Mild traumatic brain injury: when symptoms linger.

Lois, a 32-year-old woman, struck the right side of her head on the passenger-side car window when a pickup truck hit from behind. She did not lose consciousness but reported feeling briefly dazed and disoriented at the time.

Lois was examined and given a CT scan (computerized tomography) in a nearby hospital emergency room. All the findings were negative, and she was sent home to rest. She was told to call her family physician if she noticed any changes.

Lois slept for days. Awakening with aches and pains as well as an intense bilateral frontal headache and dizziness, she went to her physician. The examination was unremarkable, but he recommended she take a mild over-the-counter analgesic for discomfort. Over the next few months, the general aches and pains dissipated but not the headaches or the dizziness.

Lois noticed behavioral changes. She became irritable and short-tempered, particularly with her children; was unable to maintain attention on everyday tasks; and became forgetful. The simplest tasks, like remembering names and telephone numbers and organizing and preparing dinners without making silly errors, often seemed impossible. She was moodier than usual and sometimes cried for no apparent reason.

She quit her job as a bank clerk and isolated herself from friends. She argued with her husband. Her condition seemed to be getting worse. Because of depression, including suicidal thoughts, her doctor referred her for neuropsychological help.

Lois had suffered a traumatic brain injury, which is an insult to the brain coming from whiplash injury or a blow to the head. These injuries occur most often as a result of motor vehicle crashes but also are caused by falls, assaults, and sports-related injuries. Nerves in the brain become stretched or deformed, or chemical changes interfere with normal functioning. This kind of injury is called a mild or minor traumatic brain injury (MTBI) because -

* was only a brief or minimal loss of consciousness at the time of the injury;

* there were no obvious neurological signs with traditional tests like CT scans or MRI (magnetic resonance imaging); and

* there were no medical complications requiring hospitalization for more than 24-hour observation.(1)

An estimated 1.5 million people suffer MTBI each year (2) and Lois's case is typical. For example, at the time of the injury, she experienced changes indicating brain insult, such as temporary alteration in consciousness, confusion and disorientation, headache, dizziness, and fatigue. And, like many MTBI sufferers, she had a number of symptoms later:

* physical symptoms-headaches, dizziness, and sensitivity to noise and light;

* cognitive symptoms-problems in attention and concentration, difficulty in learning and remembering new information, and slowness in thinking; and

* behavioral/emotional symptoms - irritability, impatience, explosive temper, fearfulness, and feelings of helplessness, anxiety, and depression.

Lois's symptoms did not resolve within a week or two or even within a few months. The recommendation to take a few days off from work and gradually return to everyday activities did not help. She continued to experience the disruptive, pervasive, and lasting, probably permanent, effects of a type of injury regarded in the past by most medical professionals as inconsequential.

There is mounting evidence that post-concussional symptoms can linger and delay or prevent a "substantial minority" of MTBI patients from returning to work or resuming the same life-style they had before injury. More and more people whose lives have been disrupted by a concussion or whiplash injury seek compensation through the courts. This trend requires attorneys to be knowledgeable about MTBI and relevant issues in order to present the complexities to jurors.

Is MTBI Real?

The reality of MTBI and associated symptoms has been controversial: Are symptoms produced by an injury to the brain, or do they result from the victim's psychological difficulties and desire for compensation?

Some professionals categorically refute the existence of m MTBI-related symptom complex. How can there be an injury to the brain, they ask, when there has been no extensive loss of consciousness, and subsequent medical tests do not show evidence of structural damage?

These experts note that most people with MTBI have had only brief alterations in consciousness or have lost consciousness for less than 20 minutes and show normal findings on state-of-the-art tests (CT scans and MRI) when brought to an emergency room after the head trauma. With no evidence of neurological damage, these experts conclude that the persistent symptoms of some patients are exaggerated for psychological reasons or feigned for monetary gain.(3)

Several developments in recent years have begun to weaken this once powerful argument. Specifically, animal research and post-mortem human studies have shown pathophysiological changes after mild impact to the brain. Advances in functional imaging techniques, such as cerebral blood flow (CBF), positron emission tomography (PET), and single-photon emission computer tomography (SPECT), show neuropathology after MTBI even without evidence from structural imaging.(4) Furthermore, clinical studies have shown that pre-traumatic mental or personality disorders do not inevitably result in lasting symptoms after brain injury, and they have also dispelled he notion that litigation encourages persistence of symptoms.(5)

Consequently, the view of MTBI as either organic or psychogenic has evolved into a growing clinical consensus that MTBI is a legitimate, organically based entity with disability determined by a number of interacting factors:

* physical effects: pain, sensitivity to light and sound, and dizziness;

* neurological determinants: neurochemical or structural changes in the brain from the immediate injury or previous damage due to concussions, or developmental anomalies and substance abuse that can cause a breakdown in thought processes (attention, concentration, information processing, learning, memory);

* personality factors: "vulnerable personality styles" (for example, over-achiever) and individual differences in responses to symptoms that can result in a "shaken sense of self"; and

* psychosocial determinants: adequacy of early medical response and explanation of symptoms, demands of work and family, and stressful effects of litigation that can contribute to the patient's functional disability.(6)

How Is MTBI Determined?

In the past, physicians have inferred MTBI from their patients' symptoms and subjective complaints, much like diagnosing the common cold from sniffles and complaints about general malaise. A medical evaluation, including a detailed review of current physical and cognitive problems as well as a thorough medical history, continues to be an important first step in determining MTBI.

However, today medical experts refer patients with suspected MTBI for a neuropsychological evaluation, a battery of selected psychometric tests administered and interpreted by a neuropsychologist. The evaluation has become a primary method for clinically assessing MTBI, determining the validity of a person's complaints and symptoms, and actually identifying deficits in brain functions.

At the least, a comprehensive neuropsychological evaluation examines functioning in these areas: sensorimotor abilities, attention and concentration,language and communication, perception, (nonverbal abilities), learning and memory, and intellectual abilities including solving everyday problems. The evaluation must also consider the person's psychological state in relation to symptoms, including personality before injury and individual responses to injury.

Lawyers need to consider several important points when reviewing test results and relating them to a case. First and foremost, a person's results have to be evaluated against the performance of a reference group, usually a population of similar age and educational level. The use of reference norms is essential for establishing that results from the neuropsychological testing are abnormal.

But in addition, neuropsychologists and attorneys should remember that abnormal test findings alone are not sufficient to infer MTBI without ruling out alternative explanations or at least considering the findings in the context of the person's fife.

Specifically, results must take into account factors that may entirely or partially account for deficits attributed to mild or minor traumatic brain injury:

* pre-injury condition,

* medical trauma during birth and in childhood,

* exposure to toxins,

* developmental disorders,

* learning disabilities,

* medical co-morbidities (medical conditions or disorders in addition to the current problem) and medications,

* previous concussions, and

* psychiatric conditions.

It would probably be unusual for a person not to react emotionally to an accident after a head injury and perhaps a visit to the emergency room. So psychological influences on symptom presentation should be considered in the context of neuropsychological findings. For example, the stress after an accident can be associated with many temporary or lasting emotional symptoms (anxiety, nervousness, agitation, moodiness) that can diminish motivation or responsiveness to the environment.

Are These Changes Permanent?

Most authorities agree that physical, cognitive, and emotional symptoms are invariably present for a period of time immediately after brain trauma. There is also a consensus that most effects of a single uncomplicated MTBI in a healthy young person will dissipate in the first few months after injury? Few controlled studies have been conducted for longer post-injury periods. Some research, however, has shown that some patients' posttraumatic symptoms last years or even a lifetime.(8)

More recently researchers and clinicians have begun to consider that there is permanent but undetected damage sustained in MTBI, the effects of which may not show up until years later. Consider the boxer who becomes "punch drunk" after years of sustaining mild concussions in the ring.

Also, the deficits from these injuries can sometimes cause problems later, for example, by increasing risk for or hastening the onset of debilitating brain disorders like Alzheimer's disease.(9) Although there have been mixed results in studies on the delayed effects of mild traumatic brain injury, the residuals of these injuries not only may be permanent but also may cause progressive decline in functioning.

Professionals in the field of brain injury have known for a long time about the immediate and lasting effects of concussions. Trial attorneys involved in handling suspected MTBI cases must be prepared to provide the courts with useful information about symptoms following MTBI.

Advice for Attorneys

It may be helpful to keep several points in mind.

* Recognize the problem. Many people suffer mild traumatic brain injury without loss of consciousness or positive results on neuroimaging. Many cases go undetected or are misdiagnosed.

* Understand that most people recover from MTBI within days or weeks, but some continue with symptoms lasting months and years, even a lifetime. The expected course of recovery has to be considered in evaluating the merits of each case.

* Spare no effort in obtaining all information (for example, medical records from birth; ambulance and emergency room reports; and educational, occupational, and military records) pertaining to the pre-injury condition of the patient. These records provide the basis for comparing any current cognitive, intellectual, behavioral, and emotional deficits in functioning.

Choose experienced consultants who can explain complex facts and issues so that jurors will understand what has happened to an injury victim.

Notes

(1) Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine, Definition of Mild Traumatic Brain Injury, J. HEAD TRAUMA REHABILITATION, Sept. 1993, at 86-87. (2) Thomas Kay et al., Toward a Neuropsychological Model of Functional Disability After Mild Traumatic Brain Injury, 6 NEUROPSYCHOL. 371-84 (1992); Jess F. Kraus & Parivash Nourjah, The Epidemiology of Mild Uncomplicated Brain Injury, 28 J. TRAUMA 1637-43 (1988). (3) Lawrence M. Binder, Persisting Symptoms After Mild Head Injury. A Review of the Post-Concussive Syndrome, 8 J. CLINICAL & EXPERIMENTAL NEUROPSYCHOL. 323-46 (1986); Harvey S. Lc% & Howard M. Eisenberg, Postconcussional Syndrome, 2 NEUROTRAUMA MED. REP. 1-3 (1988); H. Miller, Accident Neurosis, 1 BRIT. MED. J. 919-25 (1961). (4) John T Pavlishock, Traumatically Induced Axonal Injury. Pathogenesis and Pathobiological Implications, 2 BRAIN PATHOLOGY 1-12 (1992); R. M. Ruff et al., Selected Cases of Poor Outcome Following a Minor Brain Trauma: Comparing Neuropsychological and Positron Emission Tomography Assessments, 8 BRAIN, INJURY 297-308 (1994). (5) George Mendleson, Not "Cured by a Verdict": Effect of Legal Settlement on Compensation Claimants, 2 MED. J. AUSTRALIA 132-34 (1982). (6) Kay et al., supra note 2; J.M. Minderhoud et al., Treatment of Minor Head Injuries, CLINICAL NEUROLOGY NEUROSURGERY 127-40 (1980). (7) Dorothy Gronwall, Minor Head Injury, 5 NEUROPSYCHOL. 253-65 (1991); Sureyya S. Dikmen & Harvey S. Levin Methodological Issues in the Study of Mild Head Injury, J. HEAD TRAUMA REHABILITATION, Sept. 1993, at 30-37; I.A. Mandelberg & Neil Brooks, Cognitive Recovery After Severe Head Injury: I Serial Testing on the Wechsler Adult Intelligence Scale, 38 J. NEUROLOGY, NEUROSURGERY PSYCHIATRY 1121-26 (1975); Philip Wrightson & Dorothy Gronwall, Time Off Work and Symptoms After Minor Head Injury, 12 INJURY445-54 (1981). (8) Wayne Alves et al., Understanding Posttraumatic Symptoms After Minor Head Injury, J. HEAD TRAUMA REHABILITATION, June 1986, at 1-12; N. Bohnen et al., Persistence of Postconcussional Symptoms in Uncomplicated, Mildly Head-Injured Patients: A Prospective Cohort Study, NEUROPSYCHIATRY, NEUROPSYCHOL & BEHAVIORAL NEUROLOGY 193-200 1993); P.G. Denker, The Post-Concussion Syndrome. Prognosis and Evaluation of the Organic Factors, 44 N.Y. ST. J. MED. 379-84 (1944); Harvey S. Levin et al., Neurobehavioral Outcome Following Minor Head Injury.- A Three-Center Study, 66 NEUROSURGERY 234-43 (1987). (9) Vijay Chandra et al., Head Trauma with Loss of Consciousness as a Risk Factor for Alzheimer's Disease, 39 NEUROLOGY 1576-78 (1989); Suzanne Corkin et al., Penetrating Head Injury in Young Adulthood Exacerbates Cognitive Decline in Later Ten, 9 J. NEUROSCIENCE 3876-83 (1989); A. Gedye et al., Severe Head Injury Hastens Age of Onset of Alzheimer's Disease, 37 J. AM. GERIATRIC SOC'Y 970-73 (1989).

Thomas Galski is the director of psychology and neuropsychology and the Brain Injury Program at the Kessler Institute for Rehabilitation in East Orange, New Jersey.