As reflected in the posts on this blog over the last several years, scientific understanding of “mild traumatic brain injury” (Mtbi) – often referred to as “concussion” – has advanced considerably over the last 30 years. Unfortunately many physicians, including those on the “front lines” for these injuries–in emergency rooms and primary care clinics–have not kept up with this evolving science. In emergency rooms, the focus is typically on ruling out catastrophic injuries. The signs and symptoms of concussion are often missed. Even where the symptoms are recognized, many physicians mistakenly believe, based on outdated information, that the symptoms of mTBI can be ignored and that virtually everyone recovers spontaneously. Compounding this misinformation is inconsistency in the definitions found in the literature, in many cases depending on when the definition was adopted.
In 2019 – to address some of these problems – the mTBI Task Force of the American College of Rehabilitation Medicine (ACRM) Brain Injury Special Interest Group undertook an updating of the 1993 ACRM definition of mTBI – one of the most widely recognized definitions. This work included rapid evidence reviews, an expert survey (to rate the diagnostic importance of various clinical signs, symptoms, test findings, and contextual factors), public and stakeholder engagement, and a Delphi consensus process with an international, interdisciplinary panel of clinician-scientists. The working group included 17 ACRM mTBI Task Force members and an external interdisciplinary expert panel of 32 clinician-scientists from seven countries and various fields such as sports, civilian trauma, and military settings. The new criteria adopted by this group are based on syntheses of current research evidence and went through several rounds of revision until more than 90 per cent of the expert panel agreed with what they were proposing. Read More
Among the chronic symptoms seen in these children were forgetfulness, memory problems, sensitivity to light and noise, ADHD and even psychological problems. Sadly, many of these children had been misdiagnosed as suffering from unrelated ADHD, sleep disorders, depression, etc. This misdiagnosis, the researchers noted, leads to treatment that is not suited to the problem, thus causing the children prolonged suffering. Read More
A new study published February 16, 2022 by the American Academy of Neurology in the Journal “Neurology” finds that the frequency of clinically meaningful poor cognitive outcomes one year after a concussion are more common than previously thought. The results, says study author Raquel Gardner, MD, of the University of California San Francisco, “highlight the need to better understand the mechanisms underlying poor cognitive outcome, even after relatively mild brain injuries, to improve therapy for recovery.” Read More
Most personal injury lawyers have represented clients suffering from the chronic consequences of concussion and musculoskeletal injuries following a rear end collision that caused minimal damage to the vehicles involved. This blog has reported on countless scientific studies showing that in some patients concussions can have long-term, chronic consequences. The standard defense employed by insurers in minimal damage rear end collisions (which they call “MIST” cases) is to argue that any injury is improbable in these accidents because the forces involved are similar to the forces involved in many activities of daily living (ADLs) where injuries rarely occur (like sitting down in a chair or sneezing.
The insurers and their defense counsel typically have an “accident reconstruction” expert they routinely use (often retired police officers) who calculate the speed change in the crash (the “delta V”) and then compare it to the delta V involved in everyday activities. (The delta V calculations by these so-called experts is often inaccurate, but that is a different issue.) Experience shows that this testimony can be very compelling to a jury, faced with judging the credibility of an injury victim whose injury is not immediately apparent. Read More
A research report from the University of Texas Medical School, just published in Frontiers in Neurology, finds a correlation between Diffusion Tensor Imaging (DTI) findings and cognitive assessments in patients with chronic complaints after concussion, providing evidence that DTI imaging may be a reliable biomarker predicting the severity of cognitive decline following concussion. (DTI is an MRI technique that detects microstructural changes in white matter such as the changes that can occur as a result of “diffuse axonal injury” in brain injuries including concussion.) Read More
For those not familiar with the term, a “meta-analysis” is a quantitative, formal, epidemiological study design used to systematically assess the results of previous research to derive conclusions about that body of research. Dr. Rebecca Acabchuk and her team at UConn’s Institute for Collaboration on Health, Intervention and Policy (InCHIP) have just published the first ever systematic review and meta-analysis on the “Therapeutic Effects of Meditation, Yoga and Mindfulness-Based Interventions for Chronic Symptoms of Mild Traumatic Brain Injury,” in Applied Psychology: Health and Well-Being, the journal of the International Association of Applied Psychology.
Studies over the last several years have shown that the lymphatic system serving the brain, located in the membranes covering the brain (the “meninges”) plays an important role in brain injury recovery.
As most people know, the lymphatic system helps to rid the body of toxins and waste, including the byproducts of the body’s immune response to injury. For brain injury this is sometimes described as “damage/danger-associated molecular patterns” – “DAMPs” – such as protein aggregates, necrotic cells, and cellular debris.
Researchers at the University of Virginia, at the Center for Brain Immunology and Glia, have released an important study furthering our understanding of the role meningeal lymphatic dysfunction plays in causing some patients to suffer severe and long-lasting impairments following even a “mild” traumatic brain injury (TBI) and helps to explain why these injuries increase the risk for neurodegenerative problems such as Alzheimer’s, ALS and dementia. Read More
An article published in April, 2020 by the American College of Emergency Physicians reports on evidence that underdiagnosis of Mild Traumatic Brain Injury (mTBI) “is a pervasive problem in the emergency setting,” and that even patients who receive a diagnosis are unlikely to receive appropriate discharge education and are therefore at risk of missing opportunities for treatment, referral and improvement in outcomes. Koval et. at., Concussion Care in the Emergency Department: A Prospective Operational Brief Report, Annals of Emergency Medicine 2020 Apr;75(4):483-490. Read More
In 2015, Dr. John Leddy and his groundbreaking concussion team at the University of Buffalo published a peer reviewed article cautioning that symptoms after head injury, including cognitive symptoms, that have traditionally been ascribed to brain injury can originate, at least in part, from injury to the neck, He counseled that the cervical spine should be examined and, if injured, should be treated to address these symptoms. “Brain or strain? Symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury.”
A review of the literature published not long after the Leddy article, in the Journal of Sports Medicine, sounded a similar theme. “Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review.” It noted that many post-concussion symptoms can be explained by injuries to structures near or in the head, other than the brain itself. “For example,” the authors note, “following a trauma, structures such as the cervical spine, the vestibular ocular system and the temporomandibular joint can be injured.” They note, for example, that “neck pain, headaches, dizziness and balance dysfunction are common symptoms associated with both mTBI and WAD” (cervical spine injury.) Addressing neck injuries, they suggest, may lead to better concussion recovery. A randomized controlled trial testing this hypothesis is currently in process. Read More