Traumatic Brain Injury, Concussions and Acquired Brain Disease CPANCF.COM
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Traumatic Brain Injury, Concussion and other Brain Injuries are described on this page with definitions, classifications, prognostic indicators and a description of our experience in the neuropsychological evaluation of Traumatic Brain Injury (TBI).
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A significant part of our practice involves performing comprehensive neuropscyhological evaluations of individuals who may have suffered neurological injury from trauma, strokes, toxic exposure or other means. Our office has more than 20 years of experience performing neuropsychological evaluations of children, adolescents and adults. Dr. Bordini is a neuropschologist who has testified as an expert in neuropsychology in federal and state jurisdictions in civil, administrative and criminal matters. Dr. Phalin has conducted research in the area of sports concussions. We have extensive experience in performing private clinical neuropsychological assessments as well as forensic neuropsychological evaluations.
Our office has performed neuropsychological evaluations by court appointment, plaintiff and defense requested neuropsychological Independent Medical Examinations (IME's), in death penalty cases and appeals, competency evaluations, requestst by Worker's Compensation carriers, Division of Vocational Rehabilitation, disability carriers as well as client's disability attorney-requested IME's. We have performed neuropsychological evaluations for fitness for duty requested by the Federal Aviation Administration, Hospitals, Employers, government agencies, and law enforcement agencies. We have experience evaluating impaired professions and evaluations requested by state licensing board programs such as the Physician's Recovery Network.
We specialize in detailed comprehensive evaluations which often may take 2-3 full days to complete. Comprehensive neeuropsychological evaluations include expanded Halstead-Reitan Battery, Wechsler scales and measures of memory, language, motor and executive functioning, effort (test validity), and personality. Click for a list of commonly used neuropsychological tests in the United States.
We feel that psychological or neuropsychological "assessment" as opposed to "testing" requires integration with history and observations, the analysis of convergent and multiple sources of information and examination of consistencies between tests. Neuropsychological assessment uses testing to examinine the consistency or discrepancy of test findings with formulations based upon the type of injury or disease that is suggested by the history and observations made by the psychologist.
Conclusions made by psychological or neuropsychological assessment are limited by the types of information obtained. We may spend up to three hours in conducting a structured review of history and performing a detailed mental status examination. Individuals complete a detailed review of childhood history, development, academic achievement, medical history, legal history, as well as emotional, interpersonal and occupational adjustment. Understanding of neuropsychological history also requires appreciation of possible developmental and other pre-existing disorders and of alcohol and drug use history. A comprehensive assessment also should include a formal structured mental status examination which reviews current and past symptoms.
Significant additional time, is devoted to reviewing records, which often include current and past medical records, school records and other collateral sources of information. A comprehensive report is produced. Defense as well as plaintiff requested evaluations both benefit from analysis and formal testing to determine the likelyhood that the presentation and test results can be considered valid, are potentially invalid, or characteristic of a presentation of gross exaggeration typical of malingering.
Neuropsychological assessment with neuropsychological testing involving established batteries allow for quantification of the range of normal as well as impaired behavior, identifies potential strengths for rehabilitiations and identifies as well as quantifies areas and patterns of deficit allowing for comparison with expectations for various forms of neurological illness or injury. In some cases, a determination of likely permanency can be made, while in others repeat assessment may be needed to gauge extent of recovery, response to medication or other treatment interventions or assess the possibility of compications or deterioration.
We strive to be thorough, fair, and objective and are dedicated to presenting defendable and sound diagnostic formulations and recommendations.
TRAUMATIC BRAIN INJURY(TBI) and MILD TRAUMATIC BRAIN INJURY (mTBI)
The terms head injury, traumatic brain injury and concussion are often interchanged. Traumatic brain injury and concussion both imply at least transitory and sometimes permanent disruption of norm brain functions as a consequence of some traumatic event, typically a blow or wound to the head. In fact much of the history of neuropsychological assessment can be traced to head injuries and traumas encountered in the military during war. In modern times this has been applied to concussions in sports, and unfortunately, again in the assessment of the concussive injuries now encountered by improved explosive devices and blast injuries.
Some use the term of traumatic brain injury to broadly to encompass a variety of traumas such as those which might result from toxic exposures or lack of oxygen to the brain (anoxia or hypoxia). In fact the Brain Injury Association now has information and support for these types of brain injuries as well as head trauma. It is also important to note that all injuries to the head, such a a laceration or bruise to the face or scalp are not synonymous with brain injury. At least transient disruption of brain function is assumed in concussion. Based on modern definitions, presented below, concussion is not synonymous with clear cut loss of consciousness.
In addition to classifications of concussion or severity of brain injury based on length of loss consciousness, amnesia and complications presented below, classifications of head injury also include closed head injury and penetrating head injury. Head injuries may be complicated by intracranial hemmorhages, epidural or subdural hematomas, edema, brain swelling, axonal shearing, diffuse axonal injury, immediate or delayed onset seizures, as well as coup and contre-coup effects. Brain swelling can cause the brain to push down on the brainstem and other structures at the base of the brain causing further damage, herniation and death. Sometimes the trauma causing the brain injury also directly or indirectly results in hypotension with associated hypoxia or anoxia which may result in further damage to the brain, most typically in areas involving executive functions and memory.
While there is a general correlation between severity of conussion, head injury complications and permanent effects in terms of motor, sensory, cognitive, memory, attention and/or executive functions, neuropsychological evaluation is necessary due to individual variabililty in skills and outcomes. Repeat evaluations may be necessary to determine course, improvement, or permanent injury. In litigation contexts, measures to assess validity of performance and effort are also routinely utilized.
CLASSIFICATIONS OF COMA, CONCUSSION AND TRAUMATIC BRAIN INJURY
Click on the link above for detailed descriptors of the following classifications:
COMA RATING SYSTEMS
CONCUSSION RATING SYSTEMS
American Academy of Neurology Concussion Severity- March 1997 Practice Parameter
Concussion Severity: R.C. Cantu, 1991
DSM-IV Criteria for further study
Head Injury or Traumatic Brain Injury Classifications:
Severity of Injury Based on Post-Traumatic Amnesia (PTA) Duration (Bigler, as cited in Lezak, 1995).
Traumatic Brain Injury (TBI) as defined by the 1993 Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine.
National Institute of Health (NIH) sponsored Traumatic Coma Data Bank (TCDB).
INDICATORS OF POOR PROGNOSIS FOR HEAD INJURY:
While severity of traumatic brain injury or concussion as noted above has predictive value in terms or recovery or permanency in terms of brain damage or neuropsychological functioning, other factors can contribute to a worse than expected outcome based on severity alone. These can include:
Hypoxic or anoxic complications
Loss of Consciousness
Retrograde and Anterograde Amnesia
Persistent abnormal EEG or seizures
IQ < 80
Alcohol or drug abuse history
Poor premorbid social and occupational history
Glasgow Coma Scale < 7
Pupils dilated do not react to light
Deficient Brainstem Auditory Evoked Response
In mild Traumatic Brain Injury, perception of negative functional impact
Our office has experience in evaluating possible brain injuries or neurotoxic effects of substances or toxins. Past evaluations have included pesticide exposure, ethyline oxide, carbon monoxide, Interferon, MDMA (Ecstacy), alcohol, and other drugs of abuse.
Neuropsychological Impairment Associated with Toxins:
Lead: Lead toxic exposure may cause sleepiness, apathy, and depression. With higher exposure, forgetfulness, difficulty with new learning, sensorimotor complaints, and GI complaints have been reported.
Post Traumatic Amnesia (PTA): a time period from the time of brain trauma until which there is continuous memory.
Second Impact Syndrome:
FREQUENTLY ASKED QUESTIONS (FAQs)
WHAT IS THE DIFFERENCE BETWEEN A NEUROLOGICAL AND A NEUROPSYCHOLOGICAL EVALUATION?
Neurological evaluations are typically performed by medical doctors (M.D.'s). Neurological examinations typically examine Cranial Nerves (very often omitting CN - I, olfactory sense) basic sensory and motor functions, reflexes, and muscle tone. Observations may be made about speech, orientation, mood and general level of alertness. Memory and cognition is usually examined briefly, such as asking for recall of 3 objects in five minutes, the current or past president's etc. Sometimes a more formal measure such as the Mini-Mental Status is performed. The neurologist relies on medical history, neuroimaging, laboratory findings, and studies such as the EEG. Some neurologists are trained in behavioral neurology and may perform other brief tests of naming, construction, praxis, and/or motor planning. While neurologists generally have the most expertise in a "neurological examination", one may often see a basic neurological examination performed in emergence settings or as part of a general physical examination. Psychiatrists or neuropsychiatrists may also employ some or all of the above techniques and measures.
A neuropsychological evaluation is typically performed by a neuropsychologist (normally a Ph.D. and sometimes a Psy.D.) licensed as a psychologist. Both the neurological and neuropsychological examination rely upon history and symptoms, and reports of medical findings are considered. Neuropsychological evaluations typically involve neuropsychological testing which includes assessment of general intelligence, basic achievement, sensory, motor, spatial, constructive, language, attentional, memory, learning, and executive functions as well as coping, personality, and adjustment. This is a more lengthy process, but offers the advantage of greater sensitivity to deficits than the typical neurological evaluation or even imaging techniques. Tests are generally well standardized allowing for fine grain comparisons with age, education and between-test differences. In litigation or forensic contexts standardized and embedded measures of test validity and/or adequacy of effort are employed, allowing for greater confidence about the validity of results.
MY DOCTOR DID A MINI-MENTAL STATUS EXAMINATION, ISN'T THAT ENOUGH?
The Mini-Mental Status Examination was primarily designed to examine for gross deficits associated with dementia in the elderly. While it has some use as a general screen and examining for gross changes over time, it has limitations in terms of diagnosing more specific or milder disorders, particularly in younger or more intelligent individuals. It also lacks any measure of effort or test validity, making it generally unsuitable by itself for forensic settings.
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