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Traumatic Brain Injuries

Traumatic Brain Injury

Traumatic brain injury (TBI) is a disruption of the brain’s normal functions. It can result in something as mild as a headache or as severe as permanent memory loss, coma, or even death. TBI happens when a person suffers a jolt or blow to the head, typically during a fall or high-impact accident. According to the American Medical Association, the injury sustained in such events is caused by damage to the brain tissue itself, or by the rupture and bleeding of blood vessels onto the brain.

Symptoms
Signs of a Mild Traumatic Brain Injury: What to watch for

After a jolt or blow to the head caused by something like a motor vehicle collision, certain signs indicate a concussion, or a Mild Traumatic Brain Injury (MTBI):

  • Loss of, or decreased consciousness
  • Increasing and unrelenting headache
  • Vomiting and nausea
  • Weakness, drowsiness, numbness, or decreased coordination
  • Slurred speech
  • Impaired attention or concentration
  • Asymmetrical pupil dilation
  • Convulsions or seizures
  • Trouble recognizing familiar faces
  • Confusion, restlessness, or agitation
Symptoms of a Traumatic Brain Injury: What does the victim experience?

In the event of a Traumatic Brain Injury, some symptoms may not present right away, but only become noticeable after a few days. Even sophisticated neuroimaging techniques such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) may produce a negative result, revealing no gross pathology at all for hours following an injury. 1 The Centers for Disease Control note that “some patients with MTBI do not present abnormalities, or the markers are not sensitive enough to accurately diagnose the condition.” 2 For this reason, it is critically important that a person who has been involved in a head trauma incident be evaluated and monitored closely by medical professionals and specialists.

The Centers for Disease Control classify the symptoms of a concussion, or a “mild” and temporary TBI, in four categories: thinking/remembering, physical, emotional, and sleep. Disruptions to thinking/remembering include feeling mentally slowed down, having difficulty concentrating, and difficulty remembering new information. Physical signs of a concussion may be headaches, blurred vision, trouble with balance, dizziness, and nausea. The emotional signs of a concussion are irritability, sadness, and nervousness and anxiety. Finally, sleep habits may be disturbed, causing a TBI victim to sleep excessively or, on the contrary, having trouble falling, or staying asleep.

A person who has suffered a head trauma may not experience symptoms until they resume the habits of their everyday life. It can then be difficult for the victim to acknowledge or admit that they are having trouble with normal activity or cognition following an accident. Nevertheless, the sooner they are treated by a medical professional, the better the prospects for recovery and rehabilitation.

How a person experiences a Traumatic Brain Injury varies significantly depending on a number of factors. Most evidently, the effects of TBI depend on the severity of the injury. Mild TBI, sometimes simply called a concussion, may have temporary effects and symptoms such as a headache, dizziness, numbness, and nausea. It is impossible to know at the time of the injury, however, whether other more severe consequences of a head injury may present at a later time. Some victims of a Traumatic Brain Injury may experience symptoms only for a short time, while other symptoms may continue for days, weeks, or longer. Although mild TBI may not be life threatening, a study of 470 patients in San Diego, California found that victims continue to have related health problems six months after the injury, including headaches, dizziness, vision problems, memory or learning difficulties. Living with these symptoms may present serious psychoemotional and financial problems. 3

Effects
Long Term Effects of Moderate to Severe Traumatic Brain Injury

Those who suffer from moderate or severe Traumatic Brain Injury, about 25% of victims, present with a range of complications and chronic health problems that affect their ability to function in everyday life. Half of those TBI victims who were hospitalized at the time of the initial injury and treated with outpatient rehabilitation, experienced further decline in their health and quality of life in the five years after the incident. A study published in the journal of Head Trauma Rehabilitation reports that ten years following a traumatic brain injury, “the experience of living with cognitive and behavioral changes and fatigue, struggling to cope with work, study, recreational activities, social interaction, and personal relationships, and in many cases, experiencing failure over long periods of time clearly causes anxiety and depression.” 4

Traumatic Brain Injury may in significant ways change a person’s life, affecting personal, social, and professional habits A brain injury may cause changes in sensation (sight and balance), language (communication and understanding), emotion (depression, anxiety, aggression, personality), and cognition (memory and reasoning). One of the most commonly reported effects of moderate to severe TBI is headaches, frequently the kind of headaches that are classified as migraines. A 2017 study in the Journal of Neurotrauma found that TBI victims had a significantly higher rate of headaches than the general population up to five years after the initial injury. Further, new headaches were sometimes reported with a latency of several years. That is, a person with a TBI may after several years suddenly experience debilitating headaches. 5

Some of the most challenging effects of TBI are the so-called “psycho-social outcomes,” including employment, personal relationships, leisure activities, and general social functioning. For the purposes of employment, a person recovering from a TBI may not be able to execute the kinds of tasks that they could easily do before the injury. Such tasks may be physical, for example heavy lifting or extended periods of standing and walking. Or the effects may be cognitive, such as difficulty retaining new and complex information, impaired problem solving, decision-making, planning and logical organization, and a decreased ability to focus attention. In addition, most professional settings require sophisticated interpersonal skills that most people take for granted, but which may be impaired as a result of TBI. A person recovering from a TBI may exhibit anger and hostility, aggressive behaviors, and poor judgment in social situations.

A person who has suffered a Traumatic Brain Injury may need to adjust the ordinary habits that they took for granted before an injury. They may need assistance with domestic chores like cooking, cleaning, shopping, yard work, etc. This usually entails a considerable expense, or places serious burden on the victim’s family and social network. Further, a person recovering from a TBI may need help with personal care and hygiene (bathing, getting dressed). While some of these functions may be carried out by family members, hired help may also be required. Such specialist services can place a financial strain on the individual and family. Nevertheless, studies show that a combination of paid support and family members’ help is best in the long-term care and accommodation of a person with a TBI. When a loved one is afflicted with a serious injury, victims and families must reorient themselves and their identities in the context of personal relationships. For example, a married couple may need to restructure the duties of the home; in the process of redefining relationships, duties, and responsibilities in this way, the added burden of also caring for the physical needs of the injured partner may be unmanageable.

Research on the overall life satisfaction versus distress of caregivers of TBI victims indicates that, although family members generally feel good about being able to care for an injured loved one, “the stress associated with caregiving can often lead to increases in depression, anxiety, [and] social isolation.” 6 Caregivers that reached out to networks of social support experienced reduced signs of stress such as sleep disturbance and loss of appetite. Research shows that the loss or reduction in family income may lead to decreased feelings of caregivers’ self-reliance, and correspond to experiences of stress, anger, and reduced life-satisfaction. This is true specifically for income change rather than current income. In other words, the source of stress for caregivers of TBI victims tends to be not a financial concern per se, but a reduction of financial stability and potentially adjustment in lifestyle.

Some pre-injury habits that provided a sense of personal freedom and mobility may be compromised as a result of a Traumatic Brain Injury. For example, driving a car may present challenges as well as potential dangers. A study in the medical journal Brain Injury found that 38% of persons who returned to driving after suffering a severe brain injury were subsequently involved in a traffic accident; of those individuals, 45% were involved in subsequent accidents more than once. The study suggests that the simultaneous coordination of multiple factors that is involved in driving a car (the gross motor skills of steering and using pedals, recognizing other vehicles in close proximity, identifying lanes, stoplights, and signs) may be difficult for a person recovering from brain damage. Because a person with a TBI may need assistance with tasks and activities that were simple before the injury, he/she may require special services, resources, and equipment. The cost of such services and equipment may be prohibitively high.

Treatment and Rehabilitation
Treatment and Rehabilitation After a Traumatic Brain Injury

The prognosis for Traumatic Brain Injury treatment and rehabilitation—the prospects of returning to a fulfilling life after an injury—depends in large part on whether the victim seeks medical evaluation promptly, whether he/she complies with the directives of healthcare professionals, and whether he/she gets access to resources and help with things that may be intimidating or overwhelming, including legal counsel from a personal injury attorney.

The Brain Injury Association of America provides the following list of specialists, whose expertise may be critical for a TBI victim’s recovery 7:

  • Neurosurgeon: An expert in diseases and conditions of the nervous system. Often the attending physician who manages the case.
  • Neurologist: A physician who specializes in the nervous system and its disorders.
  • Pulmonologist: A physician who manages problems with respiration and lung disorders.
  • Physiatrist: A physician who specializes in physical medication and rehabilitation.
  • Orthopedic Surgeon: A surgeon who specializes in diseases of the bones and treats injuries to the limbs and back.
  • Neuropsychologist: A psychologist with specialized training in relationships between the brain and behavior.
  • Nurses: Nursing staff provides direct patient care in all phases of the recovery process including administering oral and intravenous medications, positioning patients, and carrying out physicians’ orders.
  • Physical Therapist: Evaluates components of movement, including muscle strength, tone, posture, coordination, endurance, and general mobility.
  • Occupational Therapist: Focuses on reestablishing the activities of daily living, self-care, and upper body motor skills.
  • Speech/Language Pathologist: Responsible for evaluating and assisting with swallowing problems, communication difficulties, and cognitive deficits.
  • Respiratory Therapist: A person skilled in operating machines to aid breathing and keep the airway open.
  • Social Worker/Case Manager: A liaison between the professional team and other parties concerned with the patient.
Recovery

Persons with a Traumatic Brain Injury sometimes have a long road ahead of them toward recovery. With the right medical treatment and with access to the necessary resources, including consultation with a personal injury attorney, the prospects for fulfilling life post-injury are significantly increased. The most important action to be taken immediately after a head injury is to be evaluated by medical professionals. A medical professional is able to determine the best course of treatment, and supply an attorney with invaluable diagnostic information. It is prudent for a victim of a TBI to speak with a personal injury attorney in the early stages of recovery so that he/she may be connected with specialists and other support networks and services.

In a 2015 Report to Congress, the Centers for Disease Control note that the field of TBI rehabilitation has made tremendous progress in the last 20 years. The report states that, “Evidence suggests that rehabilitation services can improve a person’s quality of life and can improve the likelihood of achieving community integration, including returning to work or school, living independently, and enjoying social and leisure activities. 8 It is therefore very important to insure that TBI victims get the kind of help that they need in order to access rehabilitation services.

It is exceedingly difficult to determine what rehabilitation methods and techniques are consistently effective because patients and injuries vary widely. Every person living with TBI experiences the condition a little differently.

Tips for Recovery

I’ve been examined by a doctor and diagnosed with a mild TBI, a concussion. What should I do to increase my chances of a full and speedy recovery?

  • Perhaps the most important recovery method is to rest (including nighttime sleep), as this helps the brain heal.
  • Avoid strenuous activities, and activity that requires intense focus and concentration. These activities may hinder your recovery. And note that repeated injuries, such as those sustained in contact sports, may exacerbate the damage inflicted on the brain.
  • When you return to the habits of your normal life, do it gradually rather than all at once. Focus on one task at a time rather than attempt multi-tasking, which requires coordinated cognitive functioning.
  • Consult a medical professional regarding high risk activities requiring fast reaction times, like driving a car.
  • Do not drink alcohol or take drugs other than those prescribed by your doctor.
  • Talk with your family and friends about the recovery process, particularly regarding important decisions that you may not be fit to make on your own as a result of TBI.
Advances in Science and Technology

Research on traumatic brain injury diagnostics and treatment methods is constantly advancing. Major scientific breakthroughs make a difference for attorneys who are developing their clients’ legal cases, and for clients planning their roads to recovery.

Endocrine Dysfunction Induced by Traumatic Brain Injury

The pituitary gland, which regulates hormones that are necessary for growth and development, is located inside the skull. It is the master gland that coordinates the body’s endocrine processes. In the kind of incident that leads to traumatic brain injury, a person may be at risk for damaging the pituitary gland. Until recently, scientists considered endocrine dysfunction, or impaired hormone production, to be a relatively rare complication in TBI cases. Most long-term effects were thought to be primarily associated with the concussion itself. New findings indicate, however, that damages to the pituitary gland may be connected to a TBI, and lead to health complications. Most urgently, a disruption in the production of growth hormones is a threat to children and adolescents who suffer TBI. Still, a study in the Journal of Pediatrics reports that endocrine abnormalities associated with TBI subside about a year after the trauma.

More subtly, however, a change in an adult’s hormone levels may create personality changes that are difficult to detect, analyze, and medically treat. For example, if the pituitary gland is damaged, it may not communicate effectively with the adrenal glands which produce the hormone cortical. Because this hormone facilitates a person’s ability to cope with stress, a reduced cortical level may hinder these mechanisms to the person’s detriment. Some of the cognitive and neuropsychiatric disabilities that TBI victims experience, typically assumed to be related to the primary diagnosis of brain trauma, may in fact be caused by a condition such as hypopituitarism, or growth hormone deficiency, which means it may be treatable with hormone replacement therapy.

Traumatic Brain Injury Prognosis App

One of the first decisions that clinicians and family members have to make in the event of a traumatic brain injury is whether to intervene at all. This means making a judgment call about what the victim’s survival chances are both immediately and in the coming months. Further, an assessment must be made of the victim’s likely level of restored function after the medical intervention, an intervention that would typically involve surgery. The question that doctors and families struggle with in these crises is, What is this person’s prognosis?

In 2016 Canadian neurosurgeons developed a prototype for a TBI Prognosis Calculator, a mobile app for clinicians to use during point-of- care interactions with patients and families. The app is based on mathematical models that map markers of TBI and estimate victims’ death or functional status. It asks doctors a series of questions about the patient, including age, pupil reactivity, Glasgow Coma Scale score, and CT scan data. Of course, the app is not designed to replace the expertise and observation of doctors on site. Rather, the intent with the app is to make accurate prognoses more readily accessible in a clinical setting, where prognoses models are not typically referenced. These prognoses would assist healthcare providers with assessment and family counseling.

Employment
Employment after a Traumatic Brain Injury

Persons who have suffered a traumatic brain injury oftentimes have a difficult time returning to their regular jobs. The challenge may be attributable to physical factors, for example an inability to sit or stand for extended periods of time due to neck pain. The challenges may also be cognitive and psychological, such as difficulty retaining and processing information, or difficulty with interpersonal relationships in work-teams. One of the common effects of a Traumatic Brain Injury is a personality change, often very subtle. A previously convivial and even-keeled person may become aggressive or volatile, which employers tend to view as a liability. As a result of these long-term effects, approximately 55% of those who suffer moderate to severe TBI are not employed five years after the injury. This places a financial burden on TBI survivors and their families. From a legal standpoint, an issue of primary importance is to establish the victim’s loss of wages and future earning potential.

Before returning to work, someone with a Traumatic Brain Injury may want to discuss his/her vocational prospects with a doctor or team of medical professionals. They may be able to help develop strategies for a “new normal” at work, and also for discussing the effects of a TBI with an employer. Employers may be able to facilitate an injured person’s reintegration into a workplace more easily if they understand the victim’s experience and recognize the value of a recovery plan.

It may be wise for an injured person to talk with his/her employer about ways to increase work duties and responsibilities gradually. For example, half-days may be a good way to transition without overwhelming the injured mind, which may be struggling to adjust and keep up with pre-injury expectations. Fatigue is a common effect of TBI, and part-time work may be more manageable with time
to rest.

Vocational rehabilitation services may be a resource for persons with a TBI returning to work. These services are mandated by the Americans with Disabilities Act. Examples of vocational rehabilitation services include: neuropsychological evaluation, work hardening (preparing for work), job coaching, home and vehicle modifications, equipment, and supported employment. It is important to note that while employers are prohibited from asking about the nature of a disability or injury, the employee must with modest accommodations be able to perform the duties of the position.

Financial Burden

Life after a Traumatic Brain Injury, particularly in moderate to severe cases, can be staggeringly costly. The medical bills, rehabilitation and physical therapy, potential loss of income, and additional in-home services and resources may add up to hundreds of thousands of dollars. These are typically expenses that no one has planned for, or hopes ever to incur. For TBI victims’ families, struggling to manage the financial strain may be connected to a feeling of loyalty and hope for a loved one’s recovery and future prospects. Families sometimes struggle very hard to give the best possible care and all imaginable recovery opportunities to a family member who has been injured. In this process, psychological and emotional pressure may be shaping family dynamics in a way that the TBI victim has little control over. In these situations, it is important to seek help from someone who has the individual victim’s and the family’s best interest in mind.


In some cases, a personal injury attorney may offset a client’s medical expenses with a so-called letter of protection. In effect, this mechanism ensures that the cost of medical treatment is deferred until a case ruling or settlement has been reached; at that time, the settlement resources are directed to cover the doctor’s and/or hospital’s expenses. The client in such instances is not burdened with paying for medical expenses out of pocket.

Attorney Representation
Should I seek attorney representation if I have sustained a Traumatic Brain Injury?

Yes. Because it is the smartest way to take care of yourself and your family; not because a personal injury lawyer frightens you into an arrangement. The Brain Injury Association of America states clearly that, “It is a good idea to consult an attorney very soon after the injury. Even if there are no grounds for a lawsuit, an attorney who knows about disability can set a course to ensure all avenues are explored, evidence is preserved, medical and public records are collected, and appropriate benefits are available when necessary.” 13

Brain injuries are too important not to handle with the utmost prudence and caution. Because they are legally difficult and medically complicated, a person who does not seek representation from an attorney runs the risk of undermining his/her potential to be compensated for losses and injuries. A legal case requires strong evidence that is compellingly presented. Compared to, for example, a spinal injury case, wherein the jury is expected to reference personal experience (specifically with back pain), it is very difficult to predict how a jury will respond when presented with a case of accidental brain injury. In court, expert testimony demonstrates objectively that injury was sustained in a traumatic event. An attorney’s job is to gather evidence from medical specialists in a way that demonstrates the nature and severity of a brain injury beyond the individual victim’s self-reported experience. A skilled attorney will make a case that relies not only on the individual client’s physical experience (for example, of pain or reduced mobility and strength), but on an assessment of the client’s future obstacles to a productive and fulfilling life.

Guardianship and Power of Attorney

In severe cases, a person suffering from a Traumatic Brain Injury may not be able to determine his/her own best interests, or be capable of making rational, well-informed decisions. In those cases, guardianship or power of attorney may be established, placing limited decision-making authority with a trusted person who tends to the victim’s affairs. According to the Brain Injury Association of America, “in many cases the attorney continues to represent the person with brain injury long after the medical and rehabilitation providers have completed their work. This is particularly true when the individual may benefit from such legal options as a power of attorney or guardianship, or another legal remedy for protecting assets (e.g., a conservatorship, fiduciary trust, or special-needs trust).” 14

In addition to loss of cognitive functioning, a recurring indicator of a Traumatic Brain Injury is a personality and self-awareness lapse. Persons who have been in an accident that included head trauma may insist that the injury is “nothing to worry about,” while their family notices subtle but important changes in the victim’s demeanor, behavior, and attitude. A 2016 article in the journal of NeuroRehabilitation notes that “Outcomes from TBI may include reduced cognitive functioning, poor decision making, increased risk taking, disinhibition, [and] diminished safety skills.” 15 The compromised ability to make sound decisions about one’s care and post-injury limitations is especially critical. Those who have important decisions to make regarding their personal and financial future are well-served by consulting with an experienced attorney. The attorney knows how to navigate the legal process in conversation with family members and caretakers, while respecting the individual client’s perspective and choices.

What FVF Can Do for You

The personal injury attorneys at Fogelman & von Flatern are truly committed to client advocacy and education. This is particularly valuable in times of crisis, such as in the event of a Traumatic Brain Injury. Such an event often creates tremendous confusion and fear. Clients worry about their physical and psychological future, their medical expenses, their family’s prospects. The future may be unknown, and the victim may be confronted with bureaucracies and legal procedure that are both overwhelming and intimidating. This experience of being helpless in unfamiliar territory may in fact compromise the victim’s ability to focus on what is most important: attending to medical advice for recovery.

A primary goal for Fogelman & von Flatern is to give clients a sense of recognition for what they are going through. Working with clients, our attorneys strive above all to put TBI victims in touch with top-tier medical diagnosticians who can offer a thorough account of the injury. A specialist, for example, a neurologist, is invaluable for TBI victims for two reasons:

  1. A tangible strategy for recovery is more feasible when there is an in-depth analysis of the injury itself. We want our clients to walk away with a wealth of knowledge about the trauma that they have suffered, and its impact on their bodies and minds.
  2. A specialist can provide expert testimony to indicate the precise nature of the injury, specifically its duration or permanence. With expert testimony, a personal injury attorney can typically make a stronger case on a client’s behalf than if the client were representing him/herself. We have worked for many years with some of the top diagnosticians in Austin, TX, and we refer clients only to those medical professionals whom we know to be staunch patient advocates.

The attorneys at Fogelman & von Flatern want our clients to know that the law assures them of the right to claim compensation for loss. We want them to know that, in working with a personal injury attorney, they have done everything in their power to give themselves the best possible prospects for a good life after a traumatic injury. Sometimes personal injury cases make it difficult for victims to know whom to trust, and whom to supply with personal information. Insurance companies may be calling, asking questions about medical records. It can be deeply unsettling not to know whether to share information or not. Some clients feel helpless in comparison to the awesome power of those who make major decisions about their future. A representative of an insurance company has experience with the procedures of personal injury law, but the injured victim may not. This creates a discrepancy that puts the victim at a disadvantage. Fogelman & von Flatern is committed to minimizing that discrepancy. Allowing our clients the peace of mind to focus on recovery, we take pride in speaking on behalf of those who are protected by law.

References

1 Frank G. Hillary, et al., “Motor Vehicle Collision Factors Influence Severity and Type of TBI,” Brain Injury 16:8 (2002): 739-740.

2 National Center for Injury Prevention and Control. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. (Atlanta, GA: Centers for Disease Control and Prevention; 2003), 7.

3 Jess Krauss et al., “Physical Complaints, Medical Service Use, and Social and Employment Changes Following Mild Traumatic Brain Injury: A 6-Month Longitudinal Study,” Journal of Head Trauma Rehabilitation 20:3 (2005): 239-256.

4 Draper, Kristy, Jennie Ponsford, and Michael Schönberger, “Psychosocial and Emotional Outcomes 10 Years Following Traumatic Brain Injury,” Journal of Head Trauma Rehabilitation 22 (2007): 278-287.

5 Arthur Stacey et al., “Natural History of Headache Five Years after Traumatic Brain Injury,” Journal of Neurotrauma 34 (2017): 1558-1564.

6 R. Wells, J. Dywan, and J. Dumas, “Life Satisfaction and Distress in Family Caregivers as Related to Specific Behavioral Changes after Traumatic Brain Injury,” Brain Injury 19:3 (2005): 1106.

7 Challenges, Changes, and Choices: A Brain Injury Guide for Families and Caregivers. Copyright Brain Injury Association of America authored by Carolyn Rocchio. LINK. See especially pp. 5-6

8 Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. (Atlanta, GA), 46.

9 Christian Iorio-Morin, David Fortin, Jocelyn Blanchard, “TBI Prognosis Calculator: A Mobile Application to Estimate Mortality and Morbidity Following Traumatic Brain Injury,” Clinical Neurology and Neurosurgery 142 (2016) 48-53.

10 Anne-Marie D. Kaulferd, et al. “Endocrine Dysfunction following Traumatic Brain Injury in Children,” Journal of Pediatrics 157 (2010); 894-899.

11 Amar Agha and Christopher J. Thompson, “Anterior Pituitary Dysfunction following Traumatic Brain Injury,” Clinical Endocrinology 64 (2006): 481-488.

12 Joana Mesquita, Ana Varela, and José Luis Medina, “Trauma and the Endocrine System,” Endocrinología y Nutrición 57 (2010): 492-499.

13 Challenges, Changes, and Choices: A Brain Injury Guide for Families and Caregivers. Copyright Brain Injury Association of America authored by Carolyn Rocchio. LINK, 21.

14 Challenges, Changes, and Choices: A Brain Injury Guide for Families and Caregivers. Copyright Brain Injury Association of America authored by Carolyn Rocchio. LINK. P. 21

15 Stephanie A. Kolakowsky-Hayner, Kimberly Bellon, and Yvonne Yang, “Unintentional Injuries after TBI: Potential Risk Factors, Impacts, and Prevention,” NeuroRehabilitation 39 (2016): 364.