I travel between two worlds that may appear far apart – by day I am a trial lawyer with a focus on traumatic brain injury; nights and weekends I am a yoga teacher. I increasingly find that these worlds are very close together.
As a brain injury lawyer I work with people struggling to recover from the loss of sense of self so often caused by brain injury as well as associated depression and chronic pain. Many of my clients have reported meaningful increases in the quality of their lives following injury through “mindfulness” practices such as yoga and meditation. Practices such as yoga are designed to increase awareness of the present moment, to increase awareness of our thoughts, emotions and physical sensations without filtering them through past experience or fears of the future – to recapture our sense of ourselves. Read More
On January 23, 2014 the Defense and Veterans Brain Injury Center released new clinical recommendations with a standardized approach for concussion recovery. Included in the recommendations for managing concussion symptoms is a first of its kind five-stage approach for return to activity following a concussion. Detailed “do”s and “do not”s are specified for each stage. Movement from stage to stage is determined by scores on a simple twenty-two item “neurobehavioral symptom inventory” included in the recommendations. Read More
In August, 2013, the NFL announced that it had reached a $765 million dollar settlement of claims by more than 4,500 players alleging that they were suffering from long-term consequences of concussions that the NFL had known about for years, hid from players, and failed to minimize by establishing appropriate protocols for return to play. The alleged cover-up by the NFL, with co-conspirators in the medical community, was recently the subject of an extensively researched PBS Frontline special titled “League of Denial.”
By settling the players’ claims early in the litigation it appeared that the league would avoid further examination of what the league knew and when it knew about the long-term effects of concussion. However, several recent developments indicate that these issues will likely be examined further. The judge overseeing the litigation has appointed a “special master” to make recommendations concerning the settlement and the Brain Injury Association of America has petitioned to intervene in the litigation to make sure that the settlement takes proper account of the
“progressive physical, psychiatric and cognitive disease processes that are caused and/or accelerated by brain injury, but may not manifest in clinically significant symptoms on initial presentation.”
In a study published November 18, 2013 in Frontiers in Neurology, researchers from Penn and Baylor report that they have identified a blood biomarker – SNTF – that if found on the day of injury predicts with substantial accuracy both cognitive impairment persisting more than 3 months and the existence of abnormal brain imaging finding in the corpus callosum and uncinate fasciculus of the brain (using diffusion tensor imaging (DTI). Read More
There has been much debate over what happens to the brain following a concussion, much of it recently focused on concussions in sports. One side of the debate maintains that concussions, also referred to as “mild traumatic brain injuries,” involve only a very short term disruption of brain function with no damage to the brain. As discussed in previous posts, this view has been discounted by a growing body of research involving advanced imaging technologies as well as post-mortem pathological studies showing that in a minority of cases concussions can cause lasting damage to the brain as well as persistent symptoms.
One of the causes of the failure of clinical trials to successfully treat TBI, the authors contend, is the common classification of TBIs as “mild, moderate or severe.” These classifications do not incorporate newer insights and findings from diagnostic tools such as imaging and biomarkers and therefore do not promote “mechanistic targeting” for clinical trials. The authors support the transition to a more nuanced approach, a precise disease classification model that is based on the precise pathoanatomical and molecular features of the injury. Read More
Defense attorneys often cite “meta-analytic” reviews of neurological studies to make the argument that “mild” traumatic brain injuries (mTBIs) cause no lasting effect beyond three months post-injury. A “meta-analysis” involves a statistical study of multiple studies published in the literature.
Meta-analyses in mTBI are often used to show that persistent symptoms are “neurotic” rather than “organic”
Fortunately, it is generally agreed that the majority of people who suffer mTBIs, sometimes referred to as “concussions”, report full recovery from symptoms within three months of the injury – in fact many recover much faster. A great deal of research over the past few years has focused on the minority of people who do not fully recover within three months, described as having a “persistent post-concussion symptoms (PCS).” These patients are sometimes referred to as the “miserable minority.” The “meta-analyses” are often cited as demonstrating that changes in performance after three months have “limited statistical and clinical significance;” in other words, that persistent symptoms must be psychological or “neurotic” rather than “organic” or neurologic. Read More
Two recent peer reviewed papers support the position statement adopted by the Brain Injury Association in 2009 that “Brain Injury” be treated not as static event from which patients gradually recover over time, but as the beginning of a disease process that that can cause symptoms that change over time, in some cases getting worse instead of better, and that can impact multiple organ systems.
The good news is that most people do, in fact, recover. For those who do not, however, the disease model is more consistent with the evolving research. As McCrea, Iverson, McAllister, et. al. noted in their 2009 Integrated Review of Recovery after Mild Traumatic Brain Injury, brain injury science has advanced more in the last few years than in the previous 50, causing us to change the paradigms we have used to understand both the injury and its consequences. Read More
In July, 2013 the Defense Centers of Excellence, serving the United States Department of Defense, issued important new guidelines for neuroimaging following “mild” traumatic brain injury. The guidelines begin with the well-accepted understanding that neuroimaging is not typically included in the diagnosis of mild traumatic brain injury(“mTBI”) because only 10-15% of people who sustain trauma resulting in mTBI will have an acute brain lesion on CT (computed tomography) scans. “The lack of positive imaging findings,” the guidelines emphasize, “does not invalidate a diagnosis of mTBI.”
What is significant about the guidelines is that they recommend imaging in mTBI cases where the victim has “new, persistent or worsening symptoms” 90 days or more following the injury (described as the “chronic stage.”) Read More