Bridge Back from Brain Injury Despair

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Posted on 23rd May 2008 by Gordon Johnson in Uncategorized

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In 1997, Becca Martin and I created https://waiting.com. It is certainly the most important thing I have done in my career. One of the most important contributions of that page was that its Bridge from Despair was the first internet collection of stories from those who had suffered the tragedy of brain injury on the internet. The internet was young then, and people were just beginning to discover the value of the connection it creates.

Yesterday I got this story, and I thought this blog would be a good place to tell this story, a story we will probably add to https://waiting.com/waitingbridge.html

Dear Mr. Johnson,

10 months ago I had a serious car accident and was in coma for 1 week. I had 3 brain-bleedings and 2 brain contusions. While I was in the coma my parents were with me and spoke to me. My father is German and we live in Germany, my mother is English. And I think she spoke a lot in English with me, because since the coma I often think in English. I am very, very grateful to them that they were by my side. This is the most important thing in the world. The love of your parents. You feel it and you know that they are with you, although you are in the coma. To give this deep love is the most comforting and the most beautiful thig you can do to the person you love. And to know that there are people who don`t look at you like doctors look at their disabled patients is comforting. I want to thank you very much for your work. You really help the people. If you come back, sort of return to the world, it isn`t easy at all to talk to people about this time. Mostly they don`t understand, how could they?

I had just one possibility to get to know another person with a near death experience. And this was so different from mine. I don`t remember anything concerning the accident. And I even lost months of memory before the accident, but I can recall my near death experience. I saw multiple universes in higher dimensions. I`m sorry, I don`t know why I am telling you this. Maybe because I don`t know anyone I could talk to about this. Since I am reading books about the quantum-physical possibility of multiverses I feel a bit reliefed, because I know now, that there`s a scientific explanation for what I saw. But I know that every physicist I`d talk to about this topic would bring me to the booby hatch.
I know, that I was very lucky, that I can think again.

The neurologist couldn`t explain my improvement. Although I have problems remembering things, I want to finish the exams on the university in Munich. It might sound queer, but after I have been hating the woman who ran into me far too fast (and sometimes I still hate her and try not to do it) I thought that following Kant`s categorial imperative and wishing a peaceful earth for everyone, I hope that I can release the hate. And I am grateful that I was able to go through this near death experience.

You give the people hope, information and the feeling that one can talk about the accident. Thank you!

Lisa
alchwarizmi@web.de
Thank you Lisa for allowing me to post your story on this blog.

In Memoriam Bryant Jennett – Glasgow Coma Scale Author

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Posted on 9th April 2008 by Gordon Johnson in Uncategorized

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In general, brain injury research and work is a pretty anonymous field. I can rattle off a bunch of names of researchers, but even most defense experts have never heard of many of these people. One of the names that almost everyone in the brain injury field has heard is Bryan Jennett. If they haven’t heard of him, they have heard of his most famous work: the Glasgow Coma Scale, commonly referred to as the GCS. The GCS score is the most single common denominator in all of head injury diagnosis, and any cursory review of a brain injury medical record will have a GCS score on it.

Bryan Jennett, CBE, M.D., the brain injury expert of Glasgow, Scotland, died on 16 February 2008. For a nice treatment on Dr. Jennett click here. The North East Center also includes a nice comment on his work on such link by Nathan Zasler, M.D. that is worth reading – Reflections on the Life and Work of William Bryan Jennett, CBE, M.D., FRCS. Dr. Zasler had this to say about Dr. Jennett:

“During his career, Dr. Jennett not only distinguished himself as a clinician and scholar but lectured and wrote extensively on issues relating to brain injury.

“He remained one of the driving forces behind some of the more recent international work in the area of disorders of consciousness over the last 15 years. What was most amazing was Dr. Jennett’s ability to look back on his own work and be constructively critical of it, including acknowledging some of the limitations of his own thinking. He continued to provide encouragement to other clinicians to pursue further honing of our collective understanding of the complexities of both assessment and management of this special population of persons with acquired brain injury.”

Only if this generation of doctors, scholars and researchers can share Dr. Jennett’s passion and vision for the future of brain injury research, will the advocacy that propelled Dr. Jennett’s career, be fulfilled. I hope his death reminds the medical community of that what we don’t know about brain injury is infinitely greater than what we know. Research on…

Next: the GCS score. What it tells us and what it does not.

Understanding Neuropsychological Statistics in Diagnosing Brain Injury

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Posted on 2nd April 2008 by Gordon Johnson in Uncategorized

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Yesterday’s blog threw out a few numbers to illustrate some basic starting principles about neuropsychology. As an aid to our further discussion of this neuropsychology, today I will give some basic numerical principles to help in further understanding the numeric part of neuropsychological assessment.

First, neuropsych scores are typical given in one of three scoring methods: Standard score, percentile score and T scores. T scores are a little bit too complicated to try to explain to a laymen, so I will limit this discussion to standard scores and convert them to percentile scores.

Most people are somewhat familiar to standard scores, because IQ’s are given in them. Yesterday I used the example of our successful professional who had a post accident IQ of 135. An IQ of 100 is perfectly in the middle. Something below 70 is evidence of significant impairment. Each time you move down the standard score grid by 10 points, it represents a significant drop.

Here are the basic categories of Standard scores, with their percentile equivalents.

Very superior — 130 and above — 98% and above
Superior __ 120 to 129 — 92% to 97%
High Average — 110 to 119 — 76% to 91%
Average — 90 to 109 — 25% to 75%
Low Average — 80 to 89 — 8% to 24%
Borderline — 70 to 79 — 3% to 7%
Impaired — below 70 — 2% and below

T scores use the same basic concept, and again using 10 points as the break point, but with a T score, the mid point is 50. Some neuropsychologists may disagree as to the exact point that separates these categories, but this is certainly representative of the concept.

The second term to understand in terms of understanding the statistical analysis done by a neuropsychologist is the concept of “deviations”. While I am incapable of synthesizing the dozens of different explanations of this concept into one cohesive definition, in essence, when you move from one category like very superior, to superior, you have moved one deviation. When you move from very superior to high average, that would be two deviations. Movements of two deviations are deemed to be significant.

Yesterday’s example of an IQ score of 135, which was very superior, to an average processing speed score of 100, is a movement of three standard deviations. That could be quite significant, but of course is only one factor to be looked at in doing a full blown “assessment.”

Tomorrow: assessing premorbid IQ and other ability levels.

Neuropsychological Assessment to Establish Brain Injury

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Posted on 1st April 2008 by Gordon Johnson in Uncategorized

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In yesterday’s blog, I talked about the essentials prerequisites to proving to a jury that a plaintiff is disabled by brain injury. I said there:

  • “Now, we have more cases than we did in 1996 where the neuroimaging is abnormal. Yet, we still must show the same things: an accident with the potential to injure the brain, acute evidence that the brain was injured, deficits that can be determined in how a person functions and a CHANGED PERSON. Neuroimaging adds to the equation, but doesn’t eliminate any of the other issues. The only thing I would seriously change from what I said in 1996 is that there are other ways in addition to neuropsychological assessment, that deficits in ways in which the brain are working, can be identified.”
The big change in the way I look at the structure of a brain injury case than I did when I started in this field nearly 20 years ago, is that I don’t see pure discrepancy analysis within a neuropsychological test battery to show relative deficits, as the cornerstone to diagnosis. That is a lot of jargon; let me explain what I mean. First some terms:

Neuropsychologist: is a not an M.D., but a Ph.D. in psychology, who has typically finished a post doctoral fellowship and training in neuropsychology, which is essentially the field of brain behavior and assessment.

Neuropsychological assessment begins with the administration of a battery of psychometric tests. Then the neurospcyhologist will do an analysis of the pattern of the test scores, the clinical interview of the patient and known potential traumatic or disease processes, to make an assessment as to what pathology may exist in the brain, and from what potential causes.

Discrepancy analysis is the technical, statistical analysis of the neuropsychological test battery to determine whether there are relative weaknesses in an intraindividual comparison, upon which conclusions about pathology can be made.

An intraindividual comparison is a method of determining whether or not a portion of a brain is performing abnormaly for that person, based on the pattern of tests scores, primarily within the specific battery of tests that are being performed at that time.

A relative weakness is a test score on a specific test within the battery where the score is sufficiently lower than other tests, that it shows that a particular part of the brain may be functioning in a pathologically changed way.

All of these technical terms and approaches are usually necessary because only in rare cases does an individual have previous neuropsychological assessments that precede their injury or disease. It is thru these technical approaches to evaluations, that a neuropsychologist can make determinations of pathology, without prior batteries to contrast current testing with.

To demonstrate how the statistical part of the assessment would work lets assume a simple example – focusing on a small part of the test battery. Let us assume we are assessing a very smart professional, who had excelled throughout his or her academic life, obtaining an advanced degree and always testing at the high end of all standardized tests.

One of the key elements to all neuropsychological assessments is the administration of the IQ test. Our hypothetical individual does as expected and receives an IQ score of 135, which is considered very superior. (More on the categories of achievement levels in tomorrow’s blog.) In contrast, when given tests which measure this individuals processing speed, the score was 100, which is still average, but is more than 35 points lower than the IQ score. If this person’s processing speed was compared to all individual’s, the score would be considered normal. But if Discrepancy Analysis is used to make an intraindividual comparison of the IQ score to the processing speed score, that person would be found to have a relative weakness. That relative weakness could begin to form the basis of an opinion about pathology, and perhaps pathology related to a specific event.

The key issue in engaging in formal discrepancy analysis would be a determination of how rare it is for someone with a 135 IQ to have a 35 point difference between that score and the processing speed.

One piece of this puzzle that most neuropsychologists would not mention, but I personally find significant, is that if this individual had consistently been in the top few percentiles on standardized testing, we can almost presume that they were capable of fast thinking. If you don’t think fast, you don’t get high scores on college or graduate school admissions tests.

But my practical approach contrasted to the technical approach of most neuropsychologists, is symptomatic of another major schism in the field: the method used to determine pre-morbid (pre-injury or disease) abilities.

More on these issues later this week.

Advances in Neuroimaging – Value in Diagnosis of Brain Injury

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Posted on 31st March 2008 by Gordon Johnson in Uncategorized

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Last week’s blogs covered a series of articles about the advances in neuroimaging to assist in the diagnosis of subtle brain injury (otherwise called Mild Traumatic Brain Injury or concussion.) The key to looking back at those blogs, is the word “assist.” Imaging studies can only tell us what the structures of the brain look like. They cannot tell us how they got that way. They tell us very little about the function of the brain (although that may change dramatically with the continued development of fMRI.)

The first time a client of mine got an abnormal 3T MRI, I was so ecstatic, I thought my job had completely changed. It didn’t. The words “clinical correlation required” became an integral part of each case and frankly, it is a good thing it did. “Clinical correlation required” in essence means that did this person suffer a change in the way his brain was functioning, at a point in time consistent with the pathology that is being seen on the scan.

That is what being a brain injury lawyer is all about. Taking the technical findings of various subspecialist in the field of brain injury and putting them in front of a jury in a way that the jury can clearly see that the traumatic event, resulted in a change in this person, which is clearly related (correlated) to the brain damage that could be suffered in the accident. Without the real world picture of how this human being has been changed, with the line of demarcation of the accident, one can simply not make a diagnosis of brain injury.

I have been saying that same thing since I first wrote a web page on brain injury in 1996. Here is the words and the graphics I said at that time:

They are:

1. Sufficient Biomechanical Force;

2. One of the Four Acute Symptoms of the Rehab Congress’s definition, i.e.:

a) any period of loss of consciousness,
b) a change in mental state as a result of the accident,
c) amnesia, or
d) focal neurological deficits;

3. Neuropsychological Deficits; and

4. A Changed Person.

Click here for those words I first wrote in 1996.

Now, we have more cases than we did in 1996 where the neuroimaging is abnormal. Yet, we still must show the same things: an accident with the potential to injure the brain, acute evidence that the brain was injured, deficits that can be determined in how a person functions and a CHANGED PERSON. Neuroimaging adds to the equation, but doesn’t eliminate any of the other issues. The only thing I would seriously change from what I said in 1996 is that there are other ways in addition to neuropsychological assessment, that deficits in ways in which the brain are working, can be identified.

Advances in Neuroimaging

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Posted on 25th March 2008 by Gordon Johnson in Uncategorized

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My topic for the rest of this week is advances in diagnosing brain injury thru improved neuroimaging. A recent study out of BYU, highlights some of the exciting changes that occurring, “New study shows brain changes from concussion
By Elaine Jarvik, Deseret Morning News Published: Monday, March 17, 2008.
See http://deseretnews.com/dn/view/0,5143,695262379,00.html

The Deseret article begins:

“Even after a severe concussion, a brain can look normal and healthy on a traditional brain scan. But now a study co-authored by a Brigham Young University psychology professor, using a new kind of MRI technique, reveals brain changes that are subtle but significant.”

This article is talking about a technology called DTI imaging, but to fully understand the advances in neuroimaging, it is necessary to understand some basics about the science of neuroimaging and improvements in both the magnets and the software to interpret the raw information has changed.

The last three years have been an exciting time to be a brain injury lawyer because the implementation of 3 Tesla MRI scanners for clinical diagnosis of mild brain injury has resulted in an exponential increase in the number of abnormal scans for our clients. But increased field strength is part of the equation.

INCREASED FIELD STRENGTH

Tesla is the measurement of the strength of a magnet. 1.5 Tesla (1.5 T) is the current prevalent maximum field strength of MRI scanners found in US hospitals, with many facilities having scanners with weaker field strengths. While research facilities have been using considerably stronger field strengths than the 1.5 for at least five years, it wasn’t until mid 2004, that 3 T MRI scanners began to appear for clinical use. As I write this in March of 2008, there is likely a 3T MRI scanner at most major university medical centers, although many of these may still be restricted to research only applications.

One way to conceptualize the improvement in scanners is to compare such to similar improvements in the mega pixel capacity of a digital camera. An 8 mega pixel camera has roughly twice the resolution of a 4 mega pixel camera, and while the difference in MRI scanners don’t quite track a pure arithmetic improvement, the analogy holds quite nicely. After all, MRI scanners are essentially cameras, that use as the contrast agent, the vibrations of magnetized protons, instead of light.

My examination of a leading neuroradiologist, will a bit technical, will assist those who want to understand the details of these new advances:

My examination of a leading neuroradiologist in a recent case, may be helpful to understand the basic principles:

23 Q. My understanding is that MRI
24 imaging essentially uses an especially powerful
25 magnet with respect to 3-T to make the
1 molecules inside the brain resonate; is that
2 correct?
3 A. Correct.
4 Q. Explain what’s really going on
5 there.
6 A. What happens with an MRI
7 examination — for example, you mentioned
8 specifically 3-T. Well, the T stands for
9 Tesla. The more — the higher the Tesla
10 number, the more power the magnet. Which
11 really translates to your ability to see
12 smaller things.
13 So in many ways it’s analogous to
14 a microscope. If you have a higher powered
15 microscope you can see things better than you
16 can a lower powered microscope. An MRI
17 scanner is a higher powered. An MRI scanner
18 you can see things — many things you can
19 see better.
20 It’s not absolutely universal that
21 you see everything better, but for the most
22 part you see things much better on a higher
23 field strength magnet.
24 No matter what field strength
25 magnet you’re in, if I put you in an MRI
1 machine, basically what happens is that the
2 protons, which are part of the water
3 molecule, tend to line up with a magnetic
4 field.
5 So right now your water molecules
6 and your protons are just random in the
7 direction. They have a direction, and that
8 direction is random all over the place.
9 When I put you in an MRI machine,
10 they all line up. They all line up with a
11 magnetic field. And then what we do is we
12 give a radio frequency pulse. And it’s
13 basically very, very similar to an FM radio
14 wave. It’s almost the same energy as an FM
15 radio wave.
16 And basically what we do is we hit
17 your body with what’s called a radio
18 frequency pulse, which is really similar to
19 an FM radio wave. So it’s not dangerous.
20 There’s nothing bad about it. But what it
21 does do is it knocks those protons out of
22 that alignment.
23 And then as those protons come
24 back into alignment, they come back into
25 alignment at different rates, different speeds
1 based on the tissue, which is referred to as
2 a relaxation time.
3 So that the time it takes for
4 those protons to come back into alignment is
5 different for the skin, for the bone, for the
6 skull, for the cerebrospinal fluid. They all
7 have different rates.
8 The computer then assigns a gray
9 scale. So it’s kind of like paint by numbers.
10 If the relaxation rate has a certain number,
11 then it gets a certain color.
12 So basically, the computer does
13 something that’s completely analogous to paint
14 by numbers, and creates a picture out of
15 that.
16 And we do that with different
17 settings, depending on what we’re looking for.
18 And we can emphasize different tissues.

Increased field strength is only part of the breakthrough in neuroimaging. As more and more pathology is seen on these scans, neuroradiologists are realizing that what were considered to be insignificant findings on lower field scans, are of the pattern and nature most likely explained by traumatic forces, not disease processes or normal variants.
Tomorrow:

Dilated Perivascular Spaces in Identifying Mild Brain Injury