The Lawyer’s Guide to Traumatic Brain Injuries

Article written by Jay Vaughn of Hendy Johnson Vaughn Emery, P.S.C. in Louisville, Kentucky. You can reach him here.

There were over 64,000 deaths related to traumatic brain injury (TBI) in 2020, according to the Centers for Disease Control and Prevention. More concerning is that over 1.7 million people suffer TBIs annually. Most people get a traumatic brain injury from hitting their head during a fall, something landing on or striking them in the head, or from a motor vehicle crash (even when they don’t hit their head due to the brain bouncing or twisting within the skull due to the dynamics of the crash).

There are different degrees of severity of TBIs: Mild TBI/concussion, Moderate TBI, and Severe TBI. However, “Mild TBI” is a misnomer as many individuals with Mild TBIs have permanent, life-long deficits due to their brain injury. One of the most widely accepted definitions of Mild Traumatic Brain Injury was published by the American Congress of Rehabilitation Medicine (ACRM) in 1993:

A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:    

1. any period of loss of consciousness;
2. any loss of memory for events immediately before or after the accident;
3. any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused); and
4. focal neurological deficits that may or may not be transient;

but where the severity of the injury does not exceed the following:

– loss of conscientiousness for approximately thirty minutes or less;    – after 30 minutes an initial Glasgow Coma Scale (GCS) of 13-15;      

– post traumatic amnesia not greater than 24 hours

The published definition goes on to provide the following:

This definition includes:

1. the head being struck,
2. the head striking an object, and
3. the brain undergoing an acceleration/deceleration movement (ie, whiplash) without direct external trauma to the head.

Computed tomography, magnetic resonance imaging, electroencephalogram, or routine neurological evaluations may be normal.

Due to the lack of medical emergency, or the realities of certain medical systems, some patients may not have the above factors medically documented in the acute stage. In such cases, it is appropriate to consider symptomatology that, when linked to a traumatic head injury, can suggest the existence of a mild traumatic brain injury.

More importantly, the ACRM definition explains the varying degrees and types of symptomatology:

The above criteria define the event of a mild traumatic brain injury. Symptoms of brain injury may or may not persist, for varying lengths of time, after such a neurological event. It should be recognized that patients with mild traumatic brain injury can exhibit persistent emotional, cognitive, behavioral, and physical symptoms, alone or in combination, which may produce a functional disability. These symptoms generally fall into one of the following categories, and are additional evidence that a mild traumatic brain injury has occurred:

1. physical symptoms of brain injury (eg, nausea, vomiting, dizziness, headache, blurred vision, sleep disturbance, quickness to fatigue, lethargy, or other sensory loss) that cannot be accounted for by peripheral injury or other causes;

2. cognitive deficits (eg, involving attention, concentration, perception, memory, speech/language, or executive functions) that cannot be completely accounted for by emotional state or other causes; and

3. behavioral change(s) and/or alterations in degree of emotional responsivity (eg, irritability, quickness to anger, disinhibition, or emotional lability) that cannot be accounted for by a psychological reaction to physical or emotional stress or other causes.

Common Signs and Symptoms of Traumatic Brain Injury

Below are the most common signs and symptoms of a traumatic brain injury:

Physical

• Bothered by light or noise
• Dizziness or balance problems
• Feeling tired, no energy
• Headaches
• Nausea or vomiting (early on)
• Vision problems
• Ringing in ears
• Changes in Hearing, Taste, Smell
• Numbness or tingling
• Clumsiness

Thinking & Remembering

• Attention or concentration problems
• Feeling slowed down
• Foggy or groggy
• Problems with short- or long-term memory
• Trouble thinking clearly
• Unable to follow directions
• Takes longer to do simple tasks

Social or Emotional

• Anxiety or nervousness
• Irritability or easily angered
• Feeling more emotional
• Sadness or crying spells
• Mood swings
• Depression
• Flashbacks
• Seclusive or withdrawn

Sleep

• Sleeping less than usual
• Sleeping more than usual
• Trouble falling asleep
• Nightmares

Medical Specialties for TBI Patients

Since traumatic brain injury affects everyone in a different way and involves physical, mental/emotional, personality, and sleep changes, there are a variety of medical specialties who can help those with TBIs. These include:

• Emergency Room Physician
• Primary Care Physician
• Neurologist
• Physiatrist/Physical Medicine & Rehabilitation
• Psychologist/Neuropsychologist
• Psychiatrist/Neuropsychiatrist
• Radiologist/Neuroradiologist
• Optometrist/Neuro-optometrist
• Endocrinologist/Neuro-endocrinologist
• Ear Nose & Throat Specialist/Otolaryngologist/Neurotologist
• Sleep Specialist
• Physical Therapist
• Occupational Therapist
• Speech-Language Pathologist/Therapist
• Balance Therapist/Vestibular Rehabilitation
• Cognitive-Behavioral Therapist
• Vision Therapist

Common Misconceptions About Traumatic Brain Injuries

1. If you didn’t lose consciousness, then you cannot have a TBI

FALSE

• Muriel Lezak, Neuropsychological Assessment, 3rd, ©Oxford, 1995
• Levin, Mild Head Injury,©Oxford, 1989
• Kelly, James P., M.D. “Diagnosis and management of concussion in sports”. ©Neurology. 1997. p 575-580
• Reitan and Wolfson, Neuroanatomy and Neuropathology, A Clinical Guide to Neuropsychologists, 2nd Edition, ©Neuropsychology Press, 1992.
• Definition of Mild Traumatic Brain Injury, Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. Journal of Head Trauma Rehabilitation 1993:8(3):86-87

2. If you have a Glasgow Coma Scale score of 15, then you cannot have a TBI

FALSE

• Intracranial Pathology (CT+) in Emergency Department Patients With High GCS and High Standard Assessment of Concussion (SAC) Scores, Journal of Head Trauma Rehabilitation, May/June 2018, Volume 33, Issue 3, Pgs. E61-E66
• Levin, Mild Head Injury,©Oxford, 1989, Pg. 24
• Predictive value of Glasgow coma scale after brain trauma: change in trend over the past ten years, J Neurol Neurosurg Psychiatry 2004:75:161-162

3. The Emergency Room doctor didn’t diagnose a TBI, so you cannot have a TBI

FALSE

• Accuracy of Mild Traumatic Brain Injury Diagnosis, Arch Phys Med Rehabil 2008 Aug;89(8):1550-5
• A comparison of emergency department medical records to parental self-reporting of traumatic brain injury symptoms, Concussion. 2018 Mar; 3(1): CNC52
• Concussion Care in the Emergency Department: A Prospective Observational Brief Report, American College of Emergency Physicians, Annals of Emergency Medicine 2019:08:419

4. If you have a Mild TBI, then your symptoms will resolve in 3 months, but definitely within 12 months

FALSE

• A recent peer-reviewed medical article found that the majority of individuals with Mild TBIs have symptoms and deficits more than 12 months from their injury. Lindsay D. Nelson, PhD, et al., Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers. JAMA Neurol. 2019; 76(9):1049-1059 https://jamanetwork.com/journals/jamaneurology/fullarticle/2735106

TBI Resources

Here are some excellent resources for more information on traumatic brain injuries:

Centers for Disease Control and Prevention – Get the Facts About TBI

National Institute of Neurological Disorders and Stroke – Traumatic Brain Injury: Hope Through Research

U.S. Department of Veterans Affairs, Office of Research & Development – Traumatic Brain Injury

Military Health System – Traumatic Brain Injury Center of Excellence

Brain Injury Association of America: https://www.biausa.org/