TBI is usually broken down into three categories: severe, moderate and mild. “Mild” does not mean insignificant or minor. The term “mild” describes only the initial injury relative to other injuries. There may be no correlation between a “mild” initial injury and short-term or long-term impairment or disability. A committee of the American Congress of Rehabilitative Medicine reported that “mild traumatic brain injury” includes a trauma-induced physiological disruption of brain function manifesting by at least one of: alteration of mental state at the time of the injury, such as feeling dazed. The person may have nausea, vomiting, headache, blurred vision, fatigue, and problems with attention, concentration, memory, speech, and language/executive functions. Behavioral changes may include irritability, quickness to anger, emotional ups and downs, and lack of inhibition.
In an article written 10 years ago 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. There is a common misconception that forces sufficient to produce loss of consciousness are necessary to cause concussion.
Dr. Michael Alexander, a leading neurologist in the field of caring for people with traumatic brain injury, noted that in mild traumatic brain injury, noted that in mild traumatic brain injury, the duration of unconsciousness is brief, usually seconds to minutes, and in some cases there is no loss of consciousness but simply a brief period of dazed consciousness.
Dr. Randall Evans reported a similar finding in his chapter on traumatic brain injury: “For future studies reasonable criteria for the definition of mild closed head injury would include duration of loss of consciousness of 30 minutes or less or being dazed with out loss of consciousness.”
Neuropsychiatrists also have recognized that one can sustain a mild traumatic brain injury without losing consciousness. 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.
Many people believe that in order to suffer a brain injury, one must either hit their head or have their head struck by an object.. This is not correct.. The brain has the consistency of gelatin. Think of the brain and skull as being similar to a bowl of gelatin, 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 is struck or undergoes acceleration/deceleration forces, 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 coup contre coup.
There is a belief that today’s MRI tests are so good they will detect brain injury. This is another myth.
In a seminal piece titled “Mild Traumatic Brain Injury” in the journal Neurology, Dr. Alexander states: “By common clinical agreement, neuroimaging studies are negative.” Other leading professionals in the field of caring for persons with traumatic brain injury are in agreement.
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.”
Dr. Zasler, in discussing MRIs, CT scans and the like, writes, “Many practicing physicians believe that a patient with a normal CT and normal electroencephalogram is in fact normal.” They should keep in mind, however, the old adage: Absence of proof is not proof of absence. Historically, the lack of positive neuro-diagnostic tests in patients with mild TBI may have reflected a simple lack of sensitivity and/or specificity.
James Smith was stopped at a red light when his car was struck in the rear. At the scene, he was dazed and told the rescue squad personnel that he had pain in the back of his neck. He was taken to the local emergency room where again he complained of neck pain. He was examined, evaluated and released a couple hours later. Over the next couple of days and weeks, James began to experience problems with his attention and concentration. He began having difficulty at work and his relationship with his family began to suffer. His doctors ultimately diagnosed a mild traumatic brain injury, though doctors retained and hired by the insurance company disagreed –arguing that because James did not complain of TBI symptoms immediately following the crash he could not be suffering from a traumatic brain injury.
Are these defense doctors correct or are they simply perpetuating a myth? In 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.”
This delay in recognizing the symptoms of traumatic brain injury also was discussed in the National Institute of Health’s consensus statement, writing that as individuals with TBI attempt to resume their usual daily activities, the environment places increasing demands on them uncovering additional psychosocial consequences. For example, executive dysfunction may become obvious only in the workplace.
Because standard and traditional neuroimaging such as MRI, CT scans, and EEGs normally are neither specific nor sensitive enough to detect the damage done to the axons and neurons of the brain, the only objective testing which may be sensitive enough to detect and diagnose mild traumatic brain injury is neuropsychological testing. Neuropsychological testing consists of numerous tests designed to measure brain function. Because this testing requires a patient give his or her best efforts, some defense- oriented doctors suggest neuropsychological testing is subjective, not objective. 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.
Neuropsychological assessment is often most useful in patients with more subtle deficits. It also is useful for detecting deficits in patients with particularly high pre-morbid intelligence levels in which bedside type clinical testing may be insensitive to mild alterations.
Neuropsychiatrists also use neuropsychological testing. Formal neuropsychological testing is an essential part of the neuropsychiatric evaluation of the TBI patient. In fact, it often is the single-most sensitive indicator of subtle brain disturbances that may be contributing to the cognitive, emotional and behavioral dysfunctions that bring TBI patients to the psychiatrist, especially those with a history of only mild to moderate brain injury.
Neuropsychological assessment of the patient with TBI is essential to document cognitive and intellectual deficits and strengths.
It is not unusual that a neuropsychological evaluation report prepared by a defense neuropsychologist finds a specific patient is faking or suffering from some other problem other than a traumatic brain injury because the neuropsychological findings do not fit “a normal or predictable pattern.”
Dr. Muriel Lezak has debunked this myth. Dr. Lezack, 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.”
One of the greatest myths perpetrated is that children have better recoveries from traumatic brain injury than adults. This myth rests upon the refuted theory known as plasticity, which claims developing brain can better rebound from injury. This theory is untrue. In fact, because a child’s brain is undeveloped, it may take years to realize the impairments that the child faces as a result of a brain injury. In an excellent article on children and head injuries published in the Journal of Recovery, Dr. Ronal Savage, who for 35 years has treated children with traumatic brain injuries, examines the following children related myths and puts them to rest.
Myth: Younger children recover better than older children.
Fact: New research shows that younger children, especially between birth and five years may experience more long-term challenges.
Myth: Severe TBI means permanent disability. Mild TBI means few, if any, problems.
Fact: Measures commonly used to evaluate brain injury severity were developed for adults, no children. Children do not lose consciousness as easily as adults.
Myth: Physical recovery is a sign the child has recovered.
Fact: Motor function is not a direct indicator of cognitive or behavioral recovery.
Myth: Normal intelligence scores after TBI mean the child will have no problems in school.
Fact: Intelligence tests often are unreliable measures of a child’s learning ability after TBI. Most intelligence tests measure prior learning.
Myth: Most injuries happen to older children, especially teen-agers.
Fact: The majority of brain injuries occur to children under 10.
It was once thought that child maturation followed a step-up progression. Research done by Dr. Savage and others now clearly demonstrates the traumatic effect of a child’s brain maturation. Not only does the brain as a whole mature at different times and ages, but a child’s different brain lobes maturate at different periods of time. In examining the long-term effects of traumatic brain injury on children it is important to look at whether the child has suffered a previous TBI, whether the child has any pre-existing learning disabilities, whether the child has any pre-existing neurological or psychiatric problems and whether there is a history of family problems. All these issues are factors for poor outcome for children who have suffered a traumatic brain injury.
Over and over again defense doctors testify that everyone who sustains a mild traumatic brain injury gets better; that mild traumatic brain injury is not a permanent condition. This simply is untrue.
Dr. Michael Alexander has pointed out that at one year after injury, 10 percent to 15 percent of mild TBI patients have not recovered. Many are more symptomatic than even immediately after the injury. Some have had persistence of one particularly troubling symptom –usually headache, neck pain or dizziness. Most have persistence and even worsening of the entire symptom complex. Both groups are at high risk of permanent symptomatic persistent post-concussive syndrome.
Work to date shows that mild brain injury results in measurable deficits in speed of information, processing, attention and memory in the immediate post-injury period. Recovery from these deficits is the rule occurring over a variable period ranging from four to 12 weeks. For small group, recovery may occur much more slowly or remain incomplete.
As Silver and McAlister explain, a good recovery is not universal. They note that although the long-term prognosis is favorable for the majority of patients with a mild TBI, it is well recognized that there can be significant short-term behavioral, somatic and cognitive sequelae. Furthermore, a significant minority of patients develops a chronic, often-debilitating constellation of signs and symptoms known as the chronic post-concussive syndrome.
This myth has been rejected by the National Institute of Health. In its consensus statement, NIH writes that the consequences of TBI include a dramatic change in the individual’s life course, profound disruption of family, enormous loss of income or earning potential and large expenses over a lifetime.
There are approximately 300,000 hospital admissions annually for persons with mild or moderate TBI and an additional unknown number of traumatic brain injuries that are not diagnosed but may result in long-term disability.
The social consequences of mild, moderate and severe TBI are many and serious, including increased risk of suicide, divorce, chronic unemployment, economic strain and substance abuse.
Graham Teasdale, writing in the British Medical Journal, examined the disability effects on young people and adults one year after head injury. When the study was conceived, the authors believed the research would show that persons with severe and moderate traumatic brain injury had greater and longer disability than patients with mild traumatic brain injury. They were surprised what the research told them. Survival with moderate or severe disability was common after mild head injury and similar to that after moderate or severe injury. The incidents of disability in young people and adults with a head injury were higher than expected.
At the World Congress of Traumatic Brain Injury in Melbourne, Australia in 2005, Dr. Teasdale reported on his follow-up research five years after his initial paper was published. He reported that patients with mild TBI are still symptomatic and still suffering long-term disability.