What is mild traumatic brain injury?
The term "mild traumatic brain injury" is used to describe an injury to the brain, caused by relatively mild trauma. The effects of such an injury may not include incontinence, coma or physical problems, but so-called "mild" cognitive impairments can still cause significant disruptions of personal or family life, or total disability from competitive employment. Not every concussion or traumatic brain injury causes significant disruption of a person's life, or total disability from competitive employment, but in those circumstances where it does, it is real.
- A person does not need to be "knocked out" or in a coma to have sustained a traumatic brain injury.
- The fact that a person may be walking and talking at the scene of a collision does not rule out the presence of a traumatic brain injury.
- The fact that a persona is not diagnosed as having a brain injury in the hospital does not rule out a traumatic brain injury.
- The fact that a person is able to keep their job following a traumatic brain injury does not rule out the presence of a closed head injury.
- The fact that there is no skull fracture, cuts or bruises does not rule out the presence of a traumatic brain injury.
- The fact that the injured person as well as family members do not immediately appreciate the significance of changes in the injured person's mental function does not rule out the presence of a traumatic brain injury.
- The fact that there are normal neurological examinations, normal CT scans or normal MRI 's or other tests does not rule out the presence of a traumatic brain injury.
- The fact that there may not be a head strike does not rule out the presence of a traumatic brain injury.
There are many signs and symptoms of traumatic brain injury, sometimes referred to as closed head injury, and some of the leading ones that can be present, without any other medical problems are:
- Memory problems
- Concentration and attention problems
- Personality change
- Difficulties with organisation tasks, planning the day, preparing meals, planning a work day or planning and organizing activities
- Fatigue or inability to get going
- Inability to fall asleep or remain asleep
- Balance and dizziness problems
- Irritability, anger and/or frustration
- Difficulties with reading or watching television
- Speech and communication problems with inability to find the right words, inability to express thoughts and misunderstanding of others
- Depression which can be related to the traumatic brain injury itself, and to the changes caused by the traumatic brain injury.
It is well accepted and well recognised that a person can suffer a traumatic brain injury with serious consequences, without being knocked out or losing consciousness, or even without hitting their head.
Asphasia and Dysphasia are difficulties with speech, perhaps the most difficult and disruptive consequence for injured person and their carers, cutting the sufferer off from family friends etc and causing deep emotions of pain frustration isolation and anger, not only in the sufferer.
Aphasia is when you know what you want to say but you can't get it out. It is very disabling and very difficult to overcome.
Dysphasia can range from total inability to understand any words to a slight problem with comprehension.
Dysarthria is a physical inability to form the words you wish to say due to trouble with the tongue, voice box, palette etc. This is motor problem.
Friends and family (and your solicitor) can help by taking extra care when speaking to a person with these communication problems:
- Attract the person's attention before you speak, say their name if necessary.
- Wait for their attention. Try to have light falling on your face.
- Don't compete with other noise.
- Slow the rate down a little to give the listener more time for analysis
- Use additional clues. Accompany speech with natural gesture where appropriate. Say "lets draw the curtains" as you draw them etc. This helps give meaning to the words themselves. Use paper and pen to write down words or draw simple pictures.
- Don't rush in to supply a word they are struggling for - you may not guess right and that would make it even harder. Try to find ways to help them to succeed.
- Don't give too much information in one sentence. Better to say, "I'm going to the Bank. I need some money. I'll be back soon" than to say "I forgot to pay the electricity bill so I'm going to rush off to the Bank before they close but I won't be long and I'll make you a cup of tea when I get back".
- A simple question asking "Wednesday or Thursday?" may be successfully understood when a question is reduced to a choice of two words.
In most cases involving the type of brain injury that results in disability the injured person, or their Litigation Friend, can expect their solicitor to instruct experts in any one or more of the the following areas to analyse and present their case:
To prove how the accident happened:
- an accident reconstruction expert
- a computer animation of the crash and body movement
To prove the nature and extent of the physical brain injury
- a neurologist or neurosurgeon
- a radiologist
To prove the nature and extent of the effects of the injury
- a neuropsychologist
- a neuropsychiatrist
To prove the nature, level and extent of the injured person's needs
- a life care planner or rehabilitation consultant
- a physiotherapist
- an occupational Therapist
- a speech Therapist
- a vocational rehabilitation expert
- a vocational economic analyst (employment consultant)
- an accommodation expert
The solicitor should identify and contact any members of the family or friends who knew the injured person before and after the accident and can say how the injuries have effected them. This is often the most powerful and convincing evidence in a case.
Infants, children and teenagers can develop significant consequences following traumatic brain injury, whether mild, moderate, or severe, with or without loss of consciousness. These consequences can have a devastating impact on their quality of life for the rest of their lives. What may appear to be late developing cognitive emotional behavioural and other problems may be the consequence of a paediatric traumatic brain injury.
We are committed to helping children, teenagers and adults avoid a lifetime of suffering from the consequences of traumatic brain injury without proper diagnosis and understanding or help.
Infants and children who suffer traumatic brain injury are thought to recover completely and then years later when the child starts to have cognitive emotional and/or behavioural problems, the teachers, parents and health care providers may blame the child, without thinking of the traumatic brain injury. Those parts of the child's brain that were injured and damaged may not have been called upon until the more complex demands later in school or life.
One of the most vulnerable areas of the brain to injury from any type of trauma is in the area of the frontal lobes. This part of the brain is essential in situations
- that involve planning or decision making
- that involve the need for error correction and/or trouble shooting
- where responses are not well learned or contain novel sequences of actions
- that are judged to be dangerous or technically difficult
- that require the overcoming of a strong habitual response or resisting of temptation.
Some of these systems or processes may not even be called upon until the child is 9, 10 or older.
The following may be signs or symptoms of traumatic brain injury:
- personality change
- behavioural change
- activity level changes
- sleep pattern changes
- problems in relationships
- social withdrawal
- identity problems
- loss of interest
- loss of emotional control
- learning memory language
- attention/speed of thought processing
- periods of anger or uncontrollable temper flare-up
- aggressive or violent acting out behaviour.
It is easy to blame the child or teenager for poor school work and poor social interaction and it is very common and understandable that even parents will deny the possibility that any problems may be related to traumatic brain injury.
At Bolt Burdon Kemp we work with the family to identify, understand and ameliorate the problems and consequences of paediatric traumatic brain injury.
Where the injured person has suffered a head injury he or she may have a poor or even no memory of how the accident happened. We will obtain accident reports from the police, the employer or the health and safety executive as appropriate and trace and interview witnesses, including police officers. We will obtain photographs and sketch plans. If necessary we will instruct an accident reconstruction expert to reconstruct the accident. Bolt Burdon Kemp have succeeded in recovering compensation in many cases where other solicitors refused to act and even where insurers have refused to indemnify.
There are time limits for bringing claims. If the head injury is so serious as to affect the injured person's ability to plan and organise he or she may miss the time limit. The defendant will often try to persuade the court that such cases are brought “out of time” and should not proceed. We have a lot of experience in successfully arguing against this and we will obtain all the medical records and independent medical opinion to consider whether an injured person has legal capacity.
These are some of the common effects of a brain injury:
- Headaches: There is a 30-80% chance of headache as a result of brain injury. They are very common and very difficult to treat.
- Personality change: There is often a personality change even in minor head injury. The following often go hand in hand:
- "frontal lobe": disinhibition, explosions of unreasonable or irrational behaviour, inappropriate behaviour etc.
- "diffuse injury": ("zombie"): apathetic withdrawn lethargic, diffuse injury. Lost drive and initiative, social consequences can be devastating -difficult to get job (unless return to former employment), effects on relationships.
- Lack of insight: The capacity to recognise these changes in state is often severely impaired and usually indicates bad diffuse brain damage. However, where there is insight this can have its own, predominantly psychiatric consequences, eg depression, the symptoms of which are very similar to those of a "diffuse injury".
- Cognitive disability: Even a trivial head injury, involving no loss of consciousness, can result in cognitive disability. Problems include:
- attention/concentration deficit
- loss of "get up and go"
- short and long term learning memory deficit
- speed of information processing
A neuropsychologist will conduct a whole battery of tests to look at the effects of head injury on cognitive ability.
- Communication Difficulties: In order to answer a simple, everyday question such as "When is your brother coming to visit you next?" a person has to be able to: 1. recognise that this is a question not a statement, 2. understand the words "brother" and "visit" 3. know that the words "is coming" means the future tense, not present or past, 4. understand that the word "when" relates to time and is different from "why", "how" or "where", 5. Use speech if he or she can or writing again if he or she can, or maybe gesture to provide the answer.
- Dizziness: This has been described as "like water sloshing around inside my head", "like being in a lift", "like having got off a boat", "like being drunk all the time". The problem is to do with the balance mechanism and it may appear that the injured person is drunk.
- Depression: A brain injury survivor may have lost his or her job, have no money, lose friends and family. It may be difficult to distinguish from abulia/apathy of severe head injury. It may exacerbate cognitive impairment, because a patient "gives up". Depression can lead to emotional lability, it can exacerbate aggression and increase the risk of suicide.
- Anxiety: There can be a loss of confidence, increased apprehension, agitation, tension.
The brain consists of neurones, axons and synapses.
A neurone is a nerve cell. It transmits electrical nerve impulses in order to carry information from one part of the body to another. Each neurone has an enlarged portion, the cell body from which extend several pathways through which impulses enter from their branches. There are about 100 billion neurones. The nerve bodies are concentrated in the surface of the brain and arranged in columns across it. This bit is known as "grey matter".
An axon is a nerve fibre. It extends from the cell body of a neurone and carries nerve impulses away from it. An axon may be over a metre in length in certain neurones. In large nerves the axon has a white sheath made of myelin. This is known as "white matter". An axon ends by dividing into several branches, which make contact with other nerves or with muscle or gland membranes. There are over 10 trillion connections between the neurones.
A synapse is the minute gap across which nerve impulses pass from one neurone to the next, at the end of a nerve fibre or axon. When a nerve impulse reaches a synapse it releases a neurotransmitter, which "jumps" across the gap and triggers an electrical impulse in the next neurone. Some brain cells have more than 15,000 synapses.
The brain is made up of three important parts: the cerebrum, cerebellum and the brain stem.
The cerebrum is the largest and most highly developed part of the brain. It consists of two cerebral hemispheres. Each hemisphere has an outer layer of grey matter, the cerebral cortex. This looks like the surface of a walnut and covers the rest of the brain. Below the cerebral cortex lies white matter containing the basal ganglia. These are involved with the regulation of voluntary movements at a subconscious level.
Connecting the two hemispheres is a bridge: the corpus callosum. This is a massive bundle of nerve fibres. The cerebrum is responsible for the initiation and coordination of all voluntary activity in the body and for governing the function of lower parts of the nervous systems. The cortex is the centre of intelligence. It deals with thinking, feeling and doing. The right hemisphere controls the left side of your body and left hemisphere controls the right side of your body.
The cerebellum is the largest part of the hindbrain, bulging back behind the pons and the medulla oblongata and overhung by the occipital lobes of the cerebrum. It has an outer grey cortex and a core of white matter. Three broad bands of nerve fibres, the inferior, middle and superior cerebellar peduncles connect it to the medulla, the pons and the midbrain respectively. It has two hemispheres, one on each side of the central region and its surface is thrown into thin folds called folia. The cerebrellum is essential for the maintenance of muscle tone, balance, and the synchronization of activity in groups of muscles under voluntary control converting muscular contractions into smooth coordinated movement. It does not initiate movement and plays no part in the perception of conscious sensation or in intelligence.
The brain stem is the enlarged extension of the spinal cord upwards within the skull. It consists of the medulla oblongata, the pons and the midbrain. The brain stem deals with automatic actions, such as breathing, digestion, blood pressure etc.
The brain is located in the skull. This is lined with Meninges. These are the three connective tissue membranes that line the skull and vertebral canal and enclose the brain and spinal cord. The outermost layer is the: Dura Mater. This is inelastic, tough, and thicker than the middle layer, the Arachnoid Mater, and the innermost layer the Pia Mater.
The brain is like jelly - very fluid and loose - and is suspended in the skull by fibrous tissue. If you hit your head your brain wobbles. Fibres within the brain get shaken about and torn. Arteries and veins in the meninges, which transfer blood between the brain and the dura are easily disrupted. Your brain gets damaged by the most trivial of impacts.
Direct physical impact can produce a skull fracture, damage to the arteries and veins, and also damage to the grey and white matter etc as the brain swirls around.
Indirect impact is any sudden acceleration of the head causing the brain to move within the skull. The energy transferred to the head passes through the brain as two types of stress wave: shear waves and compression waves.
Shear waves can be seen clearly in jelly when you wobble it on a plate. If you suddenly rotate the plate the jelly at the bottom will move immediately but the top of the jelly will begin to move a fraction of a second later. The jelly is twisted, creating shear stresses in the structure. If the rotation is fast enough, the shear stresses can rip the jelly apart.
A shear wave passes through the brain at between 1 and 10 metres per second. It can take 20 milliseconds to pass from the surface to the centre of the brain - roughly the duration of an impact. So the centre of the brain is just starting to move as the outside is stopping. At the junction of the spinal cord and the brain such twisting may fracture the tissue. Axons lying in the direction of the deformation might be stretched and damaged.
Compression waves are shock waves from an impact. These can travel at around 1500 metres per second causing the brain to squash or expand like an accordion. The shock wave passes through the brain, hits the skull at the other side and most of the energy is reflected back. As the wave is reflected it causes an extreme drop in the internal pressure of the brain for a few milliseconds, enough to boil blood and rupture vessels. This is what engineers call cavitation. There are bumps on the inside of the skull – it is not a smooth surface - and these bumps can scratch and bruise the grey matter.
In a typical whiplash injury the brain accelerates back and catches up with itself. For example, in a rear end shunt the head bounces off the head rest and may or may not rotate, depending on the angle at which the vehicle was struck. The mayhem caused deep in the middle of the brain does not show up in an MRI scan but post mortems show serious damage to white matter.
A collision speed of 30 mph causes an acceleration force of 20g on the brain and neck.
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Post traumatic amnesia is very important is assessing the seriousness of the head injury. Elicit this by asking the patient. Questions asked by nursing staff - orientated in time and space? are often rubbish. It may take a long time to extract duration of PTA - Check very carefully. Get a series of snap shots of memory of the events after the accident. Still frames embedded forever, flash back memory does not change. Looking for the length of time it takes for day to day continuous memory to re-establish itself.
A minor head injury is where there is no post traumatic amnesia or where the post traumatic amnesia is less than 24 hours.
After a head injury or accident some people experience symptoms which can cause worry or nuisance. Below are some of the questions a solicitor may ask you to find out if you have had a brain injury or to find out what problems you are experiencing as a result of a brain injury. You should try to compare yourself (or the brain injury person) now (over the last 24 hours) with how you (or he or she) were before the accident. Talk to friends and family and ask them what they think.
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