UNDERSTANDING TRAUMATIC BRAIN INJURY

It is common knowledge in the brain injury community that the public does not understand the seriousness of head trauma. Television and movies are filled with images of brain injury that are wrong and can make working with brain injured patients much more difficult.

This current study ¹ compared current perceptions in the general public about traumatic brain injury (TBI) with perceptions shown in previous studies conducted up to 13 years ago. The goal was to see whether public awareness has increased over the years, and to look at misconceptions that could affect outcomes in personal injury litigation cases. 

179 individuals conducting business at a motor vehicle department in Rhode Island participated in the study by completing a 19-item survey. The mean age of participants was 42.5 years, with 45% male and 55% female. Nearly half (46.2%) reported some exposure to TBI in the past, with 17% reporting having suffered a TBI themselves, 13% indicating that a family member had suffered from a TBI, 11% noting that they encountered TBI on a daily basis through work, and 6% stating they had a friend who had suffered from TBI.

The 19-item survey evaluated knowledge about TBI, its cause, effects, and recovery from it, with 11 items drawn from previous surveys created by Gouvier ² and Willer. ³ The study authors also created 8 items designed to specifically address issues relevant to head injury litigation. Participants chose between "true", "probably true," "false," or "probably false" when answering survey questions.

Questions addressed such areas as memory loss after TBI, functional ability after TBI, the ability to return to work after moderate or severe TBI, whether complete recovery from a severe head injury is possible, learning ability after TBI, and whether brain damage matters in functioning. The forensic questions addressed whether it is possible to fake brain damage, the motivation for litigation, how brain damage is determined, whether being drunk at the time of injury "lessens" the impact of the injury, the ability to return to vocational functioning after TBI, and whether TBI affects men and women differently.

The percentage of misconceptions/wrong answers to questions about TBI in this study was overall very similar to the results obtained years ago in previous studies, especially in regards to moderate to severe injury. For instance, 42% of respondents believed that a second blow to the head could improve memory functioning after TBI, based, the authors believe, in part of the role of media and even cartoons in educating the public about TBI.  Study participants were more knowledgeable about mild TBI in this study than in Gouvier's previous study, with a larger number of respondents realizing that brain damage can occur without loss of consciousness, or from whiplash injuries.

The forensic questions showed that 25% of respondents believed it would be easy to fake brain injury, and 40% of those surveyed believed that most litigation surrounding brain injury is to obtain money, and not related to a real injury. 60% of the respondents believed that severe brain injury does not disrupt vocational functioning, and 66% believed that an X-ray was the only reliable way of determining if someone has suffered brain damage from TBI.

Perceptions about TBI were not affected by age, gender, or educational level. Exposure to those with TBI (self, family, friends) did decrease the number of true answers to the item, "The only sure way to tell if someone has suffered brain damage is by an X-ray of the brain."

Discussion

Based on study results, the authors note, "…no significant change in the level of knowledge about moderate to severe brain injury has taken place within the last 8-13 years…geographical region is also unrelated to TBI misconceptions." 

The effect of the popular misconceptions noted in the study on patients with TBI can include frustration in themselves and others, and "may impede re-integration back into the community," note the authors. The authors note that education, including initial assessment with a survey and providing materials, is important not only for patients and family members, but for insurance providers and workmen's compensation carriers in obtaining adequate care for this group.

The authors raise concerns about the large percentage of pre-existing misperceptions found during the survey about the ability to fake brain injury, that all litigation is financially motivated and not based on true injury, and that X-rays are the only reliable indicator if brain damage has occurred, on jurors during litigation. They conclude,:

"It would seem wise for attorneys to invest substantial time and effort in educating jurors about the realities of TBI, in turn counteracting false beliefs and reestablishing proper impartiality in the jury."

They feel this should be combined with ongoing public education about the effects of moderate and severe TBI to counteract misconceptions, which have overall changed little in the past 13 years.

1. Guilmette TJ, Paglia MF. The public's misconceptions about traumatic brain injury: a follow up survey. Archives of Clinical Neuropsychology 2004;19:183-189.
2. Gouvier DW, Prsetholdt PH, Warner MS. A survey of common misconceptions about brain injury and recovery. Archives of Clinical Neuropsychology 1988;3:331–343.
3. Willer B, Johnson WE, Rempel RG, Linn R. A note concerning misconceptions of the general public about brain injury. Archives of Clinical Neuropsychology 1993;8:461–465.

There is a wide range of whiplash symptoms. The most common, of course, are neck pain and headache, but a substantial percentage of patients report other, more difficult to understand problems as well. Some of these symptoms include dizziness; problems with balance; difficulties with attention and concentration; and sleep disturbances.

A number of theories have been put forth to explain these myriad symptoms. Some researchers have suggested that brain injury is responsible, while the insurance industry insists that these symptoms are fabricated.

A recent study ¹ from Sweden attempts to answer some of these questions by examining the functions of the brain in whiplash patients.

The study started with 40 patients with grades II and III whiplash injuries. The patients were given neuro-otological tests within two months of the injury and again two years later. These tests included auditory brainstem response tests (ABR) and oculomotor function tests, including evaluation of saccades (the rapid, step-like voluntary motion of the eyes used when reading or scanning an image).

ABR tests involve measuring the patient's neurological response to a repetitive sound stimulus:

"A brief sound causes a series of electrical waves, in the nanovolt range, that can be recorded from the surface of the head. The signals are so small that they are normally buried in background electrical noise, but when the same brief stimulus is presented many times and the responses are averaged, the waves can be measured reproducibly. Early peaks in the waveform represent electrical activity in the eighth nerve arriving at the cochlear nuclei, and later peaks represent combined activity at successive sites in the auditory pathway." ²

By analyzing the waveform, it is possible to identify dysfunction along the neurological pathway.

Results

At the two-year follow-up, 16 of the patients (40%) had no symptoms from the original injury. Ten patients (25%) complained of intermittent neck pain, headache, and radiating pain in one or both arms. Four patients (10%) also reported memory impairment, concentration problems, and showed neurological deficits. Another 4 patients (10%) were still on sick leave.

In the smooth pursuit tests, 5 patients showed abnormalities in the first test. Three of these patients improved, but two showed worse results at the two-year follow-up. These two patients who worsened over time also showed problems with their ABR tests.
Ten patients showed a worsened score on saccade velocity at the two-year follow-up.

What is at the root of the chronic pain and the neuro-otological signs? The authors suggest two possible explanations: altered neurological responses of the brainstem, and direct trauma to the brainstem.

The first explanation would describe the symptoms of most chronic whiplash patients and works as follows: The cervical spine plays a key role in how the brain maintains balance, and signals from the injured cervical spine travel through the spinal core to the brainstem—specifically the vestibular and oculomotor nuclei. This is the same part of the brain that receives the signals from the inner ear, via the eighth cervical nerve. A painful neck can cause overexcitation of the nerve pathways, resulting in altered functioning of the brainstem. These alterations in the brainstem can in turn cause dysfunction in eye motility and balance, since these different systems all work together as the Posture Control System.

Most patients with chronic whiplash pain and ocular and auditory signs would fit in this category. However, this mechanism may not account for those patients with the most severe symptoms: "In the present study, we found two patients with pronounced pursuit abnormalities compatible with organic brain/brainstem lesions."

So, according to this small study, about 2% of whiplash patients have signs of brainstem damage. This may seem like an insignificant number, but when we consider that there are approximately 1 million whiplash injuries in the US each year, there may be 20,000 cases of brainstem injury from auto collisions annually.

This study provides two important pieces of information about chronic whiplash: the first is that ABR and saccade tests are an objective way to measure altered neurology in these patients; the second is that some patients may have actual brain injury from these collisions.

For patients with more severe symptoms, it may be advisable to have them evaluated for saccade movements and ABR by an audiologist.

1. Wenngren BI, Pettersson K, Lowenhielm G, Hildingsson C. Eye motility and auditory brainstem response dysfunction after whiplash injury. Acta Otolaryngologica 2002;122:276-283.
2. Nolte J. The Human Brain: An Introduction to Its Functional Anatomy. 2002, Mosby, p. 355.

The biggest challenge with treating auto injuries is getting a proper diagnosis. Countless studies show that whiplash patients have objective, organic injuries; unfortunately, many of these injuries are difficult to pinpoint with conventional diagnostic imaging techniques, such as CT or MRI.

Further complicating diagnosis is the fact that the focal point of the injury in most patients is the neck. Due to the complexity of the cervical spine, many different structures can be injured and the symptoms of different types of injuries can overlap with other kinds of injuries.

A current study looks at this problem; specifically, it examines the diagnostic challenge of differentiating whiplash associated disorder (WAD) from concussion in patients with neck injuries.

For many years, researchers have realized that many patients with whiplash present with symptoms similar to patients with brain injury. The chart shows the most common symptoms of brain injury. Over the last ten years, dozens of studies have been published showing that many whiplash patients complain of the same problems. The challenge is to determine which patients have TBI and which have spinal injuries.

The authors decided to study the issue by looking at hockey players. They followed 20 teams (183 players) for a single season. During that time, 13 players received either a whiplash injury or a concussion. Each of the injured players was given a thorough examination. This is what the study found:

• All of the patients with whiplash injury (6 players) reported concussion symptoms, even if the patient had the least severe type of whiplash injury.
• "Full resolution of concussion symptoms at the 7-10 day follow-up evaluation was reported by five of the 13 subjects. Of these five subjects, two were still experiencing WAD symptoms."
• 12 of the 13 injured players reported headache; 10 of the 13 reported dizziness.

At the 7-10 day follow-up:

• 6 of the 13 injured players reported a complete resolution of whiplash symptoms, but three of the six were still experiencing the symptoms of concussion.
• "Full resolution of concussion symptoms at the 7–10 day follow-up evaluation was reported by five of the 13 subjects. Of these five subjects, two were still experiencing WAD symptoms."
• "Overall, only three of the 13 subjects or 23% experienced full resolution of both their WAD and concussion symptoms at the follow-up evaluation."

The authors have this to say about their findings:

"The athletes studied in this investigation experienced symptoms of both WAD and concussion after a head and/or neck complex acceleration/deceleration injury. However, the number of concussion symptoms they experienced did not associate with an increased severity of WAD grading. Symptom resolution during the 7–10 day follow-up period differed between athletes and injury mechanisms. Based on the observed prevalence of symptoms of both WAD and concussion irrespective of the mechanism of injury, it is important for the clinician treating a patient or athlete for WAD to evaluate for symptoms of concussion and for the team therapist/clinician to be cognizant of conducting a thorough cervical evaluation when dealing with concussed players."

The same holds true for non-athlete patients in motor vehicle collisions. Because symptoms of traumatic brain injury can overlap with those of cervical spine injury, patients with symptoms of brain injury should be carefully examined for the presence of concussion.

Of particular concern are those patients who don't seem to be recovering from the current treatment, or for those patients who experience personality changes after the collision. Undiagnosed brain injury can result in unemployment, divorce, depression, and other serious social and medical problems.

Hynes LM, Dickey JP. Is there a relationship between whiplash-associated disorders and concussion in hockey? Brain Injury 2006;20(2):179-188.

Post-Concussion Syndrome (PCS) has been identified as causing debilitating symptoms in some people with mild traumatic brain injury. These symptoms include emotional changes, cognitive dysfunction, as well as physical pain.

The problem is that many of the symptoms of PCS are the same as those experienced by patients with chronic pain. The challenge is to determine the actual origin of the symptoms so that proper treatment can be implemented.

This current study's goal was to carefully examine the symptoms reported by both brain injured patients and those individuals with chronic pain.

The study was composed of 63 patients with chronic pain (CP) and no history of neurological problems, and 32 patients with mild traumatic brain injury (MTBI). The CP patients came mainly from a multidisciplinary CP treatment program at a local rehab hospital (78%) and from the authors' private practices. Any patients with a history of head injury were excluded from this group. The MTBI patients came from outpatient evaluations at a local teaching hospital (41%) and the authors' private practices (59%). Patients with pain from injuries other than MTBI were excluded from this second group.

One factor that made differentiating the two groups difficult is that most of the MTBI patients complained of pain (27 out of the 32); in fact, pain is often associated with seeking treatment in MTBI. They most frequently reported headaches, but also reported other symptoms.

Both groups were administered the Rivermead Post Concussion Questionnaire, a 16-item questionnaire that relies on self-reporting of symptoms based on their severity, and how the patient perceived their functioning prior to injury.

The questionnaire evaluated:

• Somatic symptoms: headache, dizziness, nausea, noise sensitivity, sleep disturbance, fatigue, light sensitivity, and double vision.
• Emotional symptoms: irritability, depression, frustration, impatience, restlessness
• Cognitive symptoms: memory problems, concentration problems, taking longer to think.

Study Results

While the total scores on the Rivermead questionnaire were slightly higher for the MTBI group, their overall scores did not differ significantly from those for patients with CP overall.

The MTBI group did have more cognitive symptoms, while those with CP demonstrated more emotional symptoms when tested. However, a significant percentage of the patients with CP stated they had symptoms typically associated with MTBI. For instance, 67% of the CP group noted problems with memory, and 78% noted difficulty with concentration since their injury.  From these findings, it is clear that it is not possible to accurately diagnose MTBI based on cognitive symptoms alone.

After all the data was analyzed, there were some trends that could be useful in detecting the presence of chronic pain in some patients. Chronic pain patients were more likely to:

• Report nausea
• Complain of sleep disturbances
• Report fatigue and irritability
• Report symptoms of depression
• Complain of restlessness

The percentage of patients in the two groups meeting the criteria for post-concussion syndrome was very similar:  81.3% of the MTBI patients, and 82.5% of the patients with CP, so there is obviously a large overlap in symptoms reported by both groups of patients.

Chronic pain and brain injury are both serious conditions that require different treatment regimens. If either condition is misdiagnosed, this will delay the proper treatment and result in even more problems down the road. These patients should be referred as soon as possible for a correct diagnosis.

Traumatic brain injury (TBI) is a complex issue for a variety of reasons. First, many cases of TBI go undiagnosed for months or even years. Since patients with head injuries often times have other injuries, the brain trauma may not receive the attention it deserves.

Another problem with head injury is that it often results in psychological symptoms that can complicate the diagnosis and treatment. Traumatic brain injury can result in depression, changes in personality, anxiety, paranoia, or apathy. One of the most frustrating and challenging symptoms is aggression.

The authors of a current study on aggression after brain injury stated the problem succinctly:

"Associations between TBI and neuropsychiatric disorders have been recognized for many years. Aggressive behavior is one of the most socially and vocationally disruptive consequences of these neuropsychiatric disorders. Aggression endangers the safety of patients, families, and caregivers. It may prevent patients from receiving the care that they need and disrupt their rehabilitation process. Estimates of the frequency of aggressive behaviors during the acute period after TBI have ranged from 11% to 96%."

In this study, the researchers assessed 89 patients with TBI and 26 patients with multiple traumas, but without TBI. All of the TBI patients in the study had post-traumatic amnesia that lasted at least 30 minutes.

Aggressive behavior was assessed with the Overt Aggression Scale (OAS). The OAS allows clinicians to quantify aggression by defining four categories of aggressive behavior: verbal aggression, physical aggression against objects, physical aggression against self, and physical aggression against others. All patients also received a thorough psychiatric assessment. The authors found the following:

The frontal lobe (shown here in blue)
regulates higher "executive" functions
of the brain, such as conscious thought,
memory, intelligence, concentration,
behavior, and personality. Injury
to the frontal lobe can result in
aggression in some patients.

• Patients with TBI were much more likely to exhibit aggression. In the TBI group, 33.7% met the criteria for aggressive behavior in the first six months after injury, while only 11.5% of the non-TBI patients did.
• Within the TBI group there were no significant differences between the aggressive and the non-aggressive groups in age, gender, race, years of education, socioeconomic status, or history of anxiety disorder.
• There was a strong relationship between depression and aggression: of the 30 aggressive patients, 17 also met the criteria for major depression.
• Aggressive patients also suffered from poorer social functioning.
• Patients with aggressive behavior were more likely to have injuries to the frontal lobe. While non-aggressive patients were more likely to have diffuse brain injuries.
• Patients with aggressive behavior had a significantly higher frequency of legal interventions for aggressive behavior prior to the brain injury, and were more likely to have a history of drug or alcohol abuse.

Clearly, patients with a history of closed head injury and aggressive behavior are at a disadvantage when it comes to receiving proper treatment and vocational rehabilitation. The authors of this current study conclude:

"In summary, aggression following TBI is associated with multiple biological and psychosocial factors, including major depression, substance abuse, and impaired social function as well as the presence of brain injury involving the frontal lobe. These findings suggest that interventions aimed at treating major depression or substance abuse and improving social function may help reduce episodes of aggression in patients who have suffered traumatic brain injury."

Clinical Implications

Aggression after an injury may be due to brain damage. Patients that show signs of aggression should be carefully evaluated for the existence of head injury, and proper treatment should be sought out.

Tateno A, Jorge RE, Robinson RG. Clinical correlates of aggressive behavior after traumatic brain injury. Journal of Neuropsychiatry and Clinical Neurosciences 2003;15:155-160.

Injuries to the olfactory bulb or the
frontal area of the brain may result
in alterations in the sense of smell.

Previous studies have noted that traumatic brain injury (TBI) can cause changes in olfactory function, due to damage to the olfactory bulb and/or to the fronto-temporal brain areas that control the sense of smell. The purpose of this study conducted at University Hospital in Maastricht (Netherlands) was to determine the incidence of olfactory dysfunction present 2 weeks after mild traumatic brain injury (MTBI). The study was conducted between October 1996 and December 1998, with 61 male and 50 female subjects whose median age was 34.

To be included, study subjects must have presented in the emergency room within 6 hours of the original injury, and been diagnosed with MTBI. In this study, MTBI was defined as causing PTA (post trauma amnesia) of less than 1 hour, and an initial loss of consciousness of less than 15 minutes; a Glascow Coma scale score of 14 or 15 on presentation, and no focal neurological signs. Those with histories of past TBI, alcohol abuse, and psychiatric disorders were excluded from the study.

Two weeks after the initial MTBI, olfactory function (sense of smell) was assessed using a "Hyposmia Utility Kit," that utilized Phenyl methyl Ethyl Carbinol (PMEC) in different concentrations (the subject chose between the bottle with the PMEC concentration and one with plain water, to the weakest concentration they were able to discern a difference). Normal thresholds range from –25 to +25 dS; 30-55 dS is considered hyposmia (reduced sense of smell), and above 55 dS indicates no olfactory function for the odor.

One fourth of the patients in the study had impaired olfactory function two weeks after MTBI:  24 (22%) experienced hyposmia (thresholds in the 30-55 dS range) and five patients (4%) experienced anosmia, or a complete loss of smell (threshold above 55 dS).
 In a normal population without traumatic brain injury, hyposmia is present in 2%, and anosmia is present in 0.2% (per Olfacto Labs data). The study concludes that MTBI causes damage to the sense of smell, through the olfactory nerve of the frontal-cortical structures.

According to this preliminary study, a significant number of MTBI patients exhibit olfactory dysfunction. Patients with alterations in the sense of smell should be evaluated for head injury.