poor recovery from PCS. The hypothesis here would be that during the early PCS period, the combination of cognitive difficulties, synergistically interacting with the stress and frustration of adapting to the trauma, rewires the brain in destructive ways.
The account had just been registered and I wouldn’t want to discourage a new editor. If someone can back it up with cites, some of it might be worth keeping. LeadSongDog (talk) 19:45, 7 March 2008 (UTC)
LeadSongDog is a physicist. I wonder where they taught about amnesia/PTSD/PCS in his education? I wonder if I could bring references from depositions of defense doctors?
I suppose it is fair. Wikipedia is supposed to be the people’s encyclopedia. I wonder how he got elected chair of one of the most important pieces of information on the internet?
Brain Injury Awareness Month
EDITORS NOTE: The below press release is from the Brain Injury Association, a group all who care about brain injury should be part of.
To celebrate March as Brain Injury Awareness Month, the Congressional Brain Injury Task Force is hosting a “2008 Brain Injury Awareness Day,” on Wednesday, March 12, 2008, on Capitol Hill.
Multiple events are planned, which are designed to educate Members of Congress and their staff about brain injury. These events include an Awareness Day Fair, which will feature exhibits and informational materials from individuals and organizations working in the field of brain injury. The day will also include a Congressional Briefing focused on the topic of “Traumatic Brain Injury and Community Needs.” The end of the day will feature an early-evening Congressional Reception sponsored by various national advocacy organizations, including the National Brain Injury Treatment and Training Foundation (NBIRTT), the Brain Injury Association of America (BIAA), the National Disability Rights Network (NDRN) and the National Association of State Head Injury Administrators (NASHIA).
BIAA invites all advocates to attend “2008 Brain Injury Awareness Day” events, and help educate Members of Congress and their staff. The Day also represents an important opportunity to network with others interested in helping increase brain injury awareness.
2008 Brain Injury Awareness Day Schedule of Events
Brain Injury Awareness Fair
10:00 a.m. – 2:00 p.m.
First Floor Foyer of the Rayburn House Office Building
Congressional Briefing on “Traumatic Brain Injury and Community Needs”
3:00 p.m. – 4:00 p.m.
1116 Longworth House Office Building
Congressional Reception Celebrating Brain Injury Awareness Day
5:00 p.m. – 6:30 p.m.
2105 Rayburn House Office Building
Please RSVP by Monday, March 3, 2008, to Hope Mandel in Congressman Bill Pascrell’s office if you wish to attend and/or exhibit materials during the Awareness Fair. You may also contact Hope at (202) 225-5751 or Becky Wolfkiel in Congressman Platts’ office at (202) 225-5836 with questions or for more information. In addition, as always, you may contact Laura Schiebelhut, BIAA’s Director of Government Affairs, at lschiebelhut@biausa.org, or 703-761-0750 ext. 637, for further clarification.
To celebrate March as Brain Injury Awareness Month, the Congressional Brain Injury Task Force is hosting a “2008 Brain Injury Awareness Day,” on Wednesday, March 12, 2008, on Capitol Hill.
Multiple events are planned, which are designed to educate Members of Congress and their staff about brain injury. These events include an Awareness Day Fair, which will feature exhibits and informational materials from individuals and organizations working in the field of brain injury. The day will also include a Congressional Briefing focused on the topic of “Traumatic Brain Injury and Community Needs.” The end of the day will feature an early-evening Congressional Reception sponsored by various national advocacy organizations, including the National Brain Injury Treatment and Training Foundation (NBIRTT), the Brain Injury Association of America (BIAA), the National Disability Rights Network (NDRN) and the National Association of State Head Injury Administrators (NASHIA).
BIAA invites all advocates to attend “2008 Brain Injury Awareness Day” events, and help educate Members of Congress and their staff. The Day also represents an important opportunity to network with others interested in helping increase brain injury awareness.
2008 Brain Injury Awareness Day Schedule of Events
Brain Injury Awareness Fair
10:00 a.m. – 2:00 p.m.
First Floor Foyer of the Rayburn House Office Building
Congressional Briefing on “Traumatic Brain Injury and Community Needs”
3:00 p.m. – 4:00 p.m.
1116 Longworth House Office Building
Congressional Reception Celebrating Brain Injury Awareness Day
5:00 p.m. – 6:30 p.m.
2105 Rayburn House Office Building
Please RSVP by Monday, March 3, 2008, to Hope Mandel in Congressman Bill Pascrell’s office if you wish to attend and/or exhibit materials during the Awareness Fair. You may also contact Hope at (202) 225-5751 or Becky Wolfkiel in Congressman Platts’ office at (202) 225-5836 with questions or for more information. In addition, as always, you may contact Laura Schiebelhut, BIAA’s Director of Government Affairs, at lschiebelhut@biausa.org, or 703-761-0750 ext. 637, for further clarification.
Iraq Brain Injury Research Provides More Evidence Re the Process of Brain Injury
One of the absolute cornerstone’s to my belief system as a brain injury advocate, is that brain damage is not an immediate occurrence but part of a complex and multi-factorial process that occurs not just over minutes, but as much as 24-72 hours after the trauma. This is an issue I can almost always get defense experts to admit, but not always within the type of trauma I represent people, concussions from fall and car wrecks. Last week I was blogging on the good and the bad of the huge influx of new brain injury research coming out of Iraq, but today’s new release is clearly all positive.
In research summarized at http://www.jhu.edu/~jhumag/0208web/wholly.html#apl researchers at Johns Hopkins are saying that “Blast exposure, especially repeated exposure, can cause brain damage so subtle that soldiers may not realize they’ve been wounded. Ibolja Cernak, director of the Biomedicine Business Area at the Applied Physics Laboratory, says that these mild brain injuries can lead to gradual neurodegeneration, similar to Alzheimer’s disease.
The main researcher on this work is Ibolja Cernak, director of the Biomedicine Business Area at the Applied Physics Laboratory, at Johns Hopkins.
While there has been little controversy that blasts can cause brain damage, even without a direct blow to the head, presumably from the rapid jostling of the brain matter, inside of the skull. The Johns Hopkins story explains:
“The prevailing argument has been that waves of compressed air emanating from the blast shake the skull with enough force to strain or stretch the brain, not unlike what happens in a bad car crash. ‘It’s like a turbo-charged whiplash,” says Ross Bullock, a professor in the Department of Neurological Surgery at the University of Miami.”
But Cernak’s research posits that the blast energy is transferred in waves to the large blood vessels, which bring blood to the brain. She claims that the drastic pressure changes and rushes of blood thru these vessels from the blast, then damage the small vessels within the brain and the adjacent tissue. While not clearly more complex, analogize this to getting a bloody nose, following a series of violent sneezes.
There clearly is historical evidence to support this as an additive theory as to how the brain gets injured in combat. One of the frustrating things about modern brain injury research, is that it is done with so little historical perspective on what was known about brain damage from what I would call the “collective common sense” of centuries of working with people who were “quite right in the head” after combat. The whole concept of shell shock evolved not just because soldiers were injured by the enemies shells, but also were exposed to brain damage, from being on the sending end of shelling. Sailors on British ships of the line, were known to be at risk of getting funny, if allowed to work below deck for too long.
In research summarized at http://www.jhu.edu/~jhumag/0208web/wholly.html#apl researchers at Johns Hopkins are saying that “Blast exposure, especially repeated exposure, can cause brain damage so subtle that soldiers may not realize they’ve been wounded. Ibolja Cernak, director of the Biomedicine Business Area at the Applied Physics Laboratory, says that these mild brain injuries can lead to gradual neurodegeneration, similar to Alzheimer’s disease.
The main researcher on this work is Ibolja Cernak, director of the Biomedicine Business Area at the Applied Physics Laboratory, at Johns Hopkins.
While there has been little controversy that blasts can cause brain damage, even without a direct blow to the head, presumably from the rapid jostling of the brain matter, inside of the skull. The Johns Hopkins story explains:
“The prevailing argument has been that waves of compressed air emanating from the blast shake the skull with enough force to strain or stretch the brain, not unlike what happens in a bad car crash. ‘It’s like a turbo-charged whiplash,” says Ross Bullock, a professor in the Department of Neurological Surgery at the University of Miami.”
But Cernak’s research posits that the blast energy is transferred in waves to the large blood vessels, which bring blood to the brain. She claims that the drastic pressure changes and rushes of blood thru these vessels from the blast, then damage the small vessels within the brain and the adjacent tissue. While not clearly more complex, analogize this to getting a bloody nose, following a series of violent sneezes.
There clearly is historical evidence to support this as an additive theory as to how the brain gets injured in combat. One of the frustrating things about modern brain injury research, is that it is done with so little historical perspective on what was known about brain damage from what I would call the “collective common sense” of centuries of working with people who were “quite right in the head” after combat. The whole concept of shell shock evolved not just because soldiers were injured by the enemies shells, but also were exposed to brain damage, from being on the sending end of shelling. Sailors on British ships of the line, were known to be at risk of getting funny, if allowed to work below deck for too long.
Iraq and Brain Damage Research
One of the great advantages of working on challenging and complicated brain damage cases is that I get exposed to some of the leading neuro-scientists in the world. This year’s common denominator amongst those minds is that I know many professionals whose research is benefitting from the huge infusion of research funds for brain injury, Iraq Style. That large sums of federal dollar is now looking into brain injury is great news. And another silver lining to the tragic cloud of a whole new generation of brain damaged veterans, is the emerging media attention to the brain injuries.
But this massive research move does come with a cost, and I am not talking about huge sums of US taxpayers dollars, which of course are being thrown at this problem, because of the political ground swell to do more for our veterans. The long range cost to this may be too much research, done too quickly, by people who don’t fully comprehend the nature and scope of the civilian post concussion syndrome problem. Already, we are seeing studies that are further muddling the line of demarcation between organic brain injury and PTSD. In a combat casualty, that line would be expected to be blurred. The whole concept of PTSD is something that arose out of combat, principally the Viet Nam war.
But when you separate Post Concussion Syndrome (or Subtle Brain Injury, as I call it) from the combat situation, there are very few cases where the PTSD is even a factor. Sure you could construct a fiction that anyone who has been thru a car wreck, has a certain risk factor for anxiety from such accident – it it was in fact life threatening and there was advance warning. Take for example the person who has the half second warning as they brake before a serious head on collision. That person may have gotten the fright of his or her life from the event. But most car wrecks aren’t like that. Most are rear end collisions where there is little or no “scare” involved until the wreck is over. Anxiety causing events and PTSD (shocking events) are different.
Personally, I don’t think that PTSD should ever have really applied outside of the combat situation, except in situations with prolonged emotionally distress (such as a rape or kidnapping). But our medical community likes to pigeon hole diagnosis into neatly defined categories, and if you don’t subscribe to the theory that concussion can cause permanent damage, then you have to look around for some sort of other convenient pigeon hole. The DSM-IV, the bible of psychiatrists, is the principal tablet from above for modern medicine when the organic diagnosis is not straightforward. PTSD has very strict diagnostic criteria, which only really make sense in the prolonged shock/stress situation. So even though this is not something you would likely see in a motor vehicle wreck and certainly not in other accidents, the diagnosis appears not only in practice, but in peer reviewed literature.
However, the biggest problem in basing our next generation of diagnosis of Iraq war head injuries is that soldiers are much like young jocks: they do not accurately represent the type of person who is typically disabled by a concussion nor the type of forces a civilian is likely to endure. Soldiers are predominantly younger individuals, in good physical condition (we certainly hope so) and who are primarily male. Those disabled from concussion are predominantly over 40, female and incapable of withstanding any where near the same type of physical trauma. This has been much of the problem with basing our current generation of research on concussion and sport studies. While the good news is that this research has predominantly moved the line as to when a concussion can occur – as young jocks are far less likely to be disabled than average – they understate the potential for disability in the civilian population.
OK, now that I have vented, let me be a hypocrite and tell you what my pet project would be for all of this research money: I want them to develop a detailed, standardized questionnaire that can be administered by ER personnel to test for AMNESIA. I would like to see a protocol where every ER room would have a questionnaire that they give anyone suspected of a concussion, with questions on it, that would tell you whether such person had complete memory from the period of time 5 minutes post accident, until the period of time of the examination. And by the way, at the bottom of that questionnaire, tell the medical professional to insist that the person come back in 24 hours and be asked the same questions again. See specific to this issue, my video at http://youtube.com/watch?v=dEWHgwRywtY For a general treatment of the role of amnesia in concussion diagnosis, see the full playlist of videos on this topic at http://www.youtube.com/view_play_list?p=F4E4FC0DCD4FA2E9
The repeated followups is the standard of care to release our million dollar quarterbacks to play in the next game, it hopefully will be the evolving standard of care to allow our soldiers to return to a combat situation. It must be the standard of care before ruling out a concussion in someone far more likely to be disabled by the trauma to the brain.
But this massive research move does come with a cost, and I am not talking about huge sums of US taxpayers dollars, which of course are being thrown at this problem, because of the political ground swell to do more for our veterans. The long range cost to this may be too much research, done too quickly, by people who don’t fully comprehend the nature and scope of the civilian post concussion syndrome problem. Already, we are seeing studies that are further muddling the line of demarcation between organic brain injury and PTSD. In a combat casualty, that line would be expected to be blurred. The whole concept of PTSD is something that arose out of combat, principally the Viet Nam war.
But when you separate Post Concussion Syndrome (or Subtle Brain Injury, as I call it) from the combat situation, there are very few cases where the PTSD is even a factor. Sure you could construct a fiction that anyone who has been thru a car wreck, has a certain risk factor for anxiety from such accident – it it was in fact life threatening and there was advance warning. Take for example the person who has the half second warning as they brake before a serious head on collision. That person may have gotten the fright of his or her life from the event. But most car wrecks aren’t like that. Most are rear end collisions where there is little or no “scare” involved until the wreck is over. Anxiety causing events and PTSD (shocking events) are different.
Personally, I don’t think that PTSD should ever have really applied outside of the combat situation, except in situations with prolonged emotionally distress (such as a rape or kidnapping). But our medical community likes to pigeon hole diagnosis into neatly defined categories, and if you don’t subscribe to the theory that concussion can cause permanent damage, then you have to look around for some sort of other convenient pigeon hole. The DSM-IV, the bible of psychiatrists, is the principal tablet from above for modern medicine when the organic diagnosis is not straightforward. PTSD has very strict diagnostic criteria, which only really make sense in the prolonged shock/stress situation. So even though this is not something you would likely see in a motor vehicle wreck and certainly not in other accidents, the diagnosis appears not only in practice, but in peer reviewed literature.
However, the biggest problem in basing our next generation of diagnosis of Iraq war head injuries is that soldiers are much like young jocks: they do not accurately represent the type of person who is typically disabled by a concussion nor the type of forces a civilian is likely to endure. Soldiers are predominantly younger individuals, in good physical condition (we certainly hope so) and who are primarily male. Those disabled from concussion are predominantly over 40, female and incapable of withstanding any where near the same type of physical trauma. This has been much of the problem with basing our current generation of research on concussion and sport studies. While the good news is that this research has predominantly moved the line as to when a concussion can occur – as young jocks are far less likely to be disabled than average – they understate the potential for disability in the civilian population.
OK, now that I have vented, let me be a hypocrite and tell you what my pet project would be for all of this research money: I want them to develop a detailed, standardized questionnaire that can be administered by ER personnel to test for AMNESIA. I would like to see a protocol where every ER room would have a questionnaire that they give anyone suspected of a concussion, with questions on it, that would tell you whether such person had complete memory from the period of time 5 minutes post accident, until the period of time of the examination. And by the way, at the bottom of that questionnaire, tell the medical professional to insist that the person come back in 24 hours and be asked the same questions again. See specific to this issue, my video at http://youtube.com/watch?v=dEWHgwRywtY For a general treatment of the role of amnesia in concussion diagnosis, see the full playlist of videos on this topic at http://www.youtube.com/view_play_list?p=F4E4FC0DCD4FA2E9
The repeated followups is the standard of care to release our million dollar quarterbacks to play in the next game, it hopefully will be the evolving standard of care to allow our soldiers to return to a combat situation. It must be the standard of care before ruling out a concussion in someone far more likely to be disabled by the trauma to the brain.
Neuro Docs, the Difficulty in Keeping them Straight
I once started a lecture with this joke: the most important thing to being a brain injury lawyer, is learning how to type neuro.
It sometimes feels to me, and I am sure as often to the readers of my various web pages, that there are just too many specialities with the word neuro in them. I sometimes have a hard time sorting out the neuro this’s from the neuro thats. Sometimes the specialities can’t even agree on how to spell their speciality. Take for example, the neurootologists, who are specialists in the vestibular system. The same peer reviewed literature will spell the word: neuro-otologist, neurootologist (my preferred spelling) and neurotologists.
Any way, here is my “frontal lobe test” for myself: Name all of the neuro docs I can type in 30 seconds:
neurologist
neuropsychologist
neurootologist
neuroradiologist
If you gave me extra time, I would add… neurosurgeon, neuropsychiatrist, neurobehavioral scientist, and neurolawyer. But I am not sure that the last two are in the actual book (if there were one.)
Neurologist. Most people understand what a neurologist is – a medical doctor who specializes in the neurological system. Most people interested in brain injury don’t understand that the study of neurology is so broad that brain injury only makes up about 1% of what these doctors do. To improve your odds, try to find a “behavioral neurologist.”
Neuropsychologists – these are not medical doctors, but psychologists, who at their best are neurobehaviorists, and at their worst, are test administers, who will take the concept of lieing with statistics to obscene proportions. Neuropsychology is fundamentally based upon the theory that brain pathologies, even though they cannot be directly seen in live subjects, leave behind patterns of behavior that can pinpoint where the pathology is. In its most basic form, it is based on written tests, which will show a pattern of results, where the areas of the brain affected by the pathology, will cause the test subject to do abnormally worse on the test. But any neuropsychologist worth your time, will clearly realize that the role of neuropsychology is not to administer and interpret tests, but to do a full “neuropsychological assessement” that is not a statistical process, but an analysis of all of the “footprints of pathology”, that the written test patterns, are only a small proportion of. In the coming days, I will devote an entire blog (or perhaps series of blogs) to neuropsychology, the hope of my youth as a plaintiff’s lawyer, and the bain of my maturity as one. For more on my theory of the “footprints of pathology”, click here.
Neurootologists are doctors who specialize in the vestibular system, the remarkable and complex way in which your inner ear provides the body with a gyroscope. For more on the vestibular system, click here. Some of the best neurootologists are the ones that started as neurologists, and became more specialized in the disorders of balance and vertigo, but EMT doctors who did a fellowship in the vestibular system qualify as neurootologists as well.
Neuroradiologists are radiologists who specialize in the brain and spine. Radiologists are doctors who specialize in reading diagnostic tests such as XRay, CT scans and MRI. Most of the work of the modern neuroradiologist is in CT and especially high field strength MRI. For more on neuroradiology, click here.
Neurosurgeons are surgeons who do brain and spinal surgery.
Neuropsychiatrists are psychiatrists who cross over into the field of neurology and neurobehavior, where there is an interplay between emotional/psychiatric disease and organic processes within the brain. The irony of course in that definition is that it should apply to all brain specialties, as it is “all in the head”. Again, a topic for a blog of its own, more properly a book of its own.
Neurobehavioral scientist is somewhat my own term. I think it is the role that neuropsychologists should play, on an increasing level. The most important “footprint of pathology” is the change in a person’s behavior, and particularly that change in behavior in the real world. The problem with neurobehavioral science, is that it doesn’t reduce itself to statistical analysis, doesn’t make for definitive research studies and requires subjective analysis. Well, the reason these doctors went to school for all these years, is that they could use subjective judgment to make complicated diagnosis. The human mind is far too complex to diagnose the interplay between organic pathology and emotions, without subjective judgments of trained and experienced professionals. If you doctor is not a neurobehavioral scientist, you have the wrong doctor.
Neurolawyer? There is no such specialization, at least not a recognized one. I consider myself to be a neurobehavioral expert, but not a medical expert, nor a psychological one. I work almost exclusively in the field of brain damage, and have learned from and challenged the best medical/psychological minds in the country with my inquiries, questions and depositions. But most of what I have learned has been from you – the survivors of brain injury and the family members of those survivors. I keep learning, I keep writing, I keep asking the tough questions, the questions that because I cannot be pigeon holed into any of the above specialities, often are questions that require thought, and hopefully research to answer.
It sometimes feels to me, and I am sure as often to the readers of my various web pages, that there are just too many specialities with the word neuro in them. I sometimes have a hard time sorting out the neuro this’s from the neuro thats. Sometimes the specialities can’t even agree on how to spell their speciality. Take for example, the neurootologists, who are specialists in the vestibular system. The same peer reviewed literature will spell the word: neuro-otologist, neurootologist (my preferred spelling) and neurotologists.
Any way, here is my “frontal lobe test” for myself: Name all of the neuro docs I can type in 30 seconds:
neurologist
neuropsychologist
neurootologist
neuroradiologist
If you gave me extra time, I would add… neurosurgeon, neuropsychiatrist, neurobehavioral scientist, and neurolawyer. But I am not sure that the last two are in the actual book (if there were one.)
Neurologist. Most people understand what a neurologist is – a medical doctor who specializes in the neurological system. Most people interested in brain injury don’t understand that the study of neurology is so broad that brain injury only makes up about 1% of what these doctors do. To improve your odds, try to find a “behavioral neurologist.”
Neuropsychologists – these are not medical doctors, but psychologists, who at their best are neurobehaviorists, and at their worst, are test administers, who will take the concept of lieing with statistics to obscene proportions. Neuropsychology is fundamentally based upon the theory that brain pathologies, even though they cannot be directly seen in live subjects, leave behind patterns of behavior that can pinpoint where the pathology is. In its most basic form, it is based on written tests, which will show a pattern of results, where the areas of the brain affected by the pathology, will cause the test subject to do abnormally worse on the test. But any neuropsychologist worth your time, will clearly realize that the role of neuropsychology is not to administer and interpret tests, but to do a full “neuropsychological assessement” that is not a statistical process, but an analysis of all of the “footprints of pathology”, that the written test patterns, are only a small proportion of. In the coming days, I will devote an entire blog (or perhaps series of blogs) to neuropsychology, the hope of my youth as a plaintiff’s lawyer, and the bain of my maturity as one. For more on my theory of the “footprints of pathology”, click here.
Neurootologists are doctors who specialize in the vestibular system, the remarkable and complex way in which your inner ear provides the body with a gyroscope. For more on the vestibular system, click here. Some of the best neurootologists are the ones that started as neurologists, and became more specialized in the disorders of balance and vertigo, but EMT doctors who did a fellowship in the vestibular system qualify as neurootologists as well.
Neuroradiologists are radiologists who specialize in the brain and spine. Radiologists are doctors who specialize in reading diagnostic tests such as XRay, CT scans and MRI. Most of the work of the modern neuroradiologist is in CT and especially high field strength MRI. For more on neuroradiology, click here.
Neurosurgeons are surgeons who do brain and spinal surgery.
Neuropsychiatrists are psychiatrists who cross over into the field of neurology and neurobehavior, where there is an interplay between emotional/psychiatric disease and organic processes within the brain. The irony of course in that definition is that it should apply to all brain specialties, as it is “all in the head”. Again, a topic for a blog of its own, more properly a book of its own.
Neurobehavioral scientist is somewhat my own term. I think it is the role that neuropsychologists should play, on an increasing level. The most important “footprint of pathology” is the change in a person’s behavior, and particularly that change in behavior in the real world. The problem with neurobehavioral science, is that it doesn’t reduce itself to statistical analysis, doesn’t make for definitive research studies and requires subjective analysis. Well, the reason these doctors went to school for all these years, is that they could use subjective judgment to make complicated diagnosis. The human mind is far too complex to diagnose the interplay between organic pathology and emotions, without subjective judgments of trained and experienced professionals. If you doctor is not a neurobehavioral scientist, you have the wrong doctor.
Neurolawyer? There is no such specialization, at least not a recognized one. I consider myself to be a neurobehavioral expert, but not a medical expert, nor a psychological one. I work almost exclusively in the field of brain damage, and have learned from and challenged the best medical/psychological minds in the country with my inquiries, questions and depositions. But most of what I have learned has been from you – the survivors of brain injury and the family members of those survivors. I keep learning, I keep writing, I keep asking the tough questions, the questions that because I cannot be pigeon holed into any of the above specialities, often are questions that require thought, and hopefully research to answer.