NFL Vet Kyle Turley, Showing Signs Of Brain Damage, Crusades To Make League Help Players Like Himself

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Posted on 13th June 2010 by Gordon Johnson in Brain Injury

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 Former Kansas City Chief Kyle Turley was the Ben Roethlisberger of his day. After sustaining several bad concussions playing, Turley began having what you could call anger-management issues and acted erratically.

http://profootballtalk.nbcsports.com/2009/09/18/kyle-turley-experiencing-potentially-serious-brain-issues/

He will always be remembered as the player involved in the infamous helmet-throwing incident when he was playing for the New Orleans Saints in a game against the New York Jets in 2001. Trying to protect the Saint’s quarterback,  Turley pushed  Jets safety Damien Robinson to the ground, ripped off his helmet and threw it across the football field. 

http://nfl.fanhouse.com/2010/05/20/helmet-tossing-kyle-turley-goes-country-to-settle-scores/

Turley was tossed out of the game, fined $25,000 by the Saints and ordered to take anger management courses.

Today it would hard to find any former player more active than Turley in the battle to make the National Football League really try to help present and former players who have brain injury.

 It makes sense that Turley is championing this fight,  because it looks his concussions have had a permanent impact on his brain. Last August he collapsed in a club, and later went in and out of consciousness. Now doctors suspect he may be showing the first symptoms of Chronic Traumatic Encephalopathy, a degenerative neurological disease that contributed to the deaths of ex-NFL players Andre Water and Justine Strezelczyk.

http://sports.yahoo.com/nfl/news?slug=ms-thegameface091809

Turley is a textbook case of how concussions might impact a player’s behavior, and not for the better. The helmet- tossing incident was not his only embarrassing moment in football.    

 After suffering a severe concussion in 2003 when he was playing for the Los Angeles Rams, Turley went into the locker room, took a shower and was sitting by his locker naked when team owner Georgia Frontiere came in. He stood up and gave her a big hug, standing there stark naked.  

 In a recent exclusive interview with the blog Arrowhead Addict,  Turley offered some talk about his problems after sustaining head injuries, why he’s donating his brain to research on head trauma, and about how the NFL has failed for so long to admit the relationship between football-related-brain injury and later brain disease.

http://arrowheadaddict.com/2010/06/08/aa-exclusive-interview-with-former-chief-kyle-turley/

Turley testified before a Congressional committee last fall about his experiences, and lack of proper care, after sustaining numerous head injuries while playing for three NFL teams.  He didn’t like what he heard when he was in Washington from the NFL and still doesn’t think the league is taking its responsibility to stop brain injury and help players very seriously.  

Turley, who is now pursuing a music career in Nashville, told Arrowhead Addict that he agreed with prior remarks by Terry Bradshaw, namely that the NFL has been reactive, not proactive, in terms of dealing with the repercussions of player brain trauma.

At the hearings on the NFL and brain injury, Turley recalled watching a league doctor deny that football was the cause of long-term brain injury in players.

 ”So many guys have gone without being approved for disability and having the ability to get treatment,” he told the blog. “Guys have died, guys that were great players in this game, you know Andre Waters and Justin Strzelczyk and a few other guys that have had the same, I mean, Mike Webster had the same brain trauma as Justin Strzelczyk and Andre Waters and these others. The long-term effects from playing the game of football. There’s no question that there’s a direct relationship….To deny that this evidence exists and deny that there is any relation to these issues from football was offensive and shows exactly the NFL’s stance on the matter.”

Turley is one of a number of  ex-NFL players who have agreed to donate their brains to the Boston School of Medicine, which is creating a bank of brains to examine as part of its research on head injury and future brain disease. That research may spare potential future players, like his 1-year-old son, from the  brain trauma and the anger-management problems that Turley has lived with, he said.  

 ”I’ve suffered some issues with my feelings with my head injuries from football and its been difficult for me to deal with certain things and it has caused me to have take different medications and all kinds of other things that I don’t want my son to have to do,” he told Arrowhead Addict.

  The NFL in April donated $1 million to help fund BU’s brain-injury research. Whether it was a PR stunt or genuinc gesture  on the part of the league remains to be seen.  

 Besides, Turley pointed out that $1 million is not a lot of money for the NFL to ante up.

“If they want to make a dent in this thing the NFL’s going to have to commit some serious dollars to this research so that they can come up with solutions and not just play this fame,”  Turley said in his blog interview.   

 

Congressman Skewers College Football Conferences For Their Lenient Concussion Guidelines

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Posted on 2nd February 2010 by Gordon Johnson in Brain Injury

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A member of the House Judiciary Committee Monday blasted the Southeastern Conference and the Big 12 over their policies regarding student athletes and concussions, according to the Associated Press.
http://www.nytimes.com/2010/02/02/sports/football/02concussions.html

Rep. Steve Cohen, D-Tenn., levied the criticism during a hearing in Houston on head injuries and college football. Specifically, Cohen questioned why major college football conferences had not adopted rules on dealing with concussions that went beyond what the National Collegiate Athletic Association requires, according to AP.

During the hearing, Cohen raised the question during his discussion with Ron Courson, who is director of sports medicine at the University of Georgia and part of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports.

Cohen “seemed incensed,” according to AP, when Courson said that none of the conferences had tougher regulations regarding concussions than the minimums mandated by the NCAA.

Cohen accused the college athletic programs of caring about “money, money, money,” AP reported.

On Monday there was also testimony by Texans guard Chester Pitts, who told the committee that he hopes his 3-year-old son Chester III never plays pro football, The Houston Chronicle reported in a very comprehensive story.
http://www.chron.com/disp/story.mpl/sports/fb/texansfront/6846505.html
Pitts said that NFL football was “too rough a game,” according to the Chronicle. He played 112 NFL games without missing a start.

Pitts testified that he sustained his worst head injury while playing for San Diego State, and that the team hid his helmet to stop him from returning to the game, the Chronicle reported.

And former Rice University running back Trevor Cobb testified Monday that he had at least six concussions when he was playing football in high school, Rice and the NFL.

Monday’s hearing, held at the Prairie View A&M; College of Nursing, was the third one held by the House committee on brain injury and sports. It dealt with high school and college athletes. The first two hearings dealt with the NFL and its policies regarding concussions and players.

Neuropathologist Dr. Bennett Omalu, co-founder and director of the Brian Injury Research Instistute of West Virginia University, also testified in Houston Monday. He is a pioneer in linking concussions from football to permanent brain damage in players.

Omalu recommended that youths under 18, whose brains are still developing, should not be allowed to play until at least three months after concussion, so they won’t sustain permanent brain damage from additional hits on the field, the Houston Chronicle reported.

NFL and Concussion Hearings – Neurologist Joseph Maroon of Pittsburg Testimony

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Posted on 13th January 2010 by Gordon Johnson in Brain Injury

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Among those testifying at Congressional hearings on the NFL and Concussion was Joseph Maroon, M.D., of the Department of Neurosurgery at the University of Pittsburgh Medical Center. The hearings were held in Detroit on January 4, 2010. Maroon is also the Team Neurosurgeon, The Pittsburgh Steelers and has been on the NFL _s Mild Traumatic Brain Injury (MTBI) Committee since it was created in 1994.

Maroon called the Congress’s attention to what advances in the way in the NFL treatment of concussion since 1994. He said in his prepared remarks:

Our committee was specifically charged in 1994 with initiating and supporting independent scientific research to further the understanding of the causes, diagnosis, treatment and prevention of concussion.

This work has involved research on helmet standards, injury data collection and analysis, and an ongoing study of the long _term effects of concussions on NFL players. As a result, the NFL in recent years has initiated educational and preventive measures, guidelines for the management of concussions, and rule changes to eliminate unnecessary hits that can lead to concussions. Since the formation of the committee in 1994, there has been a significant positive culture change in the NFL on the issue of concussions. I have personally witnessed this culture change among NFL teams and players and I am confident that it will continue in a positive direction.


Clearly there was insufficient culture change between 1994 and 2009, to make a significant difference, which is why the hearings in October of 2009 caused such a stir. Maroon commented on the changes since October:

I am here today to report on additional steps relating to concussions that the NFL has taken since the October 28 hearing. The long _running arc of improvement continues.

The NFL now has stricter return _to _play guidelines. It includes the addition of an independent neurological consultant for each team approved by the medical advisors of the NFL and the NFL Players Association. The 2009 statement on return to play says that a player who suffers a concussion should not return to play or practice on the same day if he shows any signs or symptoms of a concussion. It also states that once a player is removed for the duration of a practice or game, he should not be considered for return _to _play activities until he is fully asymptomatic, both at rest and after exertion, has a normal neurological examination, normal neuropsychological testing, and has been cleared to return by both his team physicians and the independent neurological consultant.


If you read the above statement carefully, it really makes no sense. If a player suffered a concussion, by definition if a player “suffers a concussion” he would show a sign or symptom of concussion. What Maroon left out, is sign or symptom of a concussion at what point. As a football fan, I understand the enormity of keeping a star player out of a game, potentially a playoff game, because he was knocked woozy on one play. But if you are going to provide a guideline, then provide it. If there is any return to play after a concussion in the same game, then you must clearly state at what point in time, 15 minutes, 30 minutes, a quarter of the game, the symptoms must have cleared.

My biggest quarrel with what Maroon states here is the abandonment of the stated time period of not returning if the player is found to have the “signs or symptoms of a concussion.” Most sport and concussion guidelines specific 7 days or longer period for the concussion that is still symptomatic for more than a short period of time after the original injury. The best part of the guidelines is putting that finite “no play” period because it required the serial follow-ups, that are the most sensitive determination of the severity of a concussion. Leaving the finite “no play” time period out, guts the guidelines.

Maroon did get it right when he addressed the most serious problem in implementing the any guidelines, changing the culture of the sideline, the locker room so that players aren’t short sighted or intimidated into not fully reporting concussions. He stated:

The 2009 statement also addresses the responsibility of the players. It states that players are encouraged to be candid with team medical staffs and fully disclose any signs or symptoms that either they themselves or their teammates are showing that may be associated with a concussion. The nature of concussions, which can be difficult to diagnose in the absence of loss of consciousness, places an important responsibility on players to put their health above competitive considerations. This is the policy of the league with respect to its teams _ medical decisions must override playing considerations _ and it is extremely important that the players commit to meeting that standard.

In December, the NFL, in conjunction with the Centers for Disease Control (CDC), produced a public service messaged directed primarily at young athletes and their parents and coaches on the importance of head injury awareness. The theme is _Take Head Injuries Out of Play _ and the message has been airing and will continue to air on NFL game telecasts throughout the playoffs. This PSA also was sent to a group of conference commissioners of college sports so that they could adapt for their use on
television and with their athletes.


According to Maroon, the NFL is trying to make a difference outside of its own games:

In addition, the NFL is working with the CDC and other organizations on educational material for young athletes and high school coaches, and to develop an overall certification program for coaches at those levels addressing player health and safety.

Further, John Madden, in his role as a special advisor to Commissioner Goodell, is chairing a committee of coaches that is exploring ways of providing players with a safer environment to reduce the risk of head trauma in practices.



All positive steps. The biggest step is the publicity that these hearings have created on one simple theme: Concussion can be serious.

Congressional NFL Hearings – Dr. Randall Benson Testifies about Neuroimaging Advances – Diffusion Tensor Imaging

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Posted on 8th January 2010 by Gordon Johnson in Brain Injury

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In my search for the holy grail of objective proof of brain damage in those with Post Concussion Syndrome, I try to stay as current as possible on neuroimaging advances. Yesterday I focused on Dr. Randall Benson’s testimony with respect to Susceptibility Weight Imaging. Today I will focus on Diffusion Tensor Imaging, DTI.

As a professional who works exclusively in the field of brain injury I believe that DTI may offer more short term benefit in diagnosing Mild Traumatic Brain Injury (“MTBI”). The reason is that MTBI appears to be more a syndrome with attentional and processing problems which are white matter dependant functions and DTI is primarily a white matter test.

Briefly, the grey matter of the brain is primarily on the cerebral cortex of the brain and is where our memories are stored and our higher thought processes likely are centered. The white matter is the axonal fibers that connect different parts of the grey matter of different sections of the brain to each other. White matter is what allows the different brain cells to work together. A white matter injury will most often manifest itself with the attentional and processing problems easiest to prove after a concussion. Post Concussion Syndrome is far more complex than attention and processing problems, but those are the functions where there is the most consistent change across the wide range of PCS patients. For more on Diffuse Axonal Injury see http://subtlebraininjury.com/diffuse.html

Axons are extremely small. It is unlikely that neuroimaging will ever get to the point where we can see actual axonal damage in a live person. However, most axons travel through axonal pathways, which because they include tens of thousands of axons, are visible. DTI is an imaging technique that can visualize the axonal tracts. When there has been a significant disruption of any one axonal tract in the brain, DTI may show that disruption. The reason that DTI doesn’t tell us everything we want to know is that like all other imaging techniques in a live brain injured person, it is limited by the resolution of the scanner, which generally can only see pathology of as small as one millimeter.

In the image below, you can see a DTI scan with respect to the corpus callosum fiber tracts in the brain:



Dr. Benson explained DTI in his testimony this way:

Diffusion Tensor Imaging

Developed in the mid-1990’s, diffusion tensor imaging (DTI) is sensitive to the 3D flow of water inside and outside of white matter fibers (the long extensions from nerve cell bodies which connect nearby or distant cells). Closed head injuries (non-penetrating) including concussion are caused by sudden acceleration or deceleration of the head which causes local deformationsof the brain within the cranium. The anatomical and biomechanical properties of the brain are such that white matter fibers are stretched and damaged, resulting in diffuse axonal injury (DAI) which is the hallmark pathology and accounts for most of the neurological disability in TBI.

The typical cognitive deficits in TBI, i.e., slowed information processing, decreased attention and memory, and psychiatric symptoms are caused by damage to the “cables” which allow for efficient transmission of information between neurons. TBI reduces brain network efficiency resulting in decreased capacity and global functional impairment. Concussive injury such as occurs in football with high speed collisions also causes deformation of brain substance and is felt to account for many of the immediate and delayed symptoms including the post-concussive syndrome. ERP studies of sports related concussion suggest that symptomatic recovery may occur while neurologic and brain metabolic functioning continues to be impaired from weeks to months after injury.

Incurring a second concussion before neurologic recovery has been shown to worsen outcome and may begin a downward spiral culminating in chronic traumatic encephalopathy (CTE) but this is not known. Diffusion tensor imaging (DTI) is able to detect damaged white matter fibers (axons) which have altered flow of water molecules compared with healthy axons (see Figure 5). DTI, like SWI can be performed on a standard clinical scanner (1.5-3 Tesla) and is available on virtually all clinical scanners.


According to Dr. Benson, DTI is showing abnormalities in mild traumatic brain injury survivors.

Our initial investigation of DTI in 20 TBI cases found that (similar to SWI and hemorrhage) an index of DTI, fractional anisotropy (FA), is decreased uniformly in TBI compared with 14 controls (see Figure 6), and that the magnitude of the decrease in average FA for global white matter is highly correlated with TBI severity (Figure 7). Even the 6 mild TBI cases (GCS 13-15)had decreased FA compared with the controls. The separation of the milds from the controls is especially relevant to sports concussions where the great majority of injuries are mild.

In summary, DTI is able to “visualize” diffuse axonal injury from TBI. In some cases location of lesions appears to correlate with specific symptoms but generally the severity of DAI as indicated by DTI is strongly predictive of general neurocognitive disability. Since concussion produces axonal injury, particularly repetitive concussion, imaging with DTI would appear to be ideal to study NFL players. Certainly, a large scale cross-sectional study wherein head injury history, position, age, genetic risk (ApoE genotype), neuropsychological testing (focused) and possibly electrophysiological testing with EEG (ERP, qEEG) and PET are factors. In addition, a prospective study with serial scans over a player’s career, tracking concussions or hits and relating imaging to neurocognitive performance (IMPACT or similar) and other factors as in cross-sectional study. Imaging would also facilitate the evaluation of helmet and neck support designs in animal models and in the field.



In our next blog, we will focus on the value of using NFL players and other sport concussion survivors as the prototype for all concussion diagnosis and treatment.

Congressional NFL Hearings – Dr. Randall Benson Testifies about Neuroimaging Advances – Susceptibility Weighted Imaging

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Posted on 7th January 2010 by Gordon Johnson in Brain Injury

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As I have stated here and elsewhere, diagnosing accidental concussions involves reconstructed evidence and the reliance on history from someone who likely has memory problems as to what happened, because they were concussed. In contrast to football or boxing concussions, real world concussions are rarely witnessed in the critical 30 second time window when the evidence is the clearest. See today’s blog at http://www.subtlebraininjury.com/blog/2010/01/evolution-in-understanding-of_07.html

Thus, with such an imperfect diagnostic process I am always hoping that the newest neuroimaging technique can provide us with a bright light of “objective evidence” of injury. I have heard Dr. Randall Benson speak and his state of the art imaging techniques are the most promising of any of those I have seen to date. Dr. Benson testified to Congress about the advances being made in those techniques, principally through new ways of using the familiar MRI scanner.

Dr. Benson testified principally to two state of the art methods of using MRI, Diffusion Tensor Imaging (“DTI”) and Susceptibility Weighted Imaging (“SWI”).

Dr. Benson said in his prepared remarks:

Most of our work has used victims of transportation related injuries and falls, however our principle research focus has always been closed head injury, under which concussion falls and is otherwise known as mild head injury. I will also include some examples of former players scans. The focus of my testimony will be susceptibility-weighted imaging (SWI) and diffusion tensor imaging (DTI).


I have been using DTI for years now in our forensic cases, with significant success, but SWI is something new to me. Dr. Benson explained SWI as follows:

Susceptibility-Weighted Imaging (SWI) Imaging research of TBI began at WSU in 2004 when an eleven year old boy (C.G.) survived after his family’s ATV skidded off a mountain road in Colorado plunging 200 ft. He was still in coma two months later when we scanned him at WSU. His CT and standard MRI revealed a skull fracture and atrophy but not much more. Figure 1 compares a standard, clinically available T1-weighted image with a susceptibility-weighted image (SWI) through the temporal lobes and brainstem for C.G. sixty days after injury. Note the many “black holes” present in the
SWI image which are small (“micro”) hemorrhages indicating severe diffuse axonal injury (DAI) from TBI.

Developed by Mark Haacke, SWI is extremely sensitive to iron and blood products and detects microhemorrhages where conventional MRI fails. SWI detects hemorrhage at all stages, since iron remains even after the fluid from blood is reabsorbed. Prior work by Dr. Haacke with Loma Linda University (Karen Tong, M.D.) had demonstrated the value of SWI for detecting DAI in children with “shaken baby syndrome” where it was five times more sensitive than gradient echo imaging. In a series of 20 TBI patients (transportation related and falls) varying in severity and elapsed time since injury, we found an excellent correlation (Ρ =0.54) between total hemorrhage volume and the number of days in post-traumatic amnesia which is known to be a good T1‐Weighted SWI predictor of one-year neurological outcome (JMRI, 2009). We have, since 2004, scanned over 100 TBI patients with SWI at WSU alone and a similar number at Loma Linda. In addition to TBI, it is being used in stroke, cerebral amyloid angiopathy (CAA) (Figure 2), Alzheimer’s disease and disorders of iron metabolism. SWI is now clinically available on GE and Siemens MRI scanners.

Every few years, I get newly excited about a neuroimaging technique that will give us a bright line of diagnosis for those with long term problems after a concussion. In 2000 what gave me great hope was learning about the development of techniques to see hemosiderin staining, principally the technique Gradient Echo Imaging. The theory of Gradient Echo Imaging is that when bleeding in the brain occurs, it leaves behind iron deposits, even after the there is no liquid blood visible on a CT or MRI. Those iron deposits are the hemosiderin. The hemosiderin is highly magnetic because it is principally iron. So if the magnet in the MRI is tuned precisely, this imaging technique can show evidence of a non-acute bleed, in theory years after the original injury. Here is a comparison between a conventional MRI image and the SWI image. The SWI is on the right and of import is the small black circles which don’t appear on the image to the left.

Figure 1. Comparison of T1 and SWI images for C.G. Note the many dark
“holes” in the SWI image that are not present on the T1 weighted image. These
“black holes” are caused by signal loss induced by paramagnetic hemoglobin or
other iron containing blood products.


It was exciting when I learned about Gradient Echo Imaging. It has not had any actual value in my cases. The exciting news about SWI is that it is five times more sensitive than Gradient Echo Imaging. The challenge in neuroimaging is whether five times better is enough when you are talking about multiplying zero. The math analogy isn’t totally valid, but if no hemosidrin deposits show up on even disabling mild traumatic brain injury cases, it may very well be that the kind of bleeds that leave hemosiderin behind are not the principal culprit in the Post Concussion Syndrome. Time will tell.

Diffusion Tensor Imaging (DTI) is more focused at the likely pathology, injury to the axons. We will discuss Dr. Benson’s testimony about DTI in our next blog.

Congressional NFL Hearings – Dr. Ronald Benson Testifies about Neuroimaging Advances

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Posted on 6th January 2010 by Gordon Johnson in Brain Injury

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I began my treatment of the Congressional hearings on the long term brain damage of concussion in the NFL yesterday at my Brain Injury Lawyer Blog – http://www.waiting.com/blog/2010/01/nfl-concussion-hearings-in-congress.html I will continue that discussion on this blog for the next several blogs, as I tackled an even more important topic at http://waiting.com/blog that of why an experienced brain injury attorney is even more important in a severe brain injury case than it is in a non-coma brain injury case.

Much of the controversy at the hearings was over the statements of Ira. R. Casson, M.D., formerly co-chair of the NFL concussion committee, that there was insufficient scientific evidence to prove this narrow question: Whether playing NFL football causes permanent brain damage. Fortunately, Dr. Casson’s academic skepticism was not the sole testimony heard by the committee. The committee also heard about evolving neuro-imaging techniques in the diagnosis of concussion, principally from Ronald Benson, M.D. of Department of Neurology, Wayne State University Medical School. Dr. Benson’s prepared remarks begin much differently than Casson’s:

I would like to share with you some observations from eight years of evaluating traumatic brain injury cases, the vast majority of which I obtain neuropsychological testing and advanced MRimaging:
  • 1) People with TBI are frequently misdiagnosed, often by multiple physicians;
  • 2) The most frequent diagnostic category given is psychiatric—anxiety, depression, conversiondisorder;
  • 3) Two neuropsychologists studying the same patient may differ considerably regarding existence of TBI;
  • 4) TBI symptoms overlap considerably with those of “primary” psychiatric disorders;
  • 5) Without the ability to “see” the brain injury with imaging, there is no completely objective way to determine what is TBI and what is something else, e.g., posttraumatic stress, conversion, malingering;
  • 6) People with brain injury seem to vary considerably in severity of symptoms and recovery in the face of similar falls, crashes, etc. This may speak to population differences in resistance to injury or effectiveness of neural recovery mechanisms and is in agreement with Collins, et al. who found large differences in recovery from single concussion (North American Brain Injury Society Annual Meeting, 2009);
  • 7) Advanced MR imaging techniques, including susceptibility-weighted (SWI), diffusion tensor (DTI) and MR spectroscopy (MRSI) are able to reveal brain injuries where CT scans and conventional MRI appear normal.
That was a hell of an introductory statement from Dr. Benson. He seemed to capture the challenge in representing the survivors of brain injury in those seven bullet points. He goes on to detail the excitement of using state of the art MRI techniques to diagnosing mild traumatic brain injury, which I will discuss in future blogs. But today, I want to focus on the first six bullet points.

1. Misdiagnosis. Frankly all six points could all be summarized with the statement that because the diagnosis of TBI is subjective, that misdiagnosis of the existence and severity of brain injury is the norm.

2. TBI is Often Labeled Psychiatric. I have said this before and will say it again: The challenge in diagnosing and treating brain injury is not in afixing a label of organic or psychiatric on the symptoms, but on treating the entire spectrum of brain related disability. Any TBI diagnostician who labels an emotional symptom after concussion as psychiatric or pre-existing, is missing the point. Brain injury impacts the emotions and those with pre-existing emotional problems are those most likely to be impacted.

3. Neuropsychologists Disagree. As is now common knowledge within the field of brain injury, neuropsychology is as polarized as our politics and almost on party lines. Neuropsychology is made up believers and non-believers that concussion can cause permanent brain damage. There is a lot of objective and subjective evidence for the believers to rely on. There is the academic skepticism of (similar to what Dr. Casson testified to) for the non-believers to rely on. There is no middle ground. For that reason, virtually every forensic case has two neuropsychologists who radically disagree.

4. TBI Symptoms Overlap. The neurons and the emotions are both in the brain. It is fundamental that one cannot injure neurons without effecting emotions. It is less evident but as true that one cannot impact emotions without changing neurons. Our brain’s hard wiring is the synergistic total of our genetic organic network and the sum of the changes to that network as a result of our experiences and pathologies that occur whether by disease, by trauma or via living.

5. Without Seeing the Pathology, No Objective Way to Prove TBI. I disagree with Dr. Benson to some degree on this issue. Differential diagnosis is not about looking at the results of some test, in any field of medical science. It is about a learned professional looking at the clinical history, listening to the patient’s story and reviewing more objective tests. Without the subjective application of an experienced mind to the entire spectrum of the problem, no diagnosis can be made, certainly not in a field as complex and subjective as brain injury. Neuroimaging may improve the accuracy of such diagnosis in the future but the goal is not to find an objective test we can rely on but to have better and less biased professionals engage in more thorough differential diagnosis. There is no 15 minute diagnosis of brain injury and no 15 minute solution.

6. Outcome unpredictable. Something I wrote over a decade ago was an essay entitled “Miracles and Tragedies.” http://tbilaw.com/essays.mildsevere.php I wrote that essay as I contemplated the “miracles in severe cases”and the “tragedies in so-called mild cases.” Such ironic criss-crossing of outcomes has been a universal theme of my career. I am continually amazed at how much better catastrophically brain injured survivors can get while aghast at how many mild brain injury survivors get worse and worse. I have gained greater insight into the problem since I wrote that essay but only because of the frequency that the criss-crossing of outcomes occurs. It is heartening to see a nationally recognized doctor educating Congress about that irony.

In our next blog more about advances in MRI and neuroimaging.