A Collection of Medical & Legal Information About Brain Injury


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Insurance Company Blindness

There has been a great deal of advancement in the field of traumatic brain injury in the past twenty years, but unfortunately the insurance industry would just assume go back in time to the 1970’s and stay there.  This is because the recent advances in neuroscience and study of the brain have shown us that many of our earlier ideas about the brain were wrong.


Insurance companies continue to defend brain injury cases as they did twenty years ago by relying on medical ideas that are no longer valid – that someone must be rendered unconscious to suffer a traumatic brain injury, that a person with a normal CT or MRI cannot have a brain injury, that there is no mechanism by which brain injury can occur in the context of a mild traumatic brain injury.  How do they get away with treating claimants in this way, as if science had not progressed in the last twenty-years?  They do it, in part, by relying upon hand picked doctors to perform their compulsory medical exams (CME’s).  These examinations are part of every significant case that goes into litigation.  The court, the claimants and plaintiff’s attorney have no say over which doctor is chosen.  In most cases, even involving moderate or severe TBI, their doctors will find a way to blame the victim or ignore part of the medical evidence.  How is this done?


Hiring older or retired doctors who went to medical school and got their training before these discoveries were made.  They can then attempt to ignore more modern ideas unless plaintiff’s counsel forces them to do so;

Doctors rely upon “cherry picked” facts out of the case, ignoring data consistent with TBI and relying upon data of limited quality to make opinions.  An example of this, in one of my trials, was that a psychiatrist based his opinion that my client had a pre-existing personality disorder based upon a single sentence written in my client’s third grade school chart.  This was despite the fact that in 11th and 12th grade she was noted to be “well adjusted and well liked.”  This was despite ten independent witnesses that spoke to her ongoing character and work abilities.  Which is more reliable, a single sentence written thirty years ago, or the testimony of current friends and co-workers?

Another example is the issue of loss of consciousness.  When Plaintiff is claiming TBI and the medical records indicate that there was no loss of consciousness during or immediately after the accident, that fact is treated as the most important thing since the invention of the wheel by the defense doctors.  Yet, if the initial medical records show that the plaintiff was unconsciousness and had a diminished Glasgow Coma Scale (GCS), that fact will hardly ever make it into the doctors report.  Many of them feel that, while a lack of loss of consciousness can disprove a brain injury, a period of unconsciousness after an accident does not prove a brain injury.

Fortunately, a combination of the influx of our brave men and women from Iraq and Afghanistan, as well as new findings regarding NFL players, have sensitized both the public and younger doctors to the fragility of the brain.  What a wonderful and positive change it has been for our soldiers.  In the bad old days, and you might remember the movie Patton, when he slapped a “shell-shocked” soldier, there was no such thing as a mild or even moderate brain injury.   If you could walk and talk, you were not hurt.  There are many sad tales from these years of neglect, many lives in ruin through addiction, or criminal behavior following an injury.


However, the armed forces are currently doing a magnificent job studying mild traumatic brain injury, blast injuries and utilizing the latest tools such as DTI (Diffusion Tensor Imaging) to identify and rehabilitate traumatic brain injuries.  Likewise, the NFL players whose brain autopsies have come to light, have shed light on the terrifying damage done during football careers.


The “old” notions about brain injury will live on in TBI litigation, and because of this, attorneys involved in these cases need to be unceasing in their efforts to drag all insurance companies into the bright lights of the 21st Century, so the can see reality, clearly.


Glia Discoveries II

I just read Douglas Fields fascinating new book “The Other Brain” in which he brings together all of the recent findings which are now causing the overlooked glia in the brain to be studied and appreciated.


In the field of chronic pain, which costs billions of dollars in lost production and drug addiction, it has often been noted that many of these people do not show pain profiles on electrical studies indicating the presence of pain in their nerves.  This has been used to ridicule certain types of chronic pain sufferers such as those with fibromyalgia, chronic fatigue syndrome, complex regional pain syndrome (CRPS), and others.  The latest research suggests that chronic pain may have its source in the brain’s microglia, which is odd since glia have no involvement in transmitting normal pain.  They found that the microglia, which are activated as part of the immune response to injury and repair, secrete cytokines and chemokines causing neurons to become hyper excited.  Several drugs including Minocycline, have been successfully injected into animals to block the normal reaction of microglia to injury, resulting in relief of chronic pain.  Microglia has also been found to react to the presence of ATP, which is released by injured neurons, causing chronic spinal cord pain.


The study of the glia is also shedding light on possible connections between glia and addiction.  Rats in prolonged treatment with morphine showed increased amounts of inflammatory cytokines, produced by glia, in their blood stream.  Targeting glia can reduce or eliminate morphine and other drug tolerances from arising.


They also know that almost all brain cancers involve not neurons, but glia cells.  Therefore advances in determining what is formerly ignored cells are up to, will have a positive effect on fighting the horrors of brain cancer.


Part of the glia known as astrozytes are known to be two to ten times more plentiful than neurons in the brain.  Microglia are responsible for many of the positive immune responses in our brain and function as white blood cells do in other parts of our body.  However, we now know that microglia can cause collateral damage and create many neurological disorders when they are clean and attack missions get out of hand.


Researchers and writers are now speculating as to whether this vast part of the brain that has been ignored is the part of the brain that controls dreaming or the unconscious.  Even further out speculation tries to link the massive amounts of junk (DNA) in the human genome to glia cells. “Junk” DNA is DNA that has no known function and glia cells were a large part of the brain that was also thought to have little or no function.  Perhaps uncovering a relationship between these two now important features of the human body will result in discoveries that will help us understand the consciousness itself.


The Evolution of Neuroplasticity

The notion of “neuroplasticity,” that is the ability of the human brain to repair and rewire after injury or change in function, has undergone dramatic changes in the last 120 years. As early as the late 1800’s the father of modern psychology, William James, wrote extensively on the notion of neuroplasticity of the brain and quite accurately for his time. Starting in the earlier 20th century, scientist looked even closer at the brain and this notion, oddly, changed. The work of Ramon y. Cajal and others began to show structural areas of the brain that have never been described before. Further research was able to tie these newly discovered brain structures to specific functions in the human body. From this point, the 1920’s to almost the late 1990’s, the idea that the brain could significantly alter itself after injury or produce new brain cells was a lost idea. We all grew up with the idea that “You are born with a number of brain cells and then they begin dying.”


In the last twenty years amazing findings regarding the neuroplasticity of the brain have been published, including:


Taxi cab drivers after being forced to learn thousands of addresses in London, for purposes of training, developed larger areas of the brain known as the hippocampus, which is associated with memory;

The hippocampus in the olfactory areas of the brain were constantly producing new neurons though out our lives;

Children under six who undergo, unfortunately, a hemiectomy, whereby one half of their brain is taken out, are able to regain almost normal function because of the brain’s ability to rewire and literally take over the functions of the missing other half of the brain. There are limitations to this, for example, in a child who’s brain had managed to move control of a function to a new part of the brain because of the surgery, it was found that he was almost unable to learn any mathematics because the area of the brain where mathematics was learned had been occupied by another function after the surgery;

There are two types of stem cells in the human brain that can be activated for a number of reasons including injury, and can take the form and function of the missing brain matter and make repairs known as neuroregeneration. It is likely that neuroregeneration will be found to occur in all areas of the brain in the next ten years. However, it obviously does not occur at a scale where miraculous recovery from catastrophic injury can occur. Therapies and future modalities might be able to tease these cells into doing more repairs in the future.


So at the present time the brain science neuroplasticity is back in and is being talked about in thousands of studies a year. We now know that some of the plasticity, for example, in learning languages, ends at a very early age. Dr. Jeffery Schwartz in his fascinating recent book “The Mind and The Brain: Neuroplasticity and the Power of Mental Force” describes many interesting examples of neuroplasticity. It has been shown for example, that very young children of the age of two can understand and hear all of the many sounds in every language in the world. That is why language acquisition is spectacularly easy if it is done at a young age and is significantly harder as we age. Studies in Japanese adults, whereby they were asked to listen to certain English language sound, were literally unable to hear some of those sounds at all, as if they did not exists.


The young brain also responds quite adversely to lack of use. It has been shown that there is a crucial three month period in many mammals whereby if they are kept in a dark room or otherwise unable to use their eyes, that proper connections between the brain and the eye simply do not form and permanent blindness is a result. However, when there are areas in the brain that are under utilized or not utilized at all because of the lack of hearing, vision or other sensory input, that area is taken over by nearby parts of the brain and recruited to do work for them. Thus, nothing is wasted.


In a recent Wall Street Journal article, they described 2011 findings that show teenagers intellects and IQ can rise or fall as many as 20 points in just a few years. This is certainly contrary to the thinking of the last hundred years. These changes are consistent with other findings, where scientists have determined that experience can easily alter the brain and its networks of billions of neural synapses. This is consistent with some of the tenets of the relatively new concept of “Cognitive Reserve” whereby persons going through life with more active and stimulating everyday lives are more able to fend off the ravages of old age dementia and Alzheimer’s. All of these new findings but a ball squarely in each person’s court – you can alter your brain for the better and as the past President of the American Psychological Association noted “Those who are mentally active will likely benefit. The couch potatoes among us, who do not exercise themselves intellectually, will pay a price.”


While many of these findings are good news for those who have suffered brain injury, a widespread or diffuse brain injury caused by a high speed collision, for example, is currently resistant to full recovery. “Focal” or specifically located injuries are much easier for the brain to readapt and deal with. Also, unfortunately for the moderate to severely brain injured, the likelihood of becoming a couch potato because of their injury, will likely have the effect of decreasing the likelihood of positive brain restructuring through life and will result in the injured falling further and further behind their peers.


Consciousness Test Will Alter Rehabilitation

A widely publicized study recently published in The Lancet, where three patients in a “vegetative state” showed signs of consciousness on EEG testing, will have important ramifications on brain injury rehabilitation. There are two long held beliefs by both the medical community and the insurance community that are no longer valid. One is that persons in a vegetative state are not “conscious” as we understand it. This study, as well as others, is showing that assumption to be false. Secondly, the long held belief that the brain of a person in a chronic vegetative state cannot be rehabilitated is also untrue.


This development will greatly impact the already troubled field of brain injury rehabilitation. Twenty five years ago there were thousands more brain injury rehabilitation centers in the United States than there are now. The reason for the reduction has primarily been that brain injury rehabilitation is slow and expensive. Most medical coverage now in the United States severely limits the amount of brain injury rehabilitation a person can be covered for if they have suffered a severe brain injury. Most patients in a coma or in a vegetative state are simply dumped into nursing homes if they do not show improvement within the first six-months of injury.


A recent study in 2011, has shown that long term therapy for patients in a persistent vegetative state or minimally conscious state through sensory stimulation can result in long term improvements. This upsets the apple cart in an expensive way for the insurance companies. This means that common and inexpensive EEG machines can be used to measure the level of consciousness of these patients. That means, for the first time, there will be a way to objectively measure the level of improvement in a coma patient who is undergoing rehabilitation. Until these new findings came out, most patients were assessed using behavioral observations, which, of course, are mostly absent in coma patients. The recent study on rehabilitation shows us that, not only is there a way to measure the improvement in a vegetative patient undergoing therapy, but there is actually sensory stimulation therapy that can help those in a persistent vegetative state. Persistent vegetative state describes a patient who has been in a state of awake unawareness for over a year. Currently, approximately 25,000 people in the United States are in a chronic vegetative state.


While certainly larger studies need to be done on some of these issues, the revolutionary idea here is that people who appear to be in a vegetative state may, in fact, be far more conscious than we realized. We now have the tools to help them and allow for movement and communications to return in some patients. The battle over who will pay for these breakthroughs has just begun.


Glial Cells: The “Dark Matter” of the Brain

By the time a patient gets to the emergency room, unconscious from a trauma, the primary injury to the brain – that is the structural damage to the brain tissue, neurons and blood vessels of the brain has already occurred. However, we know that this acute injury also sets into motions a complex cascade of molecular events known to create “secondary damage” to the brain. While this very complex puzzle has not been completely unraveled, we do know that one of the chemical events that occur after trauma to the brain is “oxidative stress”. The human body generally stays in balance by producing reactive oxygen species (ROS) and using them as part of our immune system. These molecules are highly reactive and destructive and are essential for keeping our immune system intact. However, after a trauma the balance is thrown out of wack and far too many ROS molecules are thrown into the blood stream. This condition of oxidating stress is also thought to be important in many neuro-regenerative diseases such as Lou Gehrig’s disease, Parkinson, Huntington’s Disease and Alzheimers. Key structures of the brain in all of this are the glial cells, a long ignored part of our brains.


In the early 1900’s there was a battle that raged over the make-up of the human brain between brilliant Spanish scientist Raymond Cajal and Italian Camillo Golgi. Cajal proposed that brain function was a rising from neurons in the brain, which was correct, but his theory reduced another important part of the brain structure, the glial cells, to an insignificant structural role only. However, in the past fifteen years it has been discovered that the glial cells are active in the brain and involved in many parts of cognition and memory. This is exciting because the glial cells make up a huge part of the brain structure and are currently almost like the “dark matter” of the universe. They are there but no one pays attention to them and no one knows all of what they do quite yet. There are several type of glial cells present in the human nervous system:


Astrocytes- These cells outnumber neurons five to one and are also found in the brain capillaries that form the “blood/brain barrier” that restricts what substances and molecules can enter the brain. The BBB as it is called, is very important in regards to a traumatic brain injury. It is thought that one of the injuries in trauma is a tearing or weakening of the BBB. Once that occurs the destructive ROS type molecules that the BBB generally keeps away from the brain are let in. This causes inflammation and destruction of brain tissue. It is thought that epilepsy can arise from a tear in the BBB as well as alzheimers and other neuro-degenerative diseases. Every month brings more research about additional fucntions of astrocytes in the brain.

Microglia- These are small cells that remove waste from central nervous system cells and offer protection as part of the immune system.

Oligodendrocytes – These are central nervous system structures that wrap around axons (the telegraph wire long branch of a neuron) and its insulating coat known as the myelin sheath. The destruction of this material can occur in high speed accidents or blast injuries. When the axons are stretched the coating can fall off or be damaged. This disables or adversely affects the neuron because of its electrical signal is then impaired. The new technology of MR/DTI can visualize this type of injury in the white matter of the human brain very sensitively. Water molecules that are suppose to run along the inside of the myelin in a straight line are shown on MR/DTI to be moving almost randomly in all directions. This is how damage is visualized on an MR/DTI.

Schwann Cells- These cells are also involved in the myelin sheath of a neuron and assist in the conduction of impulses.

A Study published in January 2010, in Nature showed that astrocytes, which comprise 90% of all human brain cells, are indeed involved in the electrical process that constitute thinking. The astrocyte needs to give a burst of electricity during the process, and thus is intimately related with neurons and the creation of cognition, contrary to 60 years of prior wisdom.


Not until the glial system further studies will we know enough about the chemical cascade following traumatic brain injury to prevent it. Current animal studies have shown great promise as an anti-oxidative neuro-protective medicine for the compound edaravone (Wang GH, et al., 2011) which has been shown to inhibit oxidative stress and inflammatory response as well as reducing glial activation. These compounds will not be available, unfortunately, for several years.


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