Utah Injury Law Blog

An MSNBC.com article outlines a recently successful procedure to bring a man out of a six-year coma. At his family’s request, the man remains anonymous. The changes in his mental state, however, are for the world to know.

“My son can now eat, speak, watch a movie without falling asleep,” explained his mother. “He can drink from a cup. He can express pain. He can cry and he can laugh.” This had not been the case for the last six years, a time when the man was fed though a tube, rarely showed signs of awareness, and used thumb or eye movements to communicate. The man was beaten violently in the head during a robbery in 1999, and the doctors said he would remain in a vegetative state for the rest of his life, if he even survived at all.

Doctors brought the 38 year old man out of the coma using an experimental electrode procedure called deep brain stimulation. “Drive” was delivered to specific and crucial areas of the brain. A similar procedure has been used for years with Parkinson’s patients, but in different brain areas.

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Spinal Cord Injury (SCI) is damage to the spinal cord that results in a loss of function such as mobility or feeling. Frequent causes of damage are trauma (car accident, gunshot, falls, etc.) or disease (polio, spina bifida, Friedreich's Ataxia, etc.). The spinal cord does not have to be severed in order for a loss of functioning to occur. In fact, in most people with SCI, the spinal cord is intact, but the damage to it results in loss of functioning. SCI is very different from back injuries such as ruptured disks, spinal stenosis or pinched nerves.

A person can "break their back or neck" yet not sustain a spinal cord injury if only the bones around the spinal cord (the vertebrae) are damaged, but the spinal cord is not affected. In these situations, the individual may not experience paralysis after the bones are stabilized.

What is the spinal cord and the vertebra? The spinal cord is about 18 inches long and extends from the base of the brain, down the middle of the back, to about the waist. The nerves that lie within the spinal cord are upper motor neurons (UMNs) and their function is to carry the messages back and forth from the brain to the spinal nerves along the spinal tract. The spinal nerves that branch out from the spinal cord to the other parts of the body are called lower motor neurons (LMNs). These spinal nerves exit and enter at each vertebral level and communicate with specific areas of the body. The sensory portions of the LMN carry messages about sensation from the skin and other body parts and organs to the brain. The motor portions of the LMN send messages from the brain to the various body parts to initiate actions such as muscle movement.

The spinal cord is the major bundle of nerves that carry nerve impulses to and from the brain to the rest of the body. The brain and the spinal cord constitute the Central Nervous System. Motor and sensory nerves outside the central nervous system constitute the Peripheral Nervous System, and another diffuse system of nerves that control involuntary functions such as blood pressure and temperature regulation are the Sympathetic and Parasympathetic Nervous Systems.

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A recent study published by Northwestern University researchers and reported by Science Daily may reveal new answers about chronic pain. An estimated 10% of the United States’ population suffers from a chronic pain; thus, these findings may help improve the daily lives of millions of individuals.

Instead of focusing on the area where the pain is felt-as most doctors and researchers have in the past-the new findings reveal the pain we feel may be rooted in the brain. That is, our repeated memories of a painful event may actually cause us to feel “physical pain.” The research team concludes that chronic pain’s source may be memories that are trapped in the prefrontal cortex of the brain, a complex area responsible for learning and some emotions. Essentially, “our brain seems to remember the injury as if it were fresh and can’t forget it."

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Today, international media and technological advances have allowed the American public to view war in a way never before seen. Along with the increased visibility of the fighting in Iraq, the media has been able to show the American public the cost of war. One area that has become more and more visible is the significant rise in closed head injuries sustained by our troops. Fueled by ABC newsman Bob Woodruff’s traumatic brain injury while covering the war (and his subsequent foundation), TBI is recognized by the media more than ever before.

In a recent commentary on MSNBC.com, chief science and health correspondent Robert Bazell writes, “Much of the medical care for wounded Iraq vets remains a national shame. The mental problems caused by either brain injury or post-traumatic stress will be a legacy of this war for decades.” Bazell blames the government’s unwillingness to pay the cost of treating so many wounded veterans as the key root of this growing problem. Many of these wounded veterans are not simple cases of broken limbs or shrapnel wounds- some statistics suggest 60-65% of all wounded soldiers have an acquired brain injury. Our military technology allows troops to be better armed and protected, but we have learned one major lesson: no matter how strong the body or vehicle armor is, “the brain- which gets shaken like jelly- is frequently damaged.”

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Here’s a useful reference for any reader. Dr. Robert P. Lehr provides a concise and straight-forward list of brain areas and their functions. An interactive brain map follows the article, along with a diagram of the brain for further exploration.

Psychologists describe the animal brain as modular; that is, specific areas/systems are responsible for specific functions. For example, the occipital lobe of the brain is responsible for vision, the limbic system for emotion, and the motor cortex for muscle movement. Some psychologists have referred to this modularity as a “Swiss Army Knife model.” Like each tool in the knife, brain modules are somewhat independent; however, these modules, or tools, interact to create a larger entity.

In traumatic brain injury (TBI) cases, certain modules may be affected, while others remain completely normal. An injury to the frontal lobe may greatly affect an individual’s planning and problem solving (and thus greatly affecting that individual’s pre-injury routine), but may have no effect on the individual’s vision. Conversely, brain damage in the Occipital lobe may render an individual blind, but have little effect on frontal lobe functioning.

An oft-cited case is that of railroad worker Phineas Gage. While helping to the build a railroad in 1848, Gage’s head was severely struck by a three-foot iron (traveling so fast that it went in one side and out the other!). The iron struck mostly Gage’s frontal lobe. As his physical recovery continued to improve post-accident, Gage’s personality seemed to have drastically changed. The fact that a three-foot rod could so greatly affect personality but not affect functions such as sight and speech helped solidify the notion of a modular brain.

Continue reading "Interactive Brain Map / The “Swiss Army Knife Model” " »

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Clearly, a TBI (traumatic brain injury) can be a life-changing experience. Dr. Sam Goldstein reminds us that TBI often affect an individual’s overall mental health. Not only do structural changes in the brain affect personality, mood, etc, but so too does the task of coping with such a life-changing injury.

“The nature and incidence of psychiatric and emotional problems in adults suffering Traumatic Brain Injury was recently illuminated in a study reporting a thirty year follow-up of brain injured individuals. As has been reported in short term studies of emotional dysfunction following Traumatic Brain Injury, this study demonstrates that a significant number of individuals struggle long term with psychiatric disorders following Traumatic Brain Injury. Forty-eight percent of these individuals experienced an Axis I disorder that began after the Traumatic Brain Injury. Sixty-two percent had an Axis I disorder anytime during their lives. The most common disorders after Traumatic Brain Injury were major depression (27%), alcohol abuse or dependence (12%), panic disorder (8%), specific phobia (8%) and psychosis (7%). Fourteen subjects or 23% had at least one personality disorder. The most prevalent individual personality disorders were avoidant (15%), paranoid (8%), and schizoid (7%). Interested readers are referred directly to the article by Koponen and colleagues (American Journal of Psychiatry, August 2002, Volume 159, pages 1315-1321).

Continue reading "TBI and Psychiatric Disorders" »

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The NY Times reports a strong correlation between the number of on-field concussions and the rate of depression in retired National Football League players. According to the study by the Center for Retired Athletes at the University of North Carolina, players sustaining three or more on-field concussions were three times more likely to experience depression in retirement than other, retired NFL players.

Other developments have accompanied the study, including a NY Times report that the suicide of ex-NFL player Andre Waters in November was partially caused by his earlier concussions. NFL commissioner Roger Goodell has since announced widespread regulations for the league vis-a-vis concussions, including mandatory neuropsychological evaluations for all players, and a system where players can report a coach’s attempts to “override the wishes of a concussed player or medical personnel.”

Football is just one of many sports which include a risk of head or brain injury. According to the Brain Injury Association of Utah (BIAU), college and pro football players suffer higher rates of head injury than youth football players, because of their size and the increased speed of the game. The BIAU urges parents to teach their children to always play touch football when unsupervised, as well as to always wear a helmet. http://www.biau.org/facts/facts_prevention.html#football

Click here to read the entire NY Times article.

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Once a controversial issue, PTSD has recently become more and more accepted as a disorder in the field of psychology. PTSD refers to the “re-living” of a traumatic situation after the fact, or simply the negative after-effects of a traumatic event. We see PTSD in war veterans, rape victims, and survivors of natural disasters, etc. In any population that experiences sudden or intense trauma (including survivors of traumatic brain injuries), we predict greater chances of developing PTSD than in the normal population. Symptoms of PTSD include flashbacks, insomnia, loss of appetite, depression, and anxiety.

Research on the relation between PTSD and legal litigation remains in its infancy. Neuropsychologist Sam Goldstein explains that some studies have shown an increase in severity of PTSD symptoms in populations experiencing legal litigation. Studies have also demonstrated that financial compensation post-litigation does not decrease the severity of PTSD symptoms. Thus, while the litigation process may act as a secondary stressor adding to a victim’s ongoing traumatization, it does not appear the litigation process acts as a cure to this traumatization.

Further, PTSD symptoms tend to increase and decrease in severity over time. The unpredictability of these flows, along with the lack of a clear illustration of a specific causal link between individual experience and PTSD symptoms, make it difficult for forensic psychologists to predict “why, how, and for how long PTSD symptoms will present, evolve, and maintain.”

Click here to read Dr. Goldstein’s legal update.

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As the summer months enter into full swing, a quick warning about the dangers of All Terrain Vehicles (ATVs). When used appropriately and with proper safety precautions, ATVs can be an enjoyable form of recreation. However, when used inappropriately, these vehicles pose a great risk for catastrophic injury, including TBI (traumatic brain injury).

A recent Newsweek article focuses on children and teenagers’ use of ATVs. Doctors say that children don’t have the cognitive skills, size, or strength required to operate these machines. Dr. Denise Dowd, a member of the American Academy of Pediatrics’ injury prevention-committee, explains, “One can argue that ATVs are even more difficult to drive than a car,” citing the need to repeatedly shift weight during operation. The article highlights the experience of then 15-year-old B.J. Smith. Traveling at 60 miles per hour, Smith clipped a dog with his front tires. Smith then flew around 25 feet in the air, hitting his head on a sidewalk as he landed on the ground. "His brain was so swollen they had to cut out a piece of his skull," recalls his mother. "He's my only child. It was absolutely horrible." Today, Smith lives with the consequences of a TBI.

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Evidence suggests the brain is more dynamic and ever-changing than once thought. Psychologists once believed that the brain’s ability to change - plasticity - was limited to children and young adults. In a recent legal update, Dr. Sam Goldstein first defines neuroplasticity, and then relates it to TBI recovery.

“Neuroplasticity is defined as the capacity of brain cells to fight the chemical and structural changes that occur following trauma that can eventually kill them if not controlled. Neuroplasticity also refers to the ability of brain cells to modify their activity in response to change in the environment, to store information from the environment and to permit the organism to move about and survive. Thus, all functioning brains to some extent operate under the principle of neuroplasticity throughout life.”

Dr. Goldstein notes that “the once held belief that recovery from brain injury is limited to the first one to two years following injury has now been met with considerable challenge. Further, the idea that remediation of function can only be accomplished in the first eighteen months post accident is increasingly being challenged. The idea that the development of compensatory strategies many years post accident leading to improved daily functioning may have no direct impact on the structure and biochemistry of the brain is also increasingly in question. A significant number of studies have now demonstrated that many people can make significant physical, cognitive and behavioral recovery as long as five years or more post brain injury. As Stein noted in 1995, ‘There is no rule of neuroscience that the processes of functional recovery must occur rapidly or that treatment should be terminated after a fixed period of time because the early results are unsatisfactory.’”

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Although visibility and recognition of TBI (traumatic brain injury) has increased in recent decades, it appears public knowledge of TBI and its symptoms remains unchanged. In a recent study of the general population in an urban setting, researchers found that public levels of knowledge in 2004 were relatively unchanged from knowledge in 1988.

Dr. Sam Goldstein, a Salt Lake City-based neuropsychologist notes,“ These misconceptions appeared unrelated to age, gender or education. As others have noted, it appears that knowledge about TBI likely comes, at least in part, from popular media. Further, family members, employers and even TBI survivors likely hold these misconceptions. These incorrect ideas may play a potentially significant role in personal injury trials. For example, 35% believed that a whiplash injury could not cause brain damage. Thirty-five percent believed that after a traumatic brain injury it was not more difficult for someone to learn than previously. In regards to forensic issues, 28% believed that a concussion was ‘harmless and never results in long-term problems or brain damage.’ Twenty-five percent believed that if a person wanted to ‘it would be easy to fake brain damage from a head injury’ and 66% believed that the only way to prove brain damage from a head injury was by an x-ray of the brain. Surprisingly, 59% believed that most people with severe TBI are eventually able to return to their previous work. Finally, 44% believed that a head injury affected the brains of men and women differently.

These data, though limited in scope and total sample size, may well reflect generally held misconceptions in the broader public. Attorneys are advised to consider addressing these issues during voir dire as well as allowing time for forensic neuropsychologists and related medical specialists to educate jurors about the facts of TBI prior to offering testimony.”

As traumatic brain injuries continue to gain visibility and media attention, hopefully the general public will better understand TBI survivors and their symptoms.

Click here to read Dr. Goldstein’s entire article.

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Like many fields, psychology has traditionally been subdivided into more specific perspectives, such as behaviorism or Gestalt psychology. Recently, advances in Cognitive therapy have proved effective with TBI patients. Cognitive psychology focuses on our thought, thinking strategy, attention, memory, and even language.

In Cognitive rehabilitation, two areas are stressed: reacquiring cognitive skills, and learning to use strategies to compensate for lost skills. As physical therapy would be used to repair a damaged muscle, cognitive therapy can be used to repair a damaged cognitive system. Therapists may help TBI patients complete exercises or tasks in order to improve skills. In cases where these skills cannot be reacquired, the therapist may teach the patient specific therapies across inter-related cognitive categories, such as memory, attention, and organization. For example, a patient may be urged to use checklists and “to-do” lists to improve organization in their daily routine.

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