Legal Update #20 Discerning Fact from Fiction: Symptom Consequences in Mild Traumatic Brain Injury

NLBC LEGAL UPDATE: September, 2004 - Issue #20

Sam Goldstein, Ph.D., Editor.
Complimentary Service of the Neurology, Learning and Behavior Center

BRIEF LEGAL UPDATES

The Neurology, Learning and Behavior Center provides multi-disciplinary, clinical and forensic assessment, case management, trial consultation and treatment services for children and adults with brain injury and dysfunction, Attention-Deficit Hyperactivity Disorder, language disorders, learning disability, developmental delay, emotional disorders, Autism and adjustment problems. The Center is dedicated to the provision of treatment services.

Discerning Fact From Fiction:
Symptom Consequences in Mild Traumatic Brain Injury

Mild traumatic brain injury continues to be among the most common neurologic disorders, hypothesized to occur in up to 90% of all sustained brain injuries. An increasing volume of studies have investigated symptoms associated with mild traumatic brain injury specifically because of the controversy that many of these symptoms are generic and present in a host of psychological and medication conditions. The majority of studies demonstrate that symptoms of concussion and mild traumatic brain injury largely resolve with three months post injury, with most individuals reporting full recovery. However, a small sub-group of individuals continue to report persistent symptoms beyond three months with some individuals reporting impairment many years post injury. The relationship between concussion and chronicity of post-concussive symptoms or, for that matter, full syndrome post-concussive disorder, continues to be debated. Though an accepted medical diagnosis, Postconcussional Disorder continues to be among conditions considered requiring further research before inclusion as an accepted clinical condition by the American Psychiatric Association. Thus, Postconcussional Disorder does not appear as a defined Axis I condition in the Text Revision of the Fourth Edition of the Diagnostic and Statistic Manual of the American Psychiatric Association.

The physical, cognitive, emotional and behavioral symptoms associated with mild traumatic brain injury are often used in the forensic arena absent independently supported diagnostic data to demonstrate the experience of a neurologically traumatic incident and the persistence of post incident consequences. However, with the increasing focus on scientific foundation for expert opinion and testimony, attorneys must be aware that using these symptoms as proof of injury and impairment may place their forensic expert on very thin scientific ice. A recent study published in the Archives of Clinical Neuropsychology by a Canadian research group (Volume 19, 2004, pages 805-816) provides an overview of the longitudinal patient complaints following treated mild traumatic brain injury. Previous studies either have not employed a longitudinal design or if they did, suffered from methodological limitations. However, one longitudinal controlled study in 2000 compared post mild traumatic brain injury symptoms in a large population compared to participants with other minor injuries. By three months, the brain injured individual's symptoms reported at one week in this study had largely resolved. It should be noted, however, that this study included individuals with a history of previous head injury, neurological or psychiatric problems. Interestingly, participants who were symptomatic three months post injury were more likely to have met one of these additional criteria.

In the Canadian research group study, one month post accident, mild traumatic brain injury patients in comparison to controls evidenced significantly more complaints for poor balance, doing things slowly and fatiguing easily. None of the other forty symptoms assessed demonstrated significant difference between controls and individuals with mild traumatic brain injury. It is the case that one month post injury the mild traumatic brain injury group endorsed more items than participants in the control group. In the Canadian study the control group consisted of 118 adult participants recruited from university hospital and municipal government work places. Mild traumatic brain injury patients met criteria for the American Congress of Rehabilitation Medicines' 1993 definition of mild traumatic brain injury.

At follow-up, three months post-injury, differences were minimal between the control and mild traumatic brain injury groups with only three of forty-three items endorsed significantly. This study suggested that mild traumatic brain injury improved from baseline to follow-up, a finding consistent with previous research. Among the most commonly endorsed symptoms at follow-up were fatigue, mood swings, sleep problems, headache and irritability. These symptoms were endorsed in over 47% of mild traumatic brain injury patients. Interestingly in this study, headache was endorsed at a higher rate by the control group. Further, symptom endorsement within the control group changed from baseline to follow-up, contributing further to the evidence of the existence of traumatic brain injury like symptoms in the normal population. This also suggested symptom complaints can be highly variable, even within unaffected individuals. Doing things slowly, fatiguing quickly and poor balance were the same three post-concussive items with the highest differences in endorsement between the brain injury patients and controls at baseline and follow-up.

The following ten symptoms were most commonly endorsed by the mild traumatic brain injury patients:

The items that improved the most in the traumatic brain injury patients over the three month follow-up included poor balance, doing things slowly, fatiguing quickly, headache, dizziness, poor concentration, forgetfulness, difficulty thinking clearly, changes in appetite and sleep disturbance.

It is of interest to note the ten most commonly endorsed symptoms for the head injury and control groups by percentage were:

It has become increasingly apparent that symptoms of mild traumatic brain injury whether physical, cognitive, emotional or behavioral represent the most common complaints independent of etiology or, for that matter, when no specific etiology has been identified. The trend in the emerging data has been consistent. It is likely that research in the immediate future will provide added support for this phenomena. Attorneys employing forensic experts, whether medical or neuropsychological, should be careful and cautious when the basis for proving mild traumatic brain injury is found to reside in immediate or, for that matter, chronic complaints over time. This is not to suggest that the presentation of these symptoms is unimportant but rather to offer the opinion that these symptoms are a good place to start but insufficient for building the case for mild traumatic brain injury and consequent life impairment.

Selected References

Alexander, M.P. (1992). Neuropsychiatric correlates of persistent post concussive syndrome. Journal of Head Trauma Rehabilitation, 7, 60-69.

Alexander, M.P. (1995). Mild traumatic brain injury: Pathophysiology, natural history and clinical management. Neurology, 45, 1253-1260.

Alves, W., Macciocchi, S.N., & Barth, J.T. (1993). Post-concussive symptoms after uncomplicated mild head injury. Journal of Head Trauma Rehabilitation, 8, 48-59.

Chan, R.C. (2001). Base rates of post concussion symptoms among normal people and its neuropsychological correlates. Clinical Rehabilitation, 15, 266-273.

Dikmen, S., Machamer, J.E., Winn, R., & Tempkin, N. (1995). Neuropsychological outcome at one year post head injury. Neuropsychology, 9, 80-90.

Kashluba, S., Paniak, C., Blake, T., et al. (2004). A longitudinal controlled study of patient complaints following treated mild traumatic brain injury. Archives of Clinical Neuropsychology, 19, 805-816.

Paniak, C., Reynolds, S., Phillips, K., et al. (2002). Patient complaints within one month of mild traumatic brain injury: A controlled study. Archives of Clinical Neuropsychology, 17, 319-334.

Ponsford, J., Willmott, C., Rothwell, A., et al. (2000). Factors influencing outcome following mild traumatic brain injury in adults. Journal of the International Neuropsychological Society, 6, 568-579.

Thornhill, S., Teasdale, G., & Murray, G., et al. (2000). Disability in young people and adults one year after head injury. Prospective study. British Medical Journal, 320, 1631-1635.