Brain Injury Lawyer

Physiologic Post Concussion Disorder

rdeluca@stark-stark.com (Bruce H. Stern) — Wed, 16 May 2012 08:17:01 -0500

I just received this month’s issue of the Brain Injury Professional, the official publication of the North American Brain Injury Society (NABIS). This month’s issue covers the post concussion disorder.

The issue contains the following articles:

Physiologic Post Concussion Disorder by Barry Willer, Ph.D. and John Leddy, M.D.
Augmenting Neuro Cognitive Assessment in the Evaluation of Sports Concussion: How the vestibular and ocular issues impact recovery. Anne Mucha, DPT, Michael Collins, Ph.D., and Jonathan French, Psy.D.
Cervicogenic Post Concussion Disorder: A pain in the neck. John Leddy, M.D.
Suggestions for Facilitating Return to Learn After Concussion. Brian Rieger, Ph.D.
Providing a Continuum of Care for Concussion Using Existing Educational Frameworks. Karen McAvoy, Psy.D.
Psychologists Working in Concussion Clinics. John Baker, Ph.D.
Concussion Legislation: Variations on a theme. Gene Rickerson.
Sports Concussions.org: A new resource for brain injury professionals and families. Neal McGrath, Ph.D.

I recommend everyone joining NAIBIS. The above link will send you to the society’s web page. Please remember that NAIBIS will be holding its 25th medical legal conference and its 9th medical conference from September 12-15, 2012 in Miami, Florida.

Admissibility of the MMPI-2-RF in Forensic Evaluations of Traumatic Brain Injuries (TBI)

rdeluca@stark-stark.com (Bruce H. Stern) — Tue, 08 May 2012 08:01:03 -0500

I just received a copy of the May 2012 issue of Archives of Clinical Neuropsychology. While I didn’t see any articles that would be of interest to neuro-attorneys and those involved in neuro-litigation, there was an editorial announcement with regard to a forthcoming paper that will be published in a new section of the Archives entitled “Current Topics in Science and Practice.” The forthcoming paper will be by Yossef S. Ben-Porath focusing on the admissibility of the MMPI-2-RF in forensic evaluations.

What is disappointing in the editorial announcement, authored by Robert J. McCaffrey, Editor-In-Chief is that “commentary or rebuttal papers are not appropriate for consideration in Current Topics in Science and Practice.” One must question why this is. The use of the fake bad scale has been rejected by numerous courts. It has also been widely criticized in the medical and scientific literature.

Clearly, those advocating the use of the MMPI-2-RF in forensic evaluations will rely on the peer reviewed article by Ben-Porath to support its admissibility. Failure to permit commentary or rebuttal papers in response seems inappropriate to say the least. Hopefully, Dr. McCaffrey will reconsider the editorial board’s position on this.

A healthy debate is always welcomed.

Another NFL Death Caused by Concussions and Traumatic Brain Injuries (TBI)

rdeluca@stark-stark.com (Bruce H. Stern) — Thu, 03 May 2012 09:04:14 -0500

Junior Seau, a 12-time Pro Bowl linebacker who led the San Diego Charges to a Super Bowl victory and played in a second Super Bowl with the New England Patriots, was found dead from an apparent suicide earlier this week in his California home. Seau was only 43.

Seau’s death is the latest in a long line of professional football players who have suffered the most devastating effects of the sport: long-term, and often times deadly, results from too many hard hits and concussions sustained on the field.

Seau is the eighth member of the San Diego Chargers' 1994 Super Bowl team to pass away. The other members of the team include defensive end Chris Mims, linebacker David Griggs, running back Rodney Culver, linebacker Lewis Bush, center Curtis Whitley, defensive tackle Shawn Lee and linebacker Doug Miller and Dave Duerson.

Duerson, a former defensive back, reportedly had brain damage common to chronic head trauma citing chronic traumatic encephalopathy (CTE), which had also been found in more than 20 other deceased players. In his last note to his family, Duerson had asked his brain be sent to researchers. He wanted the world to know what had enveloped him.

Duerson shot himself in the chest, an act which preserved his brain for study. Police say Seau apparently shot himself in the chest as well.

This is one more, devastating, example of why stricter limits need to be put in place in the NFL, as well as high school, college and recreational sporting leagues. A person’s life is not worth another hit on the field and one more ring.

Rethink Cross Exams in Traumatic Brain Injury Cases

rdeluca@stark-stark.com (Bruce H. Stern) — Tue, 01 May 2012 09:34:01 -0500

I recently wrote an article for Trial, the official magazine of the American Association for Justice, entitled Rethink Cross Exams in Traumatic Brain Injury Cases. The article discusses the fact that mild traumatic brain injuries don’t have telltale signs, which will often times lead to a defense attorney using a medical expert to testify during trial that there is no objective evidence to support a client’s injury. However, I believe trial attorneys should not attempt to discredit the witness, but rather, should get that same expert to prove your case for you.

Department of Defense & Department of Veterans Affairs Stress the Importance of Early Diagnosis of Traumatic Brain Injuries (TBI)

rdeluca@stark-stark.com (Bruce H. Stern) — Fri, 27 Apr 2012 09:30:32 -0500

The Department of Defense (DOD) and the Department of Veterans Affairs (VA) are stressing the importance of early diagnosis of traumatic brain injuries (TBI). This importance is related to both “invisible” injuries such as concussions, and more severe traumatic brain injuries.

The VA and the DOD have been working with various academic institutions when it comes to traumatic brain injuries (TBI), in order to improve the methods by which service members suffering from TBI are treated. The agencies are also stressing the importance of standard care for those suffering from TBI.

Support for the Use of Diffusion Tensor Imaging in Documenting and Diagnosing Traumatic Brain Injuries (TBI)

rdeluca@stark-stark.com (Bruce H. Stern) — Wed, 25 Apr 2012 08:35:55 -0500

I just received a copy of the new 5th Edition of “Neuropsychological Assessment”. I was very pleased to see that Erin D.Bigler, Ph.D., is now a co-author of this text.

As set forth in the preface: “Three major additions distinguish the 1st and 5th Editions of Neuropsychological Assessment. Most obvious to the experienced neuropsychologist is the proliferation of tests and the wealth of readily available substantiating data. Second, a book such as this must provide practically useful information for neuropsychologists about the the generations of neuroimaging techniques that have evolved in the past 30 years. Further, especially exciting and satisfying is confirmation of once what was suspected about the neural organization underlying brain functions thanks to the marriage of sensitive, focused, clinical observations with sensitive, focus, neuroimaging data.

What is also exciting is the numerous references to the use of diffusion tensor imaging with traumatic brain injury. This, like the proliferation of articles being published weekly, is further support for the use of diffusion tensor imaging in documenting and diagnosing traumatic brain injury.

The Brain Injury Community Has Lost Neuropsychologist Irene Parisi, Ph.D.

rdeluca@stark-stark.com (Bruce H. Stern) — Wed, 18 Apr 2012 15:47:11 -0500

I was sadden to learn of the passing of Irene Parisi, Ph.D. Irene was a neuropsychologist who devoted her life to advocating on behalf of those individuals with acquired traumatic brain injury. For many years, she was a leader with the Brain Injury Association of America and Brain Injury Alliance New Jersey (formerly the Brain Injury Association-New Jersey).

She was a graduate of St. John's University, where she received her bachelor's, two master's degrees and her Ph.D. in psychology. She also received a master's in public health from Rutgers University. She was a longtime volunteer and past president of the Brain Injury Alliance of New Jersey. She was the first neuropsychologist to serve on the board of directors and was instrumental in the advancement and growth of the organization through its development. Dr. Parisi's commitment was evident in her more than 25 years of service on the board.

No one was more devoted than she. She will surely be missed.

Neuro Pathology of Mild Traumatic Brain Injury (TBI): Relationship to Neuro Imaging Findings

rdeluca@stark-stark.com (Bruce H. Stern) — Mon, 16 Apr 2012 08:01:43 -0500

I just finished reading an outstanding article entitled Neuro Pathology of Mild Traumatic Brain Injury: Relationship to Neuro Imaging Findings authored by Erin D. Bigler, Ph.D. and William L. Maxwell, ScD that appeared in a mild TBI special issue published by the Journal of Brain Imaging and Behavior (March 21, 2012). As indicated in the abstract “neuroimaging identified abnormalities associated with traumatic brain injury are but gross indicators that reflect underlying trauma-induced neuro pathology at the cellular level. This review examines how cellular pathology relates to neuro imaging findings with the objective of more closely relating how neuroimaging findings reveal underlying neuropathology.”

This article is a must read for neuro-attorneys representing both plaintiff and defense parties. The authors note “because of improvements in imaging technology [DTI among others] and methods of analysis, contemporary neuroimaging studies consistently demonstrate structural and metabolic abnormalities associated with MTBI (Mild Traumatic Brain Injury).”

This study is important as it provides to accepted authoritative published studies using DTI to document abnormalities in the brain of mild traumatic brain injury patients. It also helps debunk many of the defense myths and defenses which are advanced in neuro-litigation.

The article debunks such defense myths as:

Negative CT scan means no injury.
TBI is a singular event that is over immediately after the traumatic event.
Mild TBI is of self limiting duration.
MTBI symptoms are non heterogeneous.
Brain injuries from motor vehicle crashes are similar to those sustained in sports injury.

I have often heard both lawyers and defense doctors state that no brain injury could have occurred when the injury is not documented in an emergency record. This article debunks this belief. The authors state, “[t]he metabolic effects of MTBI may occur over hours or a few days. As such, the ‘acute’ MTBI timeframe of injury should be considered longer than just the immediate impact and presentation of the patient, but rather to extend to about 72-96 H from the time of injury…. The dynamic processes of the injured axon has often been considered as two waves of pathological effects, the first being the biomechanical traumatic even with its accompanying immediate structural injury and the second wave the sum total of evolving pathophysiological and patho-anatomical effects that may take days to weeks to months to develop in which may also intertwine with the effects of development and aging.”

The article also supports the use of the diffusion tensor imaging and the diagnosis of mild traumatic brain injury, and contains excellent citations from numerous DTI studies involving patients with mild traumatic brain injury.

The article concludes:

It must also be recognized that prior to the recent technological improvements in neuro imaging, clinicians often discounted the neuro pathological effects of an MTBI. Recognition of such post-traumatic pathological changes in MTBI combined with improved understanding of the biological and biomechanical mechanisms of such changes provides insight into how persistent symptoms may emerge in mild TBI.

As indicated, this is a must read.

New Harvard Study Upholds Use of DTI in Mild Traumatic Brain Injury

rdeluca@stark-stark.com (Bruce H. Stern) — Fri, 13 Apr 2012 08:52:33 -0500

I am so excited about a recent article entitled A Review of Magnetic Resonance Imaging and Diffusion Tensor Imaging Findings in Mild Traumatic Brain Injury which was authored by ten experts in the field from Harvard Medical School.The paper supports the use of DTI in diagnosing mild traumatic brain injury. The article was published in Brain Imaging and Behavior, March 22, 2012.

The authors recognize that conventional tools such as MRI and CT do not adequately depict brain injury in mild traumatic brain injury, because they are not sensitive to detecting diffused axonal injuries (DAI). This has “led clinicians typically to diagnose mTBI on the basis of clinical and cognitive symptoms, which are generally based on self-report and are non-specific as they overlap with other diagnoses….” Further, the authors state that while “most of the symptoms of mTBI are transient and resolve within days to weeks, approximately 15-30% of patients evince cognitive, physiological, and clinical symptoms that do not resolve three months post-injury” and that “these symptoms persist and in some cases lead to permanent disability and to what has been referred to as persistent post-concussive symptoms or post-concussive syndrome.” The authors conducted a literature review, finding that there is evidence for brain abnormalities in mTBI based on studies using advanced MRI/DTI neuro imaging techniques. The authors state, “importantly, these advances make it possible to use more sensitive tools to investigate the subtle brain alterations in mTBI…. Taken together, the findings presented below suggest that more sensitive neuro-imaging tools improve the detection of brain injuries in mTBI (i.e. diagnosis)….With the advent of DTI, however, DAI/TAI have the potential to be quantified and this information can be used for diagnosis, prognosis and for the evaluation of treatment efficacy.”

The authors conclude in summary, that while there was a great deal of variability in DTI, “nonetheless [they] were striking in that they all suggest that radiological evidence support small and subtle brain injuries in mTBI…. This evidence would not be possible if conventional MRI and CT scans alone were used to establish brain injury; it takes more advanced and sophisticated methods such as DIT that are sensitive to diffuse axonal injury to delineate these abnormalities.”

Department of Defense & Department of Veterans Affairs Work Together to Identify Traumatic Brain Injuries (TBI)

rdeluca@stark-stark.com (Bruce H. Stern) — Wed, 11 Apr 2012 08:16:07 -0500

The Department of Defense (DOD) and the Department of Veterans Affairs (VA) are currently working together in an effort to more effectively identify and treat traumatic brain injuries (TBI).

Kathy Helmick, deputy director for TBI at the Defense Centers of Excellence states, “The DOD goes hand-in-hand with the military services with early detection, understanding the barriers, and having the collaborators and partners in advancing the science. We want to eliminate undetected mild brain injury, and we do that with aggressive screening programs.”

The VA and DOD are working in conjunction with several academic institutions when it comes to traumatic brain injuries (TBI), in order to improve the methods by which service members suffering from TBI are treated. Among the agencies that they work with towards this end are the National Institutes of Health in Bethesda, Md., and the Centers for Disease Control in Atlanta.”

Election of New International Brain Injury Association's Board of Governors

rdeluca@stark-stark.com (Bruce H. Stern) — Mon, 09 Apr 2012 08:09:48 -0500

At the board meeting of the International Brain Injury Association Board of Governors, Don Stein, M.D. (USA) and Bernhard Sabel, Ph.D. (Germany) were re-elected to another four year term. Joining Drs. Stein and Sabel are as follows: Marilyn F. Kraus (USA); Ron Savage, Ed.D. (USA); Grant Iverson, Ph.D. (Canada); Jan E. Lexell, M.D. (Sweden); Enrique Noe Sebastian, M.D., Ph.D. (Spain); Olli Tenovuo, M.D. (Finland); Philippe Azouvi, MD – France and Lisandro Olmos, M.D. (Argentina).

In 2014, the 10th World Congress on Brain Injury will be held in San Francisco, California, from March 19-23, 2014. I am proud to share with everyone that David Arciniegas, M.D. was elected president of the 10th World Congress.

The International Brain Injury Association's Holds Post Congress Symposium

rdeluca@stark-stark.com (Bruce H. Stern) — Thu, 05 Apr 2012 08:01:54 -0500

On Sunday, following the IBIA World Congress Gala, we all traveled to Glasgow, Scotland, a city made famous as the location for many ground breaking advances in brain injury research and treatment. The highlight of the trip was a lecture by Sir Graham Teasdale and other renowned experts at the historic Royal College of Physicians and Surgeons of Glasgow, which was founded in 1599 by King James VI of Scotland.

The speakers reviewed the key contributions made by the “Glasgow Clan” over the past four decades. Dr. Teasdale and his colleagues discussed the development in Glasgow of approaches to assessment of early severity and late outcome of brain injury, as well as how they have been applied and modified over the years. The identification of avoidable adverse events in management in the acute stage and how they are addressed and efforts to minimize the effects of late sequelae were discussed. The relationships between neuropathological findings and late survivors and the extent of persisting impairment and the potential role of long-term processes was presented. Finally, the spread of international interest and collaboration in brain injury research resulting in the improvement of outcome was identified.

It was a real treat to travel to this historic city to hear from these outstanding physicians.

Members of UNC Create App to Aid in the Diagnosis of Concussions

rdeluca@stark-stark.com (Bruce H. Stern) — Tue, 03 Apr 2012 08:08:02 -0500

Jason Mihalik, an assistant professor of Exercise and Sports Science in UNC’s College of Arts and Sciences, and Gerard Gioia, member of the UNC’s class of 1984 who currently works for the Children's National Medical Center and George Washington University School of Medicine in Washington, D.C., co-authored a smartphone app which could help players, coaches and parents determine if someone has suffered a concussion.

The Concussion Recognition and Response App uses a checklist of symptoms like dizziness and memory problems, to guide the user through a series of questions in order to evaluate whether or not someone has suffered a concussion. The App does not provide a diagnosis, but rather provides feedback to the user to aid in the determination if the player should be removed from a game and seek additional medical attention. Removing concussed athletes from activity can be critical. A second impact after an initial head injury can often bring catastrophic consequences.

Microsoft Co-Founder, Paul Allen, Donates $300 Million to Traumatic Brain Injury (TBI) Research

rdeluca@stark-stark.com (Bruce H. Stern) — Fri, 30 Mar 2012 08:13:44 -0500

One of the co-founders of Microsoft, Paul Allen, announced last week that he will donate $300 million to the Allen Institute for Brain Science over the course of the next 10 years. The Allen Institute is a non-profit organization established by Allen, which focuses on counting and classifying the different types of neurons, illuminating the molecular machinery within the cells that can cause problems, and studying how the cells process information in networks, using as a model the visual system in mice.

Allen’s donations to the field of brain injury currently exceed over $500 million. Allen’s mother currently suffers from Alzheimer’s and so this research is close to Allen’s heart.

The Allen Institute was founded in 2003 as a resource for researchers. Since that time, the Institute has created brain “atlases” of the mouse and adult human brains and electronic maps accessible online that show which genes are switched on in neurons. The site has been getting about 50,000 visits per month.

Gala Award Winners from the International Brain Injury Association's 9th World Congress on Brain Injury

rdeluca@stark-stark.com (Bruce H. Stern) — Wed, 28 Mar 2012 07:48:38 -0500

The International Brain Injury Association (IBIA) held its gala awards dinner at the Ninth World Congress on Brain Injury this past Saturday evening. The gala awards dinner was held at the National Museum of Scotland, considered by many to be Scotland’s finest example of Victorian architecture.

As announced earlier, Harvey Levin, Ph.D. was the winner of the Jennett Plum award for distinguished scientific contributions to the field of brain injury. Anne-Lise Christensen, Ph.D. was awarded the lifetime achievement award for her work in brain injury rehabilitation. Dr. Christensen is a Danish neuropsychologist, professor, neuropsychological rehabilitation, University of Copenhagen who, in 2008 received the International Neuropsychological Society distinguished career award presented in recognition of her outstanding lifetime contribution to the field of neuropsychology and to the INS.

Rounding out the main awards was Juan Carlos Arango-Lasprilla, Ph.D. Dr. Arango-Lasprilla is an assistant professor of the Department of Physical Medicine Rehabilitation at Virginia Commonwealth University. He has been the recipient of numerous awards and has been nationally and internationally recognized for his work in the area of brain injury and cultural issues.

Congratulations to all award winners.