Question 1

Mechanisms of TBI

Accepted Answer

By Corey B. Friedman, Romano Law Group
A. Penetrating brain injury – an open head injury when there is a break in the skull.
B. Closed head injury – usually when there is a non penetrating injury to the brain with no break in the skull which can be caused by a rapid forward or backward movement and shaking of the brain inside the bony skull which results in bruising and/or tearing of brain tissue and blood vessels.
a. Focal Injuries – Direct blow to the head.
i. Contusion – a bruise on the brain in which there may be scattered areas of bleeding on the surface of the brain. Usually occurs when the brain strikes a ridge on the skull or a fold in the dura matter.
ii. Brain Laceration – tissue on or in the brain is torn or cut.
iii. Hemorrhage (and subsequent hematoma).
1. Extradural – a collection of blood that forms between the inner surface of the skull and the outer layer of the dura.
2. Subarachnoid – bleeding in the space surrounding the brain.
3. Subdural – blood coming from a blood vessel into the space below the dura (the outermost membrane of the brain).
4. Intracerebral – a subtype of stroke from a hematoma within the brain parenchyma with or without blood extension into the ventricles.
b. Diffuse Injuries – Sudden movement of the head
i. Diffuse axonal injury
1. Concussion – a mild and common type of brain injury that affects brain function.
2. Coma – a prolonged state of unconsciousness which usually lasts longer than several weeks.
c. Coup-Contrecoup – two separate brain injuries sustained during the same incident, usually on opposite sides of the brain as a result of an impact. The coup injury occurs at the site of impact while the contrecoup injury occurs opposite the area of impact.
T A Gennarelli, J Emerg Med. 1993; 11 Supple 1:5-11
https://my.clevelandclinic.org/health/diseases/21183-subdural-hematoma
https://www.ncbi.nlm.nih.gov/books/NBK553103/
https://www.uclahealth.org/medical-services/neurosurgery/conditions-treated/cerebral-contusion-and-intracerebral-hematoma#:~:text=Cerebral%20contusions%20are%20scattered%20areas,the%20brain&#8217;s%20tough%20outer%20covering
https://www.hopkinsmedicine.org/health/conditions-and-diseases/traumatic-brain-injury;

Question 2

Symptoms of TBI

Accepted Answer

By Todd Romano, Romano Law Group
A. Symptoms of Traumatic Brain Injury- Traumatic brain injury symptoms vary widely. TBI can result in both physical and psychological effects, and the signs and symptoms associated with TBI may appear shortly after a traumatic event, while others may appear much later. TBI is often characterized as mild or of the concussive type, while other TBI can be moderate or severe in nature. While this is not an exhaustive list, the signs and symptoms of TBI can consist of the following:
a. Mild TBI
i. Common Physical Symptoms:

Dizziness
Vertigo
Loss of balance (when walking; or swaying when standing still)
Nausea or vomiting
Fatigue or drowsiness
Headache
Problems with speech
Lightheadedness
Slowed reaction time

ii. Cognitive, Mental, and Behavioral Symptoms

Loss of consciousness (LOC) for any length of time
No LOC, but a state of being dazed, confused or disoriented
Difficulty sleeping or sleeping more than usual
Mood changes or mood swings
Feeling on edge or stressed
Memory or concentration problems
Confusion or difficulty concentrating on simple tasks
Forgetting where you put things such as keys, wallet, phone etc.
Feeling depressed or anxious
Anxiety when driving or as a passenger in a vehicle
Easily distracted
Difficulty multi-tasking
Increased irritability or mood swings
Difficulty reading (difficulty focusing on words or having to re-read)
Difficulty maintaining focus
Fear of falling
Restlessness
Slowed thinking
Emotional spontaneity
PTSD

iii. Sensory Symptoms

Ringing in the ears (tinnitus)
Blurred or limited vision
Lost or altered sense of taste
Lost or altered sense of smell
Sensitivity to light (photophobia) or sound (hyperacusis)

b. Moderate to Severe TBI:
 i. Common Physical Symptoms:

LOC from several minutes to hours
Dilation of one or both eye pupils
Clear fluids draining from the nose or ears
Inability to fall asleep or awaken from sleep
Persistent headache or headache that worsens
Repeated vomiting or nausea
Convulsions or seizures
Weakness or numbness in fingers and toes
Loss of coordination

ii. Cognitive, Mental, and Behavioral Symptoms:

Slurred speech
Coma and other disorders of consciousness
Profound confusion
Agitation, combativeness, or other unusual behavior
Loss of empathy
Dysregulated arousal

iii. Children’s Symptoms: Young children and infants with brain injuries might not be able to effectively communicate headaches, confusion, sensory problems, and similar symptoms. Common symptoms you may observe in children are:

Change in sleep habits
Seizures
Sad or depressed mood
Drowsiness
Loss of interest in favorite toys or activities
Change in eating or nursing habits
Unusual or easy irritability
Persistent crying and inability to be consoled
Change in ability to pay attention
Oppositional defiant disorder (ODD)

See Appendix for Sample TBI checklist

Question 3

Diagnostic Tests

Accepted Answer

By Aaron M. Clemens and Mikayla T. Taylor, Romano Law Group
A. Overview of Diagnostic Tests and Tools to Diagnose or Verify a Brain Injury- Each test listed has benefits, either when used individually or cumulatively. All listed testing should be suitable for a claim of admissibility under Frye as all tests are generally accepted by the relevant scientific community, and the Daubert factors, but naturally each claim is dependent upon caselaw and the ability of a specific treating expert to explain the use of any such test either that they themselves performed or as detailed in medical records this expert has reviewed.
a. Intracranial pressure monitor

Tissue swelling from TBI can increase pressure inside skull, causing additional damage;
Intracranial pressure (ICP) monitoring is used to measure cerebral perfusion pressure (CPP) and is an important indicator in the severity of a TBI.
ICP monitoring is typically performed by inserting an intraventricular catheter by drilling a hole into the skull. The catheter is then inserted into the area of the brain containing cerebrospinal fluid (CSF) and allows for the observing of any swelling which is then used to detect ICP wave forms and infratentorial mass lesions.
Can also be used to alleviate swelling.

b. Glasgow Coma Scale

Clinical test to measure initial severity of a brain injury, used by consensus since 1978;
Modified GSC used in pediatrics;
Alternative FOUR Score (acronym for “Full Outline of UnResponsiveness”) tests eye response, motor response, brainstem reflexes, and respiration
FOUR Score omits GSC’s verbal response section to allow intubated assessments;

c. Computerized tomography (CT) brain scans

uses series of X-rays to create a detailed view of the brain which can

quickly visualize skull fractures;
uncover evidence of

bleeding in brain (hemorrhage),
blood clots (hematomas)
bruised brain tissue (contusions),
brain tissue swelling

d. Magnetic resonance imaging (MRI)

MRI uses powerful radio waves and magnets to create a detailed view of the brain. It is more detailed than a CT scan. Due to duration of test, MRI is less likely to be used for initial TBI evaluation, and is often used in subsequent assessments for more accurate and complete evaluation.

often used after condition stabilizes, or if symptoms don’t improve soon after the injury;
many different versions and additional scans can be performed.

e. Functional Neurocognitive Imaging (fNCI)

fNCI is a form of fMRI;
measures connection between neurons and blood in the brain;
images show how blood vessels bring energy to neurons, which require a lot of energy.

f. Diffusion Tensor Imaging (DTI) and Fiber Tractography (FT)
f. DTI is MRI method and variant of diffusion-weighted imaging (DWI);

Enables measurement of the restricted diffusion of water in tissues;
Uses anisotropic diffusion to estimate the axonal (white matter) organization of brain;
Fiber Tractography (FT) is 3D reconstruction technique to assess neural tracts using data collected by DTI.

g. NeuroQuant MRI

Extra scan sequence added to brain MRI;
Produces quantitative brain imaging data and analysis;
Brain structures measured by volume using images and NeuroQuant software;
Data compares examined brain to same-age peers in FDA database adjusted for age, sex, and cranial volume.

h. Magnetic Resonance Spectroscopy (MRS)

Non-invasive, nuclear imaging method for detecting and measuring brain activity at cellular level;
Uses same machinery as MRI but instead of measuring blood flow, MRS measures concentration of specific chemicals such as neurotransmitters;
Holds great promise for future diagnosis of disease in brain and other parts of body.

i. Susceptibility-weighted imaging (SWI) 
MRI technique exquisitely sensitive to venous blood, hemorrhage and iron storage as it runs on relatively high resolution (1 mm3), and is extremely sensitive to bleeding in the gray matter/white matter boundaries;

Originally called BOLD venographic imaging as it is a blood-oxygen-level dependent (BOLD) technique;
TBI shows up on brain scans as micro-hemorrhages, shearing, and diffuse axonal injury (DAI), which are small and easy to miss on low-resolution scans, but these subtle injuries can be detected on this high-resolution scan;
High field SWI: the contrast in phase image is linearly proportional to echo time (TE) and field strength;
Higher fields allow shorter echo times, without loss of contrast which can reduce scan time and motion related artifacts;
High signal-to-noise available at higher fields also increases scan quality and allows for higher resolution scans.

j. Single-Photon Emission Computerized Tomography Scan (SPECT scan)

Uses radioisotope (99mTc), injected into blood stream, measured by gamma rays;
Provides true 3D information using multiple 2D images, then topographically reconstructed to show blood flow in brain;
Less expensive than PET scan, so more widely used.

k. Positron Emission Tomography Scan (PET scan)

Captures images of radioactive tracers absorbed into bloodstream, providing detailed 3D images of brain;
Can detect abnormal metabolism of tracer before disease shows up on other imaging tests such as CT or MRI;
Can be done in combination with CT or MRI.

l. Electroencephalogram (EEG) 
Brain uses electrical signals and EEG detects brain activity and measures natural electrical signals, using electrodes on scalp to measure brain activity;

Can detect and monitor abnormal electrical signals;
EEG can be used to distinguish between mTBI (mild TBI), otherwise known as a concussion, and PTSD, which often have similar symptoms;
Abnormalities more commonly found (56%) in patients unconscious for more than 2 minutes than in patients with briefer periods of unconsciousness (17%)

m. Heart Rate Variability Testing

Uses EEG or EKG to graph heartbeat, which can be compared to average;
normal cyclic changes in heart-rate reduced in the presence of severe brain damage;
testing shows variability decreases rapidly if intracranial pressure rises, and rate of return of variability reflects the subsequent state of neuronal function, even after intracranial pressure restored to normal.

n. Videonystagmography (VNG)

Examines eye movement, specifically involuntary eye movement known as nystagmus;
can assess the inner ear (vestibular system) as well as the part of the brain that controls balance;
nystagmus may signify brain damage in absence of vestibular system damage or, say, consumption of drugs or alcohol (police commonly use HGN or horizontal gaze nystagmus test as part of roadside DUI tests).

o. Computerized Dynamic Posturography (CDP) also called Test of Balance (TOB)

scientific framework for understanding control of balance and postural stability, used on patients in upright stance in either static or dynamic conditions;
CDP can objectively quantify functional impairments;
ideal for physical therapy and rehabilitation exercises;
can identify chronic severe brain damage as such injuries impairs ability of body to maintain balance.

p. Neuro-ophthalmological testing

Testing by eye doctor who deals with vision or eye problems associated with conditions of brain and nervous system;
12 cranial nerves include CN2 (controls vision), CN3 (oculomotor nerve), and CN4 (ocular mobility);
CN3 starts midbrain and travels through many structures of the head;
Cranial nerve dysfunction may arise from head injuries such as lack of blood flow or nerve compression.
Oculomotor Tracking can demonstrate the inability of the eye to look steadily.

q. Olfactory testing

Olfactory nerve (CN1) is shortest cranial nerve and it enables sense of smell;
Majority of mTBI or concussion patients exhibited hyposmia, or the loss of ability to smell and detect odors, abilities controlled by CN1.

r. Sleep study (polysomnography)

Some people with repeated head injuries have a sleep disorder which causes them to move limbs and shout during dream activity, during the rapid eye movement (REM) phase of sleep;
Recent studies supported by the National Institute on Aging (NIA) showed 1/3 of 247 men with chronic traumatic encephalopathy (CTE) from contact sports had probable REM sleep disorder, and men with sleep disorder were significantly more likely to show the presence of Lew bodies, or accumulations of alpha-synuclein protein filaments, or have tua tangles in the brainstem region.
As obstructive sleep apnea (OSA) associated with causing brain damage, a sleep study that determines patient has OSA may explain brain damage.

s. Objective testing of reflexes
Tests such as those performed at CME (compelled medical examinations), including:

sensory exams (using Wartenberg wheel or handle and asking patient to identify sharp or dull, or using something heated or cold and asking to identify temperature);
coordination exams (patient asked to walk normally or on a line on floor, or touch nose with eyes closed);
reflex exam, using small rubber hammer to hit different points on body such as deep tendon reflexes, which tests synaptic connections, or pathologic reflexes, which are reversions to primitive response and indicate loss of cortical inhibition;

Any abnormal responses to such testing may demonstrate nerve injury or possible brain injury.
t. Blood tests

Cortisol Levels, signaling brain dysfunction

cortisol is stress hormone, may come from physical or mental stress;
recent studies show mean cortisol levels estimated were significantly increased in mild head injury cases and were with greater increase in cases of moderate and severe head injuries;
Cushing syndrome, for patient with excess cortisol over time (from medication or by body), has shown memory impairments related to hippocampal damage, with functional dysfunctions preceding structural abnormalities as detected by brain imaging;
If patient has Cushing syndrome, this could explain brain damage.

Banyan Brain Trauma Indicator & i-STAT TBI Plasma Test

tests measures two proteins, UCH-L1 & GFAP, known to be released from brain into blood within 12 hours of head injury.
recently approved by the FDA to detect intracranial injury following mild traumatic brain injury;
developed by Defense Department to evaluate wounded soldiers in combat zones;
also used for athletes to reduce radiation exposure in young persons.

Question 4

Proving Existence of TBI

Accepted Answer

By Mikayla T. Taylor, Romano Law Group
A. You can use many different strategies in order to prove your client has a traumatic brain injury (TBI), but at the root of those strategies are these two principles.
a. Documentation of TBI Symptoms
i. It is paramount that a detailed documentation of an individual’s symptoms is kept from the time they are injured. Common symptoms of a traumatic brain injury are listed in Section 2 above.
ii. Because the list of TBI symptoms is so bountiful, it is optimal to have records documenting the severity of an individual’s TBI symptoms from the moment they are injured. Additionally, it is helpful to have medical documentation showing the extent of those symptoms that they may have had prior to the subject incident to prove lack of or aggravation of any prior condition(s).
b. Diagnostic Tests
i. According to the National Institute of Health, there are four primary diagnostic methods used in diagnosing brain injuries. These include Intracranial Pressure Monitoring, CT scan, MRI, and Glasgow Coma Scale, all of which are described in more detail in Section 3 above, along with other diagnostic tests.
B. Neuropsychological Testing
a. Neuropsychological Testing consists of a series of assessments administered by a licensed neuropsychologist, who is a psychologist with a Ph.D. or Psy.D. and who specializes in brain injury and cognitive function. The assessments are designed to evaluate attention, memory, concentration, reasoning, time and space perception, problem solving, judgment, executive decision making and overall cognitive function. Although the tests themselves are fairly standardized, the interpretation of the results is often subjective and can be influenced by the examiner’s implicit bias and other variables.
b. Neuropsychological testing is often performed by a patient’s treating doctor to help assess the full nature and extent of the patient’s brain injury, to develop an appropriate treatment plan, and to help the patient and his/her family better understand the patient’s injury, limitations, and needs. In TBI cases, such exams are also routinely requested as defense medical exams in an effort to minimize or question the patient’s injury.
https://www.nichd.nih.gov/health/topics/tbi/conditioninfo/symptoms
https://www.ncbi.nlm.nih.gov/books/NBK326713/
https://medlineplus.gov/ency/article/003411.htm#:~:text=INTRAVENTRICULAR%20CATHETER,contains%20cerebrospinal%20fluid%20(CSF)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9160102/

Question 5

Proving Causation of TBI

Accepted Answer

By Eric Romano, Romano Law Group
A. In proving causation, a good starting point is the applicable jury instructions. The Florida instruction on causation is:
FL Standard Civil Jury Instruction 401.12:
LEGAL CAUSE:
a. Legal cause generally: Negligence is a legal cause of [loss] [injury] [or] [damage] if it directly and in natural and continuous sequence produces or contributes substantially to producing such [loss] [injury] [or] [damage], so that it can reasonably be said that, but for the negligence, the [loss] [injury] [or] [damage] would not have occurred.
b. Concurring cause:In order to be regarded as a legal cause of [loss] [injury] [or] [damage] negligence need not be the only cause. Negligence may be a legal cause of [loss] [injury] [or] [damage] even though it operates in combination with [the act of another] [some natural cause] [or] [some other cause] if the negligence contributes substantially to producing such [loss] [injury] [or] [damage].
B. Three Steps to Proving Causation
a. Accident/Event was plausible cause of TBI (i.e. trauma to head)
b. Temporal association between event and onset of symptoms
c. Differential analysis to rule out other causes
C. “Florida follows the ‘more likely than not’ standard in proving causation, i.e., that the negligence ‘probably caused’ the plaintiff&#8217;s injury.” Cox v. St. Josephs Hosp., 71 So.3d 795 (Fla. 2011)
D. Directed verdict is improper where there is conflicting evidence of causation or likelihood of causation. Cox v. St. Josephs Hosp., 71 So.3d 795 (Fla. 2011)
E. Expert cannot simply state conclusion that defendant’s negligence more likely than not caused plaintiff’s injury; expert must provide reasonable foundation for opinion based on appropriate analysis. Cox v. St. Josephs Hosp., 71 So.3d 795 (Fla. 2011)
F. Neuropsychologist is competent to testify that results of psychological testing reflect presence of organic brain impairment, but is generally not competent to testify regarding cause of impairment. Grenitz v. Tomlian, 858 So.2d 999 (Fla. 2003)
G. “A qualified biomechanical expert may offer an opinion about injury causation if the mechanism of injury falls within the field of biomechanics.” Absent a medical degree, engineer cannot testify regarding injury severity or permanency. Lepera v. State, 328 So.3d 1136 (Fla. 5th DCA 2021)
H. Biomechanical engineer may offer opinion on general causation of type of injury (i.e. mechanism of injury), but may not offer opinion on causation (or lack thereof) of plaintiff’s specific injury, or nature, extent and severity of plaintiff’s injury. Maines v. Fox, 190 So.3d 1135 (Fla. 1st DCA 2016)

Question 6

Treatments for TBI

Accepted Answer

By Jessica L. Latour, Romano Law Group
A. Treatment is based on the severity of the injury
a. Mild TBI

Rest
 Over-the-counter pain reliever to treat headache
 Monitor closely for new or worsening symptoms
Avoid alcohol and other drugs
Follow up with doctor
Return to typical activities (after consulting doctor)

b. Moderate to Severe TBI

Monitor oxygen and blood supply
Maintain blood pressure
Prevent further injury to head and neck
Medications

Anti-seizure drugs
Coma-inducing drugs
Diuretics
Anti-anxiety drugs
Anticoagulants
Antidepressants
Muscle Relaxers
Stimulants

Surgery

Removal of blood clots or pools
Repair of any skull fractures
Removal of damaged or dead tissue
Stop bleeding in the brain
Relieve pressure inside the skull

A window in the skull
A shunt or drain

Rehabilitation

Physiatrist
Occupational therapist
Physical Therapist
Speech and language therapist
Psychological counseling
Social Worker or case manager
Rehabilitation nurse
Traumatic brain injury nurse specialist
Recreational therapist
Vocational counselor
Cognitive Therapy

https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/diagnosis-treatment/drc-20378561
https://www.nichd.nih.gov/health/topics/tbi/conditioninfo/treatment

Question 7

Long Term Effects of TBI

Accepted Answer

By Marjorie H. Levine, Romano Law Group
A. Because the human brain is so complicated, it is extremely difficult to predict the long-term effects of any TBI. 
a. Most cases of mild TBI will resolve over time with minimal problems. 
b. In the case of more serious TBIs, a person can experience any number of changes over the course of months and years.” Butler County Bar Ass&#8217;n v. Minamyer, 129 Ohio St. 3d 433, 446 (2011).
B. &#8220;A number of factors, including Glasgow coma scale (GCS) score, age, pupillary response and size, hypoxia, hyperthermia, and high intracranial pressure, may play an important role in predicting the outcome of traumatic brain injury. 
a. Eight hundred forty-six cases of severe traumatic brain injury (GCS8) were analyzed retrospectively to clarify the effects of multiple factors on the prognosis of patients. At 1 year after injury, the outcomes in these cases were as follows: 
i. good recovery, 31.56%; 
ii. moderate disability, 14.07%;
iii. severe disability 24.35%;
iv. vegetative status, 0.59%; 
v. and death, 29.43%.&#8221; 
C. Effects based on area of injury.
a. &#8220;The frontal lobe or forehead area regulates reasoning, problem-solving, judgment, impulse control, and planning, and damage there can lead to engaging in risky or inappropriate behaviors,&#8221; says Schiltz.
b. &#8220;Trauma to the left side of your brain can cause problems with logic, speech difficulties, trouble understanding others or talking, 
c. versus right side injury, which can cause problems processing visual information, neglect, or apraxia &#8211; the ability to perform regular or familiar tasks. For example, if you give someone a comb, they can tell you it&#8217;s a comb, but they don&#8217;t know how to use it.&#8221; 
Long-term effects of Traumatic Brain Injury. University of Utah. December 6, 2021. https://healthcare.utah.edu/healthfeed/2021/12/long-term-effects-of-traumatic-brain-injury
D. Each year about 800,000 people receive outpatient care and 270,000 require hospital admission for treatment of TBI, concluding in about 52,000 deaths and 80,000 permanent severe neurological disabilities. 
Brain Trauma Foundation and Weill Medical College of Cornell University, Ghajar, Jamshid MD., The Lancet, Vol. 356, September 9, 2000. https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9a66231849ae1d92381aac7381c346b1d613b0ff
E. Neurological damages evolve after the moment of impact, influenced by brain swelling, increased intracranial pressure and decreased cerebral perfusion. 
Brain Trauma Foundation and Weill Medical College of Cornell University, Ghajar, Jamshid MD., The Lancet, Vol. 356, September 9, 2000. https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9a66231849ae1d92381aac7381c346b1d613b0ff
F. Between 80,000-90,000 of people who suffer traumatic brain injuries (TBIs) each year develop long-term disabilities related to their TBI. 
Traumatic Brain Injury Long-Term Effects, Symptoms, and Treatment. Cognitive FxBy: Dr. Alina Fong PhD Last Updated: January 23, 2023. https://www.cognitivefxusa.com/blog/traumatic-brain-injury-long-term-effects-and-treatment
a. Increased chance of dementia, Alzheimer’s, etc.
i. Clinical studies have emphasized that people with evidence of early TBI can show an increased incidence of neurodegenerative diseases. 
Long-Term Consequences of Traumatic Brain Injury: Current Status of Potential Mechanisms of Injury and Neurological Outcomes, Journal of Neurotrauma, 2015 Dec 1; 32(23): 1834–1848, Bramlett, Helen and Dietrich, W. Dalton. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677116/
ii. Researchers found that a history of TBI may accelerate the age of onset of cognitive impairment by two or more years. 
Li, W., Risacher, S.L., McAllister, T.W. et al. Traumatic brain injury and age at onset of cognitive impairment in older adults. J Neurol 263, 1280–1285 (2016). https://doi.org/10.1007/s00415-016-8093-4
iii. People who had a TBI were four to six times as likely to get a dementia diagnosis as those without a TBI. 
Traumatic brain injury and the risk of dementia diagnosis: A nationwide cohort study. Nordström A, Nordström P (2018) Traumatic brain injury and the risk of dementia diagnosis: A nationwide cohort study. PLOS Medicine 15(1): e1002496. https://doi.org/10.1371/journal.pmed.1002496
iv. We found that moderate to severe TBI is a risk factor for developing dementia among adults 55 years and older, whereas mild TBI is a risk factor for adults 65 years and older. 
Gardner RC, Burke JF, Nettiksimmons J, Kaup A, Barnes DE, Yaffe K. Dementia Risk After Traumatic Brain Injury vs Nonbrain Trauma: The Role of Age and Severity. JAMA Neurol. 2014;71(12):1490–1497. https://jamanetwork.com/journals/jamaneurology/fullarticle/1919070
v. In addition to medical symptoms like altered consciousness, seizures, infections, nerve damage, and sensory problems, persons with TBI also experience cognitive, communication, behavioral, emotional, and sensory problems.
www.mayoclinic.com/health/traumatic-brain-injury/DS00552/DSECTION=complications.
vi. Cognitive problems can include difficulties with memory, learning, reasoning, problem-solving, speed of mental processing, judgment, attention or concentration, multitasking, organization, decision-making, and beginning and/or completing tasks. Butler County Bar Ass&#8217;n v. Minamyer, 129 Ohio St. 3d 433, 441 (2011).
b. Personality changes
i. Divorce rates among couples where one individual has experienced a traumatic brain injury (TBI) tend to be higher than the CDC-reported national average. 
Marriage Stability after Traumatic Brain Injury, Project Empowerment, Issue 10, December 2012Virginia Commonwealth University, Author Miller, Jessica. https://biav.net/wp-content/uploads/2017/06/Marriage-Stability-after-TBI.pdf.
ii. TBI can also cause PTSD. 
Traumatic Brain Injury Long-Term Effects, Symptoms, and Treatment. Cognitive FxBy: Dr. Alina Fong PhD Last Updated: January 23, 2023. https://www.cognitivefxusa.com/blog/traumatic-brain-injury-long-term-effects-and-treatment.
c. Employability
i. Injured may not be credible which tends to show that he is disabled, as it is common for individuals with TBI frontal-lobe injuries to believe they can function at a higher level than they actually are able to function. Todd v. Astrue, 2009 U.S. Dist. LEXIS 47640, (D. M.N. 2009).

Many individuals with TBI are able to return to work and other meaningful and productive work-related activities following TBI, although they may be unable to return to their pre-injury job and/or may require additional support/accommodations to maintain successful employment.

“Employment Issues Following TBI.” The Brain Injury Guide and Resources. https://braininjuryeducation.org/topics/employment.html.
ii. In one study, 35% of the individuals with a mild to severe brain injury were employed one year after their injury, 37% after two years, and 42% after three or four years. 
“Return to Work and Job Stability After Traumatic Brain Injury.” Brain Injury Association of America. https://www.biausa.org/professionals/research/tbi-model-systems/return-to-work-and-job-stability-after-traumatic-brain-injury.
iii. More than one-fifth (92 [21%]) experienced a decline in annual income. 
Gaudette É, Seabury SA, Temkin N, et al. Employment and Economic Outcomes of Participants With Mild Traumatic Brain Injury in the TRACK-TBI Study. JAMA Netw Open. 2022;5(6). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2793771.
iv. Overall employment probability trajectories remained relatively stable between 1 and 10 years. Baseline socio-demographic and injury characteristics were predictive of employment trajectories. 
Howe EI, Andelic N, Perrin PB, Røe C, Sigurdardottir S, Arango-Lasprilla JC, Lu J, Løvstad M and Forslund MV. (2018) “Employment Probability Trajectories Up To 10 Years After Moderate-To-Severe Traumatic Brain Injury.” Front. Neurol. 9:1051. https://www.frontiersin.org/articles/10.3389/fneur.2018.01051/full.

Question 8

Authoritative Studies/Publications

Accepted Answer

By Caroline Zapiec, Romano Law Group
A. Types of TBI
a. Concussions are one of the most prevalent type of TBI. Every year, three out of four TBIs are concussions. People who suffer from a mild traumatic brain injury (mTBI) may suffer from confusion for about a day. 
b. Modest or moderate TBI is the second level of TBI. Less than 30 minutes of loss of consciousness are common with this kind of brain injury. Confusion may last for about a week. 
c. With a severe TBI a person can lose consciousness for about a full day. 
d. Uncomplicated TBI is another type in which a head CT or brain MRI is expected, regardless of whether it is mild, moderate, or severe. 
e. TBI in which the head CT/brain MRI shows changes such as hemorrhage is referred to as complicated TBI. Most TBIs are closed type. 
i. A closed TBI means that an outside force causes a blow or impact to the head that does not penetrate the skull. This blow injures the brain and causes it to swell. 
f. Some TBIs, however, are the open variety. The majority of medical professionals refer to an open TBI as a penetrating TBI. A bullet, knife, or other object penetrating the skull causes this damage. Brain tissue may be directly damaged when the object enters the brain
Traumatic brain injury: classification, models, and markers. Najem D, Rennie K, Ribecco-Lutkiewicz M, et al. Biochem Cell Biol Biochim Biol Cell. 2018; 96:391–40
B. Causes of TBI &#8211; There are several causes of TBI.
a. The growing population and increasing dependence on motorized vehicles and machinery are one of the causes of increasing TBI cases. 
b. Stress is one of the reasons that lead to TBI. A person with significant anxiety may experience a traumatic brain injury or will eventually do so.
c. A sudden blow to the head can cause traumatic brain injury.
d. A bullet or any other object that penetrates the brain or skull can directly damage the brain and cause traumatic brain injury.
e. A sudden fall from a height can also result in traumatic brain injury. It includes falls from a ladder, stairs, etc.
f. Traumatic brain injury can result from violent behaviors including child abuse, domestic violence, and gunshot wounds. 
g. Traumatic brain damage can also result from sports injuries. This sort of injury includes a ball strike to the head. 
h. TBI is frequently brought on by explosive blasts in active-duty military personnel. 
i. Traumatic brain injuries can also result from penetrating wounds and hard impacts to the head from objects like splinters or debris. 
j. Traumatic brain injuries can also result from automobile collisions. TBI is frequently brought on by collisions with cars, motorcycles, or bicycles, as well as any injured pedestrians in such incidents.
C. Symptoms
a. Common Physical Symptoms
i.Headache
ii. nausea or vomiting
iii. exhaustion or drowsiness,
iv. difficulty speaking
v. dizziness
vi. issues with balance 
These are only a few of the common physical symptoms. Some of these effects may come on quickly, others may take time, and others may become a lasting problem.
b. Sensorimotor Symptoms
i. ringing in the ears
ii. vision abnormalities
iii. impaired vision
iv. having a bad taste on your tongue
v. having trouble smelling.
TBI can lead to persistent sensorimotor and cognitive deficits, including long-term impaired sensory processing. These symptoms usually occur as sensory symptoms in patients suffering from TBI.
Perceived change in physical, cognitive, and emotional symptoms after mild traumatic brain injury in patients with pre-injury anxiety or depression. Karr JE, Iverson GL, Huang S-J, Silverberg ND, Yang C-C. J Neurotrauma. 2020; 37:1183–1189
Many patients who present to level I trauma centers with mild traumatic brain injury experience difficulties at 12 months postinjury, suggesting that this injury is not always benign; better follow-up and treatment appear to be needed
Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study Nelson LD, Temkin NR, Dikmen S, et al. JAMA Neurol. 2019, 76(9):1049–1059.
Common mTBI symptoms include both somatic complaints (headaches, vertigo, sleep problems, nausea, light or sound sensitivity) and affective symptoms (clinical depression, anxiety, irritability and emotional instability)
Evaluation and Treatment of Mild Traumatic Brain Injury: The Role of Neuropsychology. Prince C, Bruhns MEBrain Sciences. 2017; 7(8):105. https://doi.org/10.3390/brainsci7080105
D. Physical Therapy and Treatment
a. Traumatic brain injury (TBI) is seen by the insurance industry and many health care providers as an &#8220;event.&#8221; Once treated and provided with a brief period of rehabilitation, the perception exists that patients with a TBI require little further treatment and face no lasting effects on the central nervous system or other organ systems. 
b. In fact, TBI is a chronic disease process, one that fits the World Health Organization definition as having one or more of the following characteristics: 
i. it is permanent, 
ii. caused by non-reversible pathological alterations,
iii. requires special training of the patient for rehabilitation, 
iv. and/or may require a long period of observation, supervision, or care.
Traumatic brain injury: a disease process, not an event. Masel BE, DeWitt DS. J Neurotrauma (August 2010); 27:1529–1540
c. Therapies are helpful in the treatment of TBI. They are equally important as the medication and surgical treatment methods of TBI. 
d. Treatment or simple therapies are usually meant for rehabilitation purposes. 
e. Alternative treatments are also available for those suffering from traumatic brain injuries. 
f. Chiropractors, osteopaths, and physical therapists can all provide therapy.
Physical therapy management of adults with mild traumatic brain injury. Kane AW, Diaz DS, Moore C. Semin Speech Lang. 2019;40:36–47
g. High Compliance with prescribed exertion/vestibular rehabilitation therapies enhances clinical outcomes for previously recalcitrant patients with chronic mild TBI-related vestibular disorders.
Effect of Patient Compliance With Treatment Recommendations on Clinical Outcomes in Chronic mTBI: A TEAM-TBI Study. Jessica L Galey, BS, Shawn R Eagle, PhD, Nicholas A Blaney, BS, Cynthia L Holland, MPH, Hannah B Bitzer, BS, Walt Schneider, PhD, David O Okonkwo, MD, PhD, Anne Mucha, DPT, Michael W Collins, PhD, Anthony P Kontos, PhD, Military Medicine, Volume 185, Issue 7-8, July-August 2020, Pages e1229–e1234, https://doi.org/10.1093/milmed/usaa025
Preliminary evidence for improvement in symptoms, cognitive, vestibular, and oculomotor outcomes following targeted intervention with chronic mTBI patients. Kontos AP, Collins MW, Holland CL, et al. : Mil Med 2018; 183(Suppl_1): 333–8.
Functional Recovery, Symptoms, and Quality of Life 1 to 5 Years After Traumatic Brain Injury. Nelson LD, Temkin NR, Barber J, et al. JAMA Netw Open. 2023;6(3):e233660. doi:10.1001/jamanetworkopen.2023.3660
Assessment of follow-up care after emergency department presentation for mild traumatic brain injury and concussion: results from the TRACK-TBI study. Seabury SA, Gaudette É, Goldman DP, et al. JAMA Network Open. 2018;1(1):e180210. doi:10. 1001/jamanetworkopen.2018.0210
Longitudinal Study of Post concussion Syndrome: Not Everyone Recovers. Hiploylee C, Dufort PA, Davis HS, Wennberg RA, Tartaglia MC, Mikulis D, et al. J Neurotrauma. 2017;34(8):1511–1523.
E. Memory Loss
a. TBI leaves its mark on the person affected. Not everyone has the same problems or effects after a traumatic brain injury. 
b. Following a TBI many people can not concentrate or lower their concentration level; 
i. they have trouble in concentrating or focusing. 
ii. they have trouble in learning what they used to remember, which can be called memory difficulty.
Pathophysiology and treatment of memory dysfunction after traumatic brain injury. Paterno R, Folweiler KA, Cohen AS. Curr Neurol Neurosci Rep. 2017;17:52
F. TESTING
a. The overwhelming consensus of a substantial body of scientific inquiry supports DTI for detecting pathology in mTBI patients.
Clarifying the Robust Foundation for and Appropriate Use of DTI in mTBI Patients. Lipton ML, Bigler ED. AJOB Neurosci. 2014;5(2):41-43. doi: 10.1080/21507740.2014.884191. PMID: 25386384; PMCID: PMC4223772.
A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. Mucha A, Collins MW, Elbin RJ, et al. The American Journal of Sports Medicine. 2014;42(10):2479-2486. doi:10.1177/0363546514543775
b. Modalities that measure the physiological change after a sports related concussion include: 
i. functional MRI (fMRI), 
ii. diffusion tensor imaging (DTI), 
iii. magnetic resonance spectroscopy (MRS), 
iv. cerebral blood flow (CBF), electrophysiology, 
v. heart rate, measure of exercise performance, 
vi. fluid biomarkers, 
vii. transcranial magnetic stimulation (TMS).
Consensus statement on concussion in sport- the 5th international conference on concussion in sport held in Berlin. McCrory P, Meeuwisse W, Dvorak J, et al. October 2016. Br J Sports Med 2018; 51:838-47.
Clarifying the Robust Foundation for and Appropriate Use of DTI in mTBI Patients. Lipton ML, Bigler ED.. AJOB Neurosci. 2014;5(2):41-43
A review of magnetic resonance imaging and diffusion tensor imaging findings in mild traumatic brain injury. Shenton ME, Hamoda HM, Schneiderman JS, et al. Brain Imaging Behav 2012 Jun;6(2):137-92.
Diffusion tensor imaging of mild traumatic brain injury. Niogi SN, Mukherjee P. J Head Trauma Rehabil. 2010 Jul-Aug; 25(4):241-55. Neuropathology of mild traumatic brain injury: relationship to neuroimaging findings. Bigler ED, Maxwell WL. Brain Imaging Behav. 2012 Jun;6(2):108-36.
c. Challenges exist with identifying mTBI in the emergency room setting, and sometimes only 20% of patients receive an accurate diagnosis. mTBI is under diagnosed in the emergency room setting.
Challenges in the acute identification of mild traumatic brain injuries: results from an emergency department surveillance study. Pozzato I, Meares S, Kifley A, et alBMJ Open 2020;10:e034494. doi: 10.1136/bmjopen-2019-034494
G. Definition of Mild TBI
a. According to the Mild TBI Committee of the American Congress of Rehabilitation Medicine, revised by the World Health Organization (WHO), mTBI is defined by a Glasgow Coma Scale score between 13 and 15 at 30 minutes post-injury, and one or more of the following symptoms: 
 i. <30min loss of consciousness; 
 ii. <24hours post-traumatic amnesia (PTA); 
 iii. impaired mental state at time of accident (confusion, disorientation, etc.); 
 iv. and/or transient neurological deficit. 
 v. If a focal lesion is found on computed tomography (CT) or magnetic resonance imaging (MRI), the term &#8220;complicated mild TBI&#8221; has been proposed.
Definition and epidemiology of mild traumatic brain injury. Lefevre-Dognin C, Cogné M, Perdrieau V, Granger A, Heslot C, Azouvi P. Neurochirurgie. 2021 May;67(3):218-221. doi: 10.1016/j.neuchi.2020.02.002. Epub 2020 May 6. PMID: 32387427.
Definition of mild traumatic brain injury. Mild Traumatic Brain Injury Committee, Head Injury Interdisciplinary Special Interest Group, American Congress of Rehabilitation Medicine. J Head Trauma Rehabil 1993;8(3):86-7.

Question 9

APPENDIX

Accepted Answer

SAMPLE TRAUMATIC BRAIN INJURY CHECKLIST

Anxiety &#8211; Feeling stressed or on edge
Y or N

Anxiety when driving or as a passenger in a vehicle

Y or N

Balance problems &#8211; swaying when standing still

Y or N

Balance Problems &#8211; Feeling a loss of balance when walking

Y or N

Balance Problems &#8211; Feeling uneasy or balance problems in the shower

Y or N

Easily Distracted &#8211; Lose your train of thought easily

Y or N

Blurred Vision &#8211; Tired eyes after reading

Y or N

Confusion &#8211; Difficulty concentrating on simple projects

Y or N

Depressed &#8211; Since this incident, or increased depression

Y or N

Difficulty Multi-Tasking

Y or N

Difficulty Reading &#8211;Can&#8217;t focus on the words as well when reading

Y or N

Difficulty Reading &#8211; Can&#8217;t seem to focus on what you read and have to re-read it

Y or N

Difficulty Maintaining Focus

Y or N

Diminished Attention Span
Y or N

Diminished Ability to Concentrate

Y or N

Difficulty carrying on conversations and tasks

Y or N

Diminished smell

Y or N

Diminished taste 
Y or N

Dizziness

Y or N

Facial Muscle Weakness

Y or N

Fatigue &#8211; Tired Easy

Y or N

Fear of Falling

Y or N

Headaches

Y or N

Diminished Hearing Loss Since the Incident

Y or N

Interrupted Sleep &#8211; Difficulty Staying Asleep

Y or N

Difficulty Falling Asleep

Y or N

Light Headed

Y or N

Memory Problems

Y or N

Forgetful &#8211; Easily forget where you put things

Y or N

Increased Irritability &#8211; Mood Swings

Y or N

Nausea

Y or N

Restlessness

Y or N

Ringing in the ears

Y or N

Sensitivity to light

Y or N

Sensitivity to sound

Y or N

Slowed Thinking &#8211;Taking longer to make up your mind or decisions

Y or N

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