by the legal times staff
thelegaltimes.net
Many years ago I suffered a “mild brain injury” which resulted in a seizure disorder. It’s one of those hidden disabilities which are so popular in the news currently. I can function in a crowd, for short periods of time. Overload is an ongoing problem which I have used many different strategies to overcome. My comfort zone has been to avoid anything confusing, busy, noisy or new…but I am not one to give up.
Brain injury is a dilemma for those who suffer from it. You can’t take an hour to explain to people you meet what sets you off, or what overwhelms you. Most of the time you have to just do the best you can.
Some years ago I began Tae Kwon Do classes. During one of the first classes, in the midst of a class routine, I seized. I have the kind of petit mal seizures that allow me to still hear everything going on around me, but I lose the ability to respond. My instructor asked if I was all right and in a moment I was and went on with the class, slightly embarrassed that I just appeared to have something mentally wrong with me. It’s the sort of embarrassment that often defeats those with brain injury…but I prevailed.
I cleverly learned never to position myself where I could see the class in the mirrors…my mind couldn’t process the double load of visual information. I learned that even if I couldn’t absorb a complicated routine on the first run through when everyone else was getting it, the next time I would come back with the information totally processed and be fine. I learned not to panic when I couldn’t filter out the instructor’s voice in a room full of background noise. I became hyper-observant. Over time I developed very complicated coping skills all designed to hide the fact that something was “wrong” with me. I earned my black belt and a heightened control over the seizures, panic and need to withdraw which I started with.
Last summer it was sort of brought to mind again as I took my dog through agility classes. I would listen very carefully to instructions, overworking to filter out the noise around me, and then find that listening didn’t mean processing. It’s somewhat lucky I had a smart dog, she usually picked up on what expectations were before I did. We always came back strong the following class when we both were on the same page. It helped to have a dog to turn to when the overload became too much, she became a convenient time out. We would go home and I would crash, totally exhausted by having to be so hyper-attentive. Much like the exhaustion that came after a karate class.
I was proud of myself for working through coping strategies which enabled me to tackle some pretty major accomplishments. In the end, it didn’t make the brain injury disappear. In some ways it made it harder to live with. People look at the accomplishments and not the effort it took to get there against all odds.
What they don’t see is the toll those efforts took, the amount of “down time” needed to recuperate, the hours I spent in total quiet to give an overworked and low frustration level brain time to recharge. They see independence in the isolation I maintain. They don’t see the meltdowns from overload, because I maintain that isolation. They don’t see how one thing can throw me off track for days. I have learned to cover, hide, avoid and conceal very well. I have even learned it is better to be quiet, because the seizures aren’t so noticed when they do occur. I have hit upon a definition of “normal” that I can live with.
In a world where the press is finally addressing the devastation brain injury can have on an individual, I still wonder if the majority of those affected don’t follow the easier course of creatively coping with their deficits? After all, you’re not likely to advise a prospective employer of your lack of ability to concentrate or tell a potential date that you have a brain injury and sometimes have issues with emotional response. It’s not only a hidden disability, it carries with it the fear of being labeled as “different”. Social awareness is a two-edged sword when it comes to brain injury. The public has been given enough information to acknowledge it exists and not enough information to understand how profoundly it affects the individual living with it.
Patterns of Footprints of Brain Injury
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.
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.
What is a Mild Brain Injury?
Head injuries (or otherwise called brain injuries) have been traditionally classified into three categories, mild, moderate and severe. Mild head injuries are typically brain injuries that do not involve loss of consciousness for more than 20 minutes. Moderate involve significant loss of consciousness, but not do not involve extended coma. Severe brain injuries are those that involve a coma for a substantial length of time. For our treatment of severe brain injury, see http://waiting.com
The problem with these classifications schemes that define the severity of the brain injury in terms that relate to a period of loss of consciousness, is that they severely understate the risk factors associated with mild brain injury. Mild brain injury, which is also synonymous with concussion, can leave a person completely and totally disabled. Even though a brain injury may not involve a significant disruption of the part of the brain that triggers consciousness, it can involve severe damage to either specific parts of the cerebral cortex, or disruptive damage to the white matter of the brain.
Focal versus Diffuse Brain Damage. Brain injury is usually broken out into two geographic classes, focal and diffuse. A focal brain injury involves damage to a specific area of the brain, and in mild brain injuries, this can be a very small area. Diffuse damage means the damage is spread out throughout the brain, but the pathology in any one area is large enough for specific pathology in that one area to be identifiable.
Mild Focal Injury. Again the term mild here is something of a misnomer. The type of focal injury which would be classified as mild, would typically be a focal injury that does not involve a significant portion of one of the major lobes of the brain, but can still be identified as existing, because it has compromised a specific function of that particular part of the brain. Most of the significant mild focal injuries, involve injuries to the frontal lobes, particularly the underside of the frontal lobes. The reason these relatively small areas of damage can become disabling, is that the underside of the brain hold particularly important functions in terms of adult like behaviors and productivity.
Diffuse Injury. Diffuse injury to the white matter is referred to as diffuse axonal injury. An axon the long skinny wire like part of a neuron, that transmits the electrical impulse from the cell nucleus of the neuron, to the next part of the brain or nervous system, that must receive that signal, for the appropriate function to occur. Neuron’s are microscopic, and axons, even smaller. Typically an axon can only be seen by an electronic microscope. While there are massive numbers of these microscopic axons transmitting signals throughout the white matter of the brain, injury to even thousands of these axons in the same area, may not be concentrated enough pathology for it to show up on even a high resolution MRI. For more information on Diffuse Axonal Injury, click here.
Most of the controversy in brain injury cases involves battles about whether or not a mild brain injury even occurred and if so, whether it was severe enough to leave any last deficits. The reason such controversy exists is that most mild brain injuries do not involve clear cut loss of consciousness. For most of the 20th century, a identifiable loss of consciousness was required in order for there to be the diagnostic possibility of a brain injury. While this issue began to change as considerable research on axonal injury evolved between 1971 and 1990, the significant definition change occurred in 1992, with the publishing by the American Congress of Rehabilitation Medicines definition of Mild Traumatic Brain Injury. See http://subtlebraininjury.com/noloc.html
“It is not necessary to have a loss of consciousness to suffer permanent brain injury.”
Source: Definition of Mild Traumatic Brain Injury Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. J Head Trauma Rehabil 1993:8(3):86-87
In that definition, loss of consciousness was only one of four acute symptoms, that could form the basis of a diagnosis of concussion or MTBI. Those four events are:
Loss of Consciousness (of less than 20 minutes);
A change in mental state;
Amnesia, for events both before OR after the event; or
Focal neurological deficits.
With this 1992 definition, the medical community began to look at brain injury differently, and in subsequent years, the American Academy of Neurology and the CDC, adopted similar definitions. Now, no recognized organization still maintains the Loss of Consciousness is a prerequisite for a diagnosis of brain injury, but there are still holdouts. One of the challenges of being a brain injury attorney, is finding ways to get defense neurologists to admit that what it says in the old textbooks about loss of consciousness, is no longer good medicine or good science.
This discussion here has used the classical term of mild traumatic brain injury. However, this has been used strictly in the context of the definitional scheme that is laid out throughout our three tiered classification of brain injury. I have been since creating the web page http://subtlebraininjury.com in 1999, using the word subtle brain injury© to describe MTBI.
The problem with these classifications schemes that define the severity of the brain injury in terms that relate to a period of loss of consciousness, is that they severely understate the risk factors associated with mild brain injury. Mild brain injury, which is also synonymous with concussion, can leave a person completely and totally disabled. Even though a brain injury may not involve a significant disruption of the part of the brain that triggers consciousness, it can involve severe damage to either specific parts of the cerebral cortex, or disruptive damage to the white matter of the brain.
Focal versus Diffuse Brain Damage. Brain injury is usually broken out into two geographic classes, focal and diffuse. A focal brain injury involves damage to a specific area of the brain, and in mild brain injuries, this can be a very small area. Diffuse damage means the damage is spread out throughout the brain, but the pathology in any one area is large enough for specific pathology in that one area to be identifiable.
Mild Focal Injury. Again the term mild here is something of a misnomer. The type of focal injury which would be classified as mild, would typically be a focal injury that does not involve a significant portion of one of the major lobes of the brain, but can still be identified as existing, because it has compromised a specific function of that particular part of the brain. Most of the significant mild focal injuries, involve injuries to the frontal lobes, particularly the underside of the frontal lobes. The reason these relatively small areas of damage can become disabling, is that the underside of the brain hold particularly important functions in terms of adult like behaviors and productivity.
Diffuse Injury. Diffuse injury to the white matter is referred to as diffuse axonal injury. An axon the long skinny wire like part of a neuron, that transmits the electrical impulse from the cell nucleus of the neuron, to the next part of the brain or nervous system, that must receive that signal, for the appropriate function to occur. Neuron’s are microscopic, and axons, even smaller. Typically an axon can only be seen by an electronic microscope. While there are massive numbers of these microscopic axons transmitting signals throughout the white matter of the brain, injury to even thousands of these axons in the same area, may not be concentrated enough pathology for it to show up on even a high resolution MRI. For more information on Diffuse Axonal Injury, click here.
Most of the controversy in brain injury cases involves battles about whether or not a mild brain injury even occurred and if so, whether it was severe enough to leave any last deficits. The reason such controversy exists is that most mild brain injuries do not involve clear cut loss of consciousness. For most of the 20th century, a identifiable loss of consciousness was required in order for there to be the diagnostic possibility of a brain injury. While this issue began to change as considerable research on axonal injury evolved between 1971 and 1990, the significant definition change occurred in 1992, with the publishing by the American Congress of Rehabilitation Medicines definition of Mild Traumatic Brain Injury. See http://subtlebraininjury.com/noloc.html
“It is not necessary to have a loss of consciousness to suffer permanent brain injury.”
Source: Definition of Mild Traumatic Brain Injury Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. J Head Trauma Rehabil 1993:8(3):86-87
In that definition, loss of consciousness was only one of four acute symptoms, that could form the basis of a diagnosis of concussion or MTBI. Those four events are:
Loss of Consciousness (of less than 20 minutes);
A change in mental state;
Amnesia, for events both before OR after the event; or
Focal neurological deficits.
With this 1992 definition, the medical community began to look at brain injury differently, and in subsequent years, the American Academy of Neurology and the CDC, adopted similar definitions. Now, no recognized organization still maintains the Loss of Consciousness is a prerequisite for a diagnosis of brain injury, but there are still holdouts. One of the challenges of being a brain injury attorney, is finding ways to get defense neurologists to admit that what it says in the old textbooks about loss of consciousness, is no longer good medicine or good science.
This discussion here has used the classical term of mild traumatic brain injury. However, this has been used strictly in the context of the definitional scheme that is laid out throughout our three tiered classification of brain injury. I have been since creating the web page http://subtlebraininjury.com in 1999, using the word subtle brain injury© to describe MTBI.