THE TRAUMA TRIAD AND CO-MORBID FACTORS
IN CLOSED HEAD INJURIES
John K. Powers
Powers & Santola, LLP
39 North Pearl Street
Albany, New York 12207
(518) 465-5995
It has been estimated that there are 2,000,000 head injuries in the United States each year. These result in 500,000 hospitalizations. Between 70,000 and 90,000 of these injuries result in serious disability. Nearly 50 percent of all head injuries are the result of automobile accidents. When screening new clients, it is essential to understand the causes of mild brain injury and to recognize the symptoms of such injury. These symptoms can generally be divided into three separate spheres: cognitive, physical and emotional. The interaction of these symptoms tends to multiply their effect on the victim's ability to function at a pre-morbid level.
Head injuries can generally be divided into two categories: open head injuries - in which both the skull and the brain are damaged; and closed head injuries - in which the brain is damaged but the skull is not. Of the two types, closed head injuries are, by far, the most common.
Closed head injuries are further subdivided into four types:
1. Injuries involving acceleration and deceleration. Such injuries occur as the result of the skull moving while the brain remains stationary. When the head suddenly stops moving, the brain smashes into the interior wall or the base of the skull. The result is hemorrhaging, bruising or swelling of the brain.
2. Compression injuries. The brain has a limited amount of space inside of the skull. When bleeding inside of the skull occurs, this results in compression of the brain, thus affecting its functions.
3. Rotational injuries. These occur when the brain twists around the axis of its stem just above the spine where it enters the skull. This results in a shearing of the brain stem or damage to its nerve fibers.
4. Anoxia. Damage occurs to the brain when it is deprived of oxygen or when the amount of oxygen to it is reduced as a result of reduced blood flow.
The results of closed head injury are often overlooked by both the acute care physician and by the patient. The effects of closed head injury are often delayed and subtle. As a result, many patients, who are more concerned with recovering from their more obvious injuries, fail to report their symptoms or to seek treatment for these injuries.
To determine whether a client has sustained a closed head injury, the attorney needs to conduct a careful and focused interview of both the client and his or her family members.
During the interview of the client, the attorney should be aware of any of the following symptoms which may indicate a closed head injury:
COGNITIVE DEFICITS:
i) Lethargy, lack of alertness
ii) Lack of attention span
iii) Slowing of mental processes
iv) Inability to plan ahead
v) Difficulty concentrating
vi) Easily distracted
vii) Short or long term memory difficulties
viii) Does the client compensate by making lists or taking notes?
ix) Difficulty with learning new information or skills
x) Difficulty understanding written or spoken information
xi) Impairment of writing skills
xii) Vision problems (field cuts, double vision, failure to recognize familiar objects)
xiii) Hearing problems
xiv) Reduced tactile sensitivity
xv) Difficulty with abstract reasoning
xvi) If the client is a student, has there been a decrease in grades or difficulty studying?
PHYSICAL DEFICITS:
xvii) Motor weakness in one or more limb
xviii) Lack of muscle coordination and dexterity
xix) Difficulty maintaining balance, dizziness, fainting spells or sudden involuntary movements
xx) Speech problems
xxi) Vision problems
xxii) Impairment of sense of smell or taste
xxiii) Hearing impairment
xxiv) Impairment of sense of touch or feeling
xxv) Numbness, tingling, weakness or heaviness
xxvi) Fatigue
EMOTIONAL DEFICITS:
xxvii) Is there a normal range of expression?
xxviii) Is the expression of emotion flat?
xxix) Are there inappropriate outbursts such as laughter or crying?
xxx) Periods of aggression or agitation
xxxi) Impulsiveness or childish behavior
xxxii) Repetitive behavior
xxxiii) Increase in swearing or verbal abuse
xxxiv) Disinhibition
xxxv) Changes in interpersonal relationships
xxxvi) Depression
xxxvii) Paranoia
xxxviii) Lack of tact or humor
xxxix) Reduced sexual interest
xl) Sleep disorders
In addition, complete ambulance and medical records should be obtained and scrutinized. A determination must be made whether the client suffered:
a. Any period of loss of consciousness;
b. Any episodes of confusion or disorientation;
c. Any blurring of vision or double vision;
d. Any injuries to the head or neck.
If a review of the records, or the interview of the client and the client's family results in any of the above questions being answered in the affirmative, the patient should be referred for neuropsychological testing to determine whether a closed head injury has occurred.
Neuropsychology is the study of the relationships between the brain and behavior. Clinical neuropsychology relies on the concept of deficit measurement. It assumes that the patient once functioned in a certain manner. If a behavior change has emerged, there is a corresponding deviation from the normal expected premorbid pattern of test performance.
Neuropsychology relies upon three primary methods of deficit measurement. The first, and most reliable, is to compare pre-injury standardized tests to the results of post-injury tests. To accomplish this, it is necessary for the attorney to obtain any standardized tests which were administered while the client was in school, in the military, or in other situations where such tests might have been administered. These test results should be furnished to the neuropsychologist.
If no pre-injury tests can be obtained, the neuropsychologist will assume that the patient was an average person before the tests and compare the post-injury results to average test scores. This method can be further refined by estimating whether the patient's pre-injury level was above or below average based upon his educational or vocational history.
In the absence of pre-injury tests, an alternate method is to compare one side of the body to the other side. In doing so, it is necessary to take into consideration that motor speed and strength should be approximately 10 percent better in the dominant limb.
For such testing to be valid, the neuropsychologist must also rule out any other factors which may influence the post-injury test results. These may include pre-existing deficits, orthopedic problems or peripheral nervous system impairments.
Testing performed by the neuropsychologist is designed to evaluate personality and behavior, motor skills and intelligence. As any individual test may give a false impression, testing is usually conducted by giving the patient an extensive battery of tests designed to provide detailed information from many different sources. The two tests most often employed are the Halstead-Reitan Neuropsychological Test Battery, which can take six to eight hours to administer, and the Luria-Nebraska Neuropsychological Test Battery.
The results of these tests provide specific information as to which parts of the brain have been damaged. Injuries to specific portions of the brain are known to produce precisely defined disorders. As closed head injuries often produce damage to several portions of the brain simultaneously, mixed symptoms often result.
Due to the anatomy of the skull's interior contours, acceleration injuries are more likely to impact frontal lobes and the poles of the temporal lobes. Thus, the most common type of brain injuries resulting from automobile accidents are to those areas of the brain.
The frontal lobes are the portion of the brain primarily responsible for judgment, insight, creativity and foresight. These lobes are critical to the ability to maintain concentration, vigilance, perseverance and response inhibition. In addition, the ability to smell requires an intact frontal lobe.
Persons sustaining injury to the orbito-frontal area of the frontal lobes often exhibit behavior which is hostile, compulsive and inappropriate sexually. Such behavior is often described as silly, childish and outlandish.
Persons suffering from injury to the dorso-lateral part of the frontal lobes often become apathetic and indifferent. In addition, the victims of such injuries often suffer from an inability to concentrate, have difficulty carrying out sequential tasks, and may repeat themselves frequently when speaking.
Injuries in the medial-frontal area often result in a variety of movement disorders called akinesias. This most often results in a lack of spontaneous movement or the loss of the ability to initiate motor activity. In addition, persons sustaining severe injury to these areas are often incontinent of urine and feces.
The temporal lobe of the brain has three major functions:
1. The interpretation of a variety of auditory functions, including written and spoken language;
2. The awareness of the relevance of time, which includes memory; and
3. The regulation of some forms of emotional expression and primitive drives and affects.
Thus, damage to the temporal lobes may impair the ability of the victim to discriminate words and to understand speech sounds. In addition, extensive injuries to the temporal lobes may result in severe anterograde amnesia and impaired ability for new learning. Retrograde amnesia, which involves difficulty in remembering events prior to the onset of the amnesia, is also commonly present.
Bilateral damage to the undersurface of the temporal lobes, if extensive, can create a condition in which the patient reacts to virtually all stimuli with extreme rage which is beyond the person's control.
The parietal lobes of the brain govern much of the appreciation of many kinds of sensation including touch, temperature, pain, pressure, vibration, the ability to distinguish among a variety of shapes, sizes and textures. Persons suffering damage to the right parietal lobe may become easily disoriented. Damage to the left parietal lobe often leads to confusion between the left and right sides of the body and inability to calculate and to write.
The occipital lobe of the brain is primarily devoted to visual perception and recognition. When injury occurs to this area of the brain, the symptoms include a range of visual field defects, bizarre visual hallucinations or illusions, an inability to recognize persons who should otherwise be familiar to the patient and a loss of color vision.
Before the client is seen by a neuropsychologist, the attorney should obtain the following records for review by the expert:
1. Ambulance records;
2. Complete medical records, both before and after the accident;
3. Education records, including any standardized test results;
4. Statements from family, co-workers and friends who knew the patient before the injury;
5. Employment history and records; and
6. Military service records.
