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Traumatic Brain Injury (TBI) & Nerve Damage

7/25/2008
Christopher M. Davis
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Top 10 Myths About Traumatic Brain Injury
I've been representing traumatic brain injury clients for about 15 years now.  Over the years, you hear typical arguments or comments from the insurance company or their lawyers and experts that are designed to minimize the claim or refute the existence of the injury itself.  Here are my Top Ten Myths About Traumatic Brain Injury:
10. Mild Traumatic Brain Injury (MTBI) Is Not Disabling.
Not true.  MTBI can cause severe disabling problems for people.  What also compounds things is the MTBI patient looks perfectly normal so people don't believe the person has significant cognitive problems.
9. Mild TBI Is Not Permanent.
Another myth.  Various studies show that as many as 15% to %25 of MTBI victims will have permanent and long-lasting symptoms associated with the injury.
8. Children With MTBI Will Get Better and Recover.
Many do, but there is a sizeable percentage that do not.  There are also recent studies showing that a child with MTBI may develop new problems later on.  This is because the part of the brain that has been damaged (e.g., the frontal lobes) may not become fully developed until later on so the damage caused to that part of the brain may not be fully recognizable until the time where the part of the brain matures.
7. Cognitive Impairments on Neuropsychological Testing Must Fit a Pattern.
A very prominent neuropsychologist, Dr. Muriel Lezak, and author of Neuropsychological Assessment –the bible of neuropsychology –writes:

“However, the behavioral repercussions of brain damage varied with the nature,extent, location and duration of the lesion. With the age, sex, physical condition and psycho-social background and status of the patient and with individual neuroanatomical and  physiological differences, not only does the pattern of neuropsychological deficits differ with different lesion characteristics and locations but two persons with similar pathology and lesion cites may have distinctly different neuropsychological profiles.”
6. All Neuropsychological Testing is Subjective.
Neuropsychological testing consists of numerous tests designed to measure brain function. Because this testing requires a patient give his best efforts, many defense experts state that neuropsychological testing is subjective and not objective because the patient has too much control over the outcome. This viewpoint has been rejected by mainstream medicine.
Strubb and Black in their text, Mental Status Examination in Neurology, explain that the neuropsychological evaluation is a comprehensive objective assessment of a wide range of cognitive adaptive and emotional behaviors that reflect the adequacy or inadequacy of higher brain functions. In essence, the neuropsychological evaluation is a greatly expanded and objectified mental status examination. The objective and highly qualified nature of most neuropsychological tests aids in the detection of subtle changes in performance over time.
The American Academy of Neurology assembled a subcommittee to examine and validate the use of neuropsychological testing. They found that neuropsychological assessment is accepted and appropriate by the practicing medical community.
5. The TBI/MTBI Injury Is Immediate and Easily Recognizable.
In the noted medical treatise, Greenfield’s Neuropathology, the authors write:
“Under conditions of mild to moderate TBI, it is now apparent that there is a process of delayed axonomy in which the actual disruption of some axons does not occur until some time after the original injury. Axonomy only becoming apparent between six and 12 hours after injury. Thereafter, the proximal segment continued to expand.”
The National Institute of Health’s consensus statement has also recognized the delay in recognizing the symptoms of traumatic brain injury.  Many researches believe that the injury can produce bio-chemical changes in the brain which may lead to further symptoms over time (several days).  The notion that a TBI must produce immediate symptoms is now known to be untrue.
4. You Must Have a Positive MRI or CT Scan to Show that a TBI Has Occurred.
Not true.  Most MTBI cases involve a negative MRI and/or CT scan.  In the article, “Mild Traumatic Brain Injury” in the journal Neurology, Dr. Alexander states: “By common clinical agreement, neuroimaging studies are negative.”
In the text Neuropsychiatry of Traumatic Brain Injury, the authors write: “In addition, many patients with a history of minor brain injury will not have abnormalities on even MRI yet can manifest clear evidence of functional impairment on neuropsychological measures.”
Many practicing physicians who treat TBI/MTBI believe that a patient with a normal CT and normal electroencephalogram is in fact normal for this type of injury. They should keep in mind, however, the old adage: Absence of proof is not proof of absence. Historically, the lack of positive neurodiagnostic tests in patients with mild TBI may have reflected a simple lack of sensitivity and/or specificity.
3. You Must Receive a Blow to the Head to Suffer a TBI/MTBI.
Think of the brain as being similar to soft gelatin in a bowl.  The bowl is the skull.  Except that unlike a bowl, the underside of the skull is rough with many bony protuberances. These ridges can result in injury to the temporal lobe of the brain during rapid acceleration. When the head undergoes rapid acceleration/deceleration forces (i.e. whiplash), the impact causes the brain to bump the opposite side of the skull. Damage then occurs at the area of impact and on the opposite side of the brain. This is called a Coup Contra Coup injury.  This type of injury can tear and stretch neurons in the brain.  These neurons help the brain communicate messages by electrical impulse.  This stretching and tearing of neurons is also called Diffuse Axonal Injury (DAI). 
2. You Must Become Unconscious to Sustain a TBI/MTBI.
This is a big misconception.  In the journal Neurology, James Kelly and Jay Rosenberg noted that more than 30 years of earlier the then-Congress of Neurological Surgeons concluded that head injury leading to mental status alterations without loss of consciousness is a form of concussion. Dr. Kelly –writing in the Journal of the American Medical Association (JAMA) –noted in certain facts    underscore the need to educate physicians and other health care professionals about the effects of mild head injury. There is a common misconception that forces sufficient to produce loss of consciousness are necessary to cause concussion.
According to the American Psychiatric Press’ Textbook of Neuropsychiatry, “Patients with mild TBI may present with somatic, perceptual, cognitive and emotional symptoms that have been characterized as the post-concussion syndrome.” By definition, mild TBI is associated with a brief duration of loss of consciousness, less than 20 minutes or no loss of consciousness at all.
In the Journal of Neuropsychiatry, doctors at Silver and McAlister state they believe there is sufficient clinical and research evidence to suggest that clear unconsciousness is not the sin qua non for brain injury.
Most of the reputable medical community who often see and treat TBI/MTBI patients now know that a person can suffer a traumatic brain injury without suffering a prolonged period of loss of consciousness.
1. Mild TBI is Not Serious.
The Washington State Legislature enacted a new law that states:
The center for disease control estimates that at least five million three hundred thousand Americans, approximately two percent of the United States population, currently have a long-term or lifelong need for help to perform activities of daily living as a result of a traumatic brain injury. Each year approximately one million four hundred thousand people in this country, including children, sustain traumatic brain injuries as a result of a variety of causes including falls, motor vehicle injuries, being struck by an object, or as a result of an assault and other violent crimes, including domestic violence. Additionally, there are significant numbers of veterans who sustain traumatic brain injuries as a result of their service in the military.  

Traumatic brain injury can cause a wide range of functional changes affecting thinking, sensation, language, or emotions. It can also cause epilepsy and increase the risk for conditions such as Alzheimer's disease, Parkinson's disease, and other brain disorders that become more prevalent with age. The impact of a traumatic brain injury on the individual and family can be devastating.  
In the book Medical Rehabilitation of Traumatic Brain Injury, Dr. Nathan Zasler wrote:
   
“Modifiers such as subtle, minimal and minor are to be discouraged. Practitioners must understand that the term “mild” describes only the initial insult relative to  the degree of neurological severity. There may be no correlation with the degree of short or long-term impairment or functional disability.”
There is no question that MTBI can cause serious and life-long problems for the victim of TBI as well as the person's family, friends and co-workers.
Christopher M. Davis has been representing brain injured victims for 15 years.  He has been recognized as a Super Lawyer for his expertise and success in helping injured victims.


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