NOTICE: Brain Injury Claims Concussion Mild Traumatic Brain Injury Postconcussion Syndrome Posttraumatic Headache More severe brain injuries

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1 Brain Injury Claims Concussion Mild Traumatic Brain Injury Postconcussion Syndrome Posttraumatic Headache More severe brain injuries NOTICE: All contents of this presentation remain the property of Dr. Barth, and cannot be used for any purpose in the absence of Dr. Barth s specific authorization. Contact Information: Robert J. Barth, Ph.D. Parkridge Hospital Plaza Two 2339 McCallie Ave. Chattanooga, TN / RJBarth@BarthNeuroScience.org Robert J. Barth, Ph.D. Introduction Final reviewer for the AMA Guides protocol for brain injury. (also final reviewer for the pain and mental illness chapters, and contributor for the discussion of CRPS, the upper extremity chapter, and the lower extremity chapter) Robert J. Barth, Ph.D. Introduction Selected to teach formal continuing medical education programs regarding brain injury for: American Medical Association American College of Occupational and Environmental Medicine American Academy of Disability Evaluating Physicians Robert J. Barth, Ph.D. Introduction Named a Fellow of the National Academy of Neuropsychology for having made a significant contribution to the science and profession of neuropsychology 1

2 Robert J. Barth, Ph.D. Introduction Invited by ODG Treatment in Workers Comp to assist with the development of their guidelines for mild traumatic brain injury (when a state government specifically requested such guidelines) Mind-warping scientific fact #1 There is NO relationship (zero, naught, nada, nil, zip, zilch, zippo) between postconcussion syndrome and concussion Mind-warping scientific fact #2 There is NO relationship (zero, naught, nada, nil, zip, zilch, zippo) between prolonged posttraumatic headache and head trauma Fact #3 All of the following organizations have published attempts at comprehensively reviewing the scientific literature All of these organizations have published attempts at comprehensively reviewing the scientific literature and their reviews revealed that there is no credible scientific support for claims of permanent impairment from concussion / mild traumatic brain injury (or even persistent impairment) no credible scientific support for claims of permanent impairment from concussion American Medical Association World Health Organization American Academy of Clinical Neuropsychology 2

3 What about the NFL and chronic traumatic encephalopathy? What about the NFL and chronic traumatic encephalopathy? British Journal of Sports Med 2013 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 What about the NFL and chronic traumatic encephalopathy? British Journal of Sports Med 2013 it is not possible to determine the causality or risk factors with any certainty. As such, the speculation that repeated concussion or subconcussive impacts cause CTE remains unproven. Body mass index, playing position, race, and the cardiovascular mortality of retired professional football players. Baron SL, et al. National Institute for Occupational Safety and Health Am J Cardiol Mar 15;109(6): National Institute for Occupational Safety and Health, ,439 National Football League players with 5 seasons from 1959 to 1988 compared player mortality through 2007 to the United States population of men stratified by age, race, and calendar year Overall player mortality was significantly decreased National Institute for Occupational Safety and Health, 2012 Cause of death: Mental, psychoneurotic, and personality disorders NFL: 4 Expected number based on matched controls (non-nfl): 11.7 NFL experience is PROTECTIVE against the effects of death associated with mental disturbance (e.g. suicide)? 3

4 Mayo Clin Proc Mayo Clinic Proceedings Apr;87(4): High school football and risk of neurodegeneration: a community-based study. Savica R, et al. American football players from 1946 to 1956 did not have an increased risk of later developing dementia, Parkinson s Disease, or ALS (Lou Gehrig s Disease) compared with non-football-playing high school males, despite poorer equipment and less regard for concussions compared with today and no rules prohibiting head-first tackling (spearing). Mayo Clin Proc Indeed, the rate of PD and ALS was LOWER in the football group than in the glee club, choir, and marching band group. Mild Traumatic Brain Injury (MTBI) Question and Answer format MTBI Questions Is permanent cognitive impairment associated with MTBI / concussion? Is postconcussion syndrome caused by MTBI / concussion? Does head trauma cause prolonged headaches? MTBI Questions How do you determine that a brain injury is mild? How do you determine that a MTBI has occurred (and does it matter)? What are the typical causes of a claim of prolonged postconcussion syndrome? 4

5 MTBI Questions Are these people faking? What does neuropsychology testing have to offer for such cases? What can we do for someone with prolonged complaints? MTBI Bottom Line: Not associated with permanent impairment. PCS is not correlated with MTBI-concussion. Head trauma is not correlated with prolonged headache. Non-injury-related factors are the best predictors of prolonged complaints following MTBI. A doctor s job in the assessment of such cases is to identify relevant non-injury-related issues for the individual examinee, and to create a treatment plan based on those findings. Traumatic Brain Injury Simple Definitions American Psychological Association Dictionary of Psychology, 2007 damage to brain tissue caused by external mechanical forces, as evidence by objective neurological findings, posttraumatic amnesia, skull fracture, or loss of consciousness because of brain trauma. Traumatic Brain Injury International Neuropsychological Society Dictionary of Neuropsychology, 1999 Brain injury caused by an external mechanical force such as a blow to the head, concussive forces, acceleration-deceleration forces, or projectile missile (e.g., bullet). The primary causes of TBI are motor vehicle accidents, falls, and interpersonal violence. Severity of injury can be assessed with the Glasgow Coma Scale score or by measuring the duration of loss of consciousness (coma, LOC), with each measure adding increased prognostic value. Mild Traumatic Brain Injury World Health Organization definition WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Operational Definition of MTBI Holm L, et al. J Rehab Med, 2005, 37(3):

6 WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Operational Definition of MTBI MTBI is an acute brain injury resulting from mechanical energy to the head from external forces Operational criteria for clinical identification include WHO Operational criteria for clinical identification include A. One or more of the following 1. Confusion or disorientation 2. Loss of consciousness for 30 minutes or less 3. post-traumatic amnesia for less than 24 hours 4. Other transient neurological abnormalities such as focal signs, seizure, intracranial lesion not requiring surgery (continued) WHO Operational criteria for clinical identification include B. Glasgow Coma Scale score of after 30 minutes postinjury or later upon presentation for healthcare C. These manifestations of MTBI must not be: 1. Due to drugs, alcohol, medication 2. Caused by other injuries or treatment for other injuries 3. Caused by other problems 4. Caused by penetrating craniocerebral injury Concussion Concussion is typically used to refer to a MILD traumatic brain injury International Neuropsychological Society Dictionary of Neuropsychology, 1999 mild traumatic brain injury characterized by at least a brief loss of consciousness or brief post-traumatic amnesia Concussion Technically, is simply means any brain injury caused by a blow to the head or sudden movement Dorland s Illustrated Medical Dictionary 32 nd Edition, 2012 concussion of the brain loss of consciousness as the result of a blow to the head or sudden movement of the brain within the head as from violent shaking of the head. In mild concussion there is transient loss of consciousness with possible impairment of higher mental functions, such as retrograde amnesia and emotional lability. In severe concussion there s prolonged unconsciousness with impairment of the functions of the brain stem, such as transient loss of respiratory reflex, vasomotor activity, and dilatation of the pupils. Postconcussion Syndrome International Classification of Diseases, 10 th Revision (1992) ICD-10 The only formalized definition & diagnostic protocol 6

7 ICD-10 Postconcussional Syndrome ICD-10 Postconcussional Syndrome The syndrome occurs following head trauma (usually sufficiently severe to result in loss of consciousness), Postconcussional Syndrome and includes a number of disparate symptoms such as headache, dizziness (usually lacking the features of true vertigo), fatigue, irritability, difficulty in concentrating and performing mental tasks, impairment of memory, insomnia, and Postconcussional Syndrome and reduced tolerance to stress, emotional excitement, or alcohol. Postconcussional Syndrome These symptoms may be accompanied by feelings of depression or anxiety, resulting from some loss of self-esteem and fear of permanent brain damage. Such feelings enhance the original symptoms and a vicious circle results. Postconcussional Syndrome Some patients become hypochondriacal, embark on a search for diagnosis and care, and may adopt a permanent sick role. 7

8 Postconcussional Syndrome This passage is basically saying that the syndrome might simply be psychological, rather than neurological or injury-related. The etiology of the symptoms is not always clear, and both organic and psychological factors have been proposed to account for them. The nosological status of this condition is thus somewhat uncertain. There is little doubt however, that the syndrome is common and distressing to the patient. Postconcussional Syndrome Diagnostic guidelines At least three of the features described above should be present for a definite diagnosis. Careful evaluation with laboratory techniques (electroencephalography, brainstem evoked potentials, brain imaging, oculonastagmography) may yield objective evidence to substantiate the symptoms but results are often negative. The complaints are not necessarily associated with compensation motives. Postconcussion Syndrome NOTE: A different definition and diagnostic protocol was actually formulated for potential inclusion in the American Psychiatric Association s diagnostic system (DSM), but it as rejected. DSM-IV, rejection specified p DSM-IV-TR, rejection specified p DSM-5, not indexed Contusion, brain International Neuropsychological Society Dictionary of Neuropsychology, 1999 a bruise, typically on the brain surface, without cerebral hemorrhage MTBI Question #1 Is permanent cognitive impairment associated with MTBI? 1. Is permanent cognitive impairment associated with MTBI? Answer: NO 8

9 Permanent cognitive impairment is NOT associated with MTBI. Examples of relevant literature Examples of relevant literature The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury Carroll LJ, Cassidy JD. PROGNOSIS FOR MILD TRAUMATIC BRAIN INJURY: RESULTS OF THE WHO COLLABORATING CENTRE TASK FORCE ON MILD TRAUMATIC BRAIN INJURY. J Rehabil Med 2004; Suppl. 43: World Health Organization reviewed more than 38,000 scientific citations "The stronger studies, utilizing appropriate control groups and controlling for confounding factors, suggest that postconcussion symptoms are largely resolved within three months to a year. Studies that examined the relationship between litigation and/or compensation issues and slower recovery after mild traumatic brain injury consistently reported an association between them. Examples of relevant literature American Medical Association Guides to the Evaluation of Permanent Impairment 6 th Edition (2008,2009) the symptoms of MTBI generally resolve in days to weeks, and leave the patient with no impairment Examples of relevant literature American Academy of Clinical Neuropsychology Mild Traumatic Brain Injury And Postconcussion Syndrome. Author: McCrea MA. Oxford University Press Examples of relevant literature Meta-Analysis of neuropsychological test data: Binder, L. M., Rohling, M. L., and Larrabee, G. J. (1997). A Review of Mild Head Trauma, Part I. Journal of Clinical and Experimental Neuropsychology, 19, pp

10 Meta-Analysis of neuropsychological test data: The effect size for MTBI is smaller than the effect sizes associated with Litigation Hypertension MTBI Question #2 Is postconcussion syndrome caused by MTBI concussion? NO Postconcussion syndrome is NOT caused by MTBI concussion Meares S, et al. The Prospective Course of Postconcussion Syndrome: The Role of Mild Traumatic Brain Injury. Neuropsychology, 2011, 25, 4, Prospective consecutive admissions to a Level 1 trauma hospital were assessed a mean 4.9 days and again days post-injury. The final sample comprised 62 mtbi and 58 non-brain-injured trauma controls. MTBI did not predict PCS. Postconcussion syndrome is NOT caused by MTBI concussion PCS in the non-braininjured general population Iverson GL & Lange RT. Applied Neuropsychology, 2003, 10: How many healthy people without a history of head injury satisfied diagnostic criteria for PCS? DSM-IV Criteria 79.6% How many healthy people without a history of head injury satisfied diagnostic criteria for PCS? ICD-10 Criteria 72.1% 10

11 PCS in the non-braininjured general population Bottom Line: The historical-formal conceptualizations of postconcussion syndrome are not actually correlated with whether someone has had a concussion Postconcussion syndrome is NOT caused by MTBI concussion PCS in the non-brain-injured claimant/plaintiff population Dunn JT et al. J Clin Psychology, 1995, 51: Ingebrigtsen T et al. J Neurology, 1998, 245: PCS in the non-brain-injured claimant/plaintiff population Non-TBI MTBI Claimants 3 months post Headache 77% 42% Dizziness 41% 26% Irritability 63% 28% Memory sx 46% 36% Concentration sx 71% 25% PCS in the non-brain-injured claimant/plaintiff population Bottom Line: The historical conceptualizations of postconcussion syndrome are more strongly associated with filing a medical-legal claim, rather than being specific to a history of concussion. postconcussion syndrome is not actually correlated with whether someone has had a concussion This is one of many reasons why postconcussional disorder was REJECTED by the American Psychiatric Association, when considered for inclusion in the Association s diagnostic system (DSM-IV-TR p759). MTBI Question #3 Does trauma cause prolonged headaches? NO Barth RJ. Obstacles to Claiming Permanence and Injury-Relatedness for Posttraumatic Headache. The Guides Newsletter, May/June, American Medical Association. 11

12 Trauma is not a cause of prolonged headaches Berry H. Chronic whiplash syndrome as a functional disorder. Arch Neurol Apr;57(4): Study of Demolition Derby Drivers Average collision experience per driver: 1900 collisions/driver How many have clinically significant headache problems: 0 Trauma is not a cause of prolonged headaches Couch JR, Bearss C. Chronic daily headache in the posttrauma syndrome: relation to extent of head injury. Headache Jun;41(6): the risk of developing posttraumatic chronic daily headache is greater for less severe head injury Trauma is not a cause of prolonged headaches In other words: In terms of both incidence and severity, trauma is not correlated with headache. All of this is the exact opposite of a causative connection between trauma and the headaches, according to health causation standards. Trauma is not a cause of prolonged headaches Obelieniene D, et al. J Neurol Neurosurg Psychiatry Mar;66(3): Headache is common immediately following head trauma, but such headache is associated with an overwhelmingly positive prognosis (maximum duration outside of a compensation context = 20 days). Outside of a legal claims context, the percentage of trauma patients who continue to complain of headache is essentially the same as the percentage of non-injured people who complain of persistent headaches. Trauma is not a cause of prolonged headaches Schrader H, et al. Lancet May 4;347(9010): the vast majority (85%) of people who complain of frequent headaches following a trauma, but who are removed from litigation/compensation contingencies, acknowledge that they also had frequent headaches prior to the trauma. Trauma is not a cause of prolonged headaches Warner, J. S. and Fenichel, GM (1996). Chronic posttraumatic headache often a myth? Neurology, 46, pp In research focused on claims of persistent posttraumatic headache, more than 80% of the sample of such patients were found to actually have a non-injury-related headache syndrome. In most cases, the true diagnosis was medicationinduced headache. For those cases, a treatment plan focused on medication elimination led to the headache going away. 12

13 Trauma is not a cause of prolonged headaches Such scientific findings are supportive of textbook conclusions that medication (e.g. narcotics, ergotamine derivatives, nsaids, etc.) is the necessary and sufficient cause of chronic daily headache complaints. Levenson JL. Textbook of Psychosomatic Medicine. American Psychiatric Publishing; Trauma is not a cause of prolonged headaches Mathew NT. Chronic refractory headache. Neurology Jun;43(6 Suppl 3):S patients with chronic daily headache 73% overused symptomatic medication, particularly analgesics and ergotamine, and as a result, suffered from drug-induced headache or rebound headache. The medication over-utilizers also commonly reported: Fatigue Irritability Depression Memory difficulties Headache worsening with small amounts of effort (mental or physical) Trauma is not a cause of prolonged headaches Mathew NT. Chronic refractory headache. Neurology Jun;43(6 Suppl 3):S The medication over-utilizers also commonly reported: Chronic headache Fatigue Irritability Depression Memory difficulties Headache worsening with small amounts of effort (mental or physical) Is it just me??? Or does this medication overutilization syndrome appear to be awfully similar to the failed concepts of PCS? Trauma is not a cause of prolonged headaches In the absence of a claims context and medications, the most common cause of persistent headaches is various forms of depression or anxiety. Ropper AH, and Brown, RH (2005). Adams and Victor's Principles of Neurology, Eighth Edition. McGraw-Hill. Question #4: How do you determine that a brain injury is mild? How do you determine that a brain injury is mild? Glasgow Coma Scale Mild = initial score of 13 or higher Jennett B & Teasdale G. Management of Head Injuries. FA Davis

14 Question #5: How do you determine that a MTBI has occurred (and does it matter)? How do you determine that a MTBI has occurred? Ropper AH, and Brown, RH (2005). Adams and Victor's Principles of Neurology, Eighth Edition. Clinical manifestations of concussion: The immediate abolition of consciousness, suppression of reflexes (falling to the ground if standing), transient arrest of respiration, a brief period of bradycardia, fall in blood pressure following a momentary rise at the time of impact Rarely, if these abnormalities are sufficiently intense, death may occur at the moment of impact, presumably from respiratory arrest. usually vital signs return to normal and stabilize within a few seconds while the patient remains unconscious. Brief tonic extension of the limbs, clonic convulsive movements lasting up to about 20 seconds and other peculiar movements may occur immediately after the loss of consciousness How do you determine that a MTBI has occurred? Ropper AH, and Brown, RH (2005). Adams and Victor's Principles of Neurology, Eighth Edition. Clinical manifestations of concussion: In all patients with cerebral concussive injury, there remains a gap in memory (traumatic amnesia) spanning a variable period from before the accident to some point following it. This gap is permanent How do you determine BOTH that a brain injury occurred, and that it was mild? WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Operational Definition of MTBI Holm L, et al. J Rehab Med, 2005, 37(3): WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Operational Definition of MTBI MTBI is an acute brain injury resulting from mechanical energy to the head from external forces Operational criteria for clinical identification include WHO Operational criteria for clinical identification include A. One or more of the following 1. Confusion or disorientation 2. Loss of consciousness for 30 minutes or less 3. post-traumatic amnesia for less than 24 hours 4. Other transient neurological abnormalities such as focal signs, seizure, intracranial lesion not requiring surgery (continued) 14

15 WHO Operational criteria for clinical identification include B. Glasgow Coma Scale score of after 30 minutes postinjury or later upon presentation for healthcare C. These manifestations of MTBI must not be: 1. Due to drugs, alcohol, medication 2. Caused by other injuries or treatment for other injuries 3. Caused by other problems 4. Caused by penetrating craniocerebral injury Contra-Indications of a Brain Injury scenario: Contra-Indications of Brain Injury: 1. Posttraumatic Stress Disorder, and many of its symptoms. The scientific literature tells us that brain injury and PTSD do not occur together. Subsequently, if a patient is presenting with PTSD, or even with just a few PTSD-like symptoms (such as nightmares and flashbacks), then a brain injury probably did not occur. >>> Contra-Indications of Brain Injury: 1. Posttraumatic Stress Disorder Claimants who simultaneously claim brain injury and PTSD, from the same event, demonstrate an elevated rate of faking on objective testing. Contra-Indications of Brain Injury: 2. Complaints that worsen over time are specifically inconsistent with a brain injury scenario. Question #6: What are the typical causes of a claim of prolonged postconcussion syndrome? 15

16 What are the typical causes of a claim of prolonged postconcussion syndrome? The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury Carroll LJ, Cassidy JD. PROGNOSIS FOR MILD TRAUMATIC BRAIN INJURY: RESULTS OF THE WHO COLLABORATING CENTRE TASK FORCE ON MILD TRAUMATIC BRAIN INJURY. J Rehabil Med 2004; Suppl. 43: (continued) The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury "The most consistent predictors of delayed recovery after mild traumatic brain injury are compensation and litigation factors, independent of mild traumatic brain injury severity." The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury the question of whether pre-morbid personality is an important predictor of persistent symptoms after mild traumatic brain injury. One study that addresses this issue in a unique and highly selected sample of individuals who had been administered psychological tests prior to their injury found that post-mild traumatic brain injury psychological problems reflected pre-morbid personality, rather than the effects of the injury." What are the typical causes of a claim of prolonged postconcussion syndrome? Iverson GL. Outcome from mild traumatic brain injury. Current Opinion In Psychiatry, 2005, May, 18 (3), All of the following have a stronger effect than does MTBI All of the following have a stronger effect than does MTBI Claims context Mood disorders ADHD Exaggeration/malingering Benzodiazepines Marijuana Symptomatic HIV >>> What are the typical causes of a claim of prolonged postconcussion syndrome? Remember that we already saw that hypertension has a stronger effect than does MTBI. We have only talked about the issues that have been shown, in head to head comparison, to have a stronger effect than MTBI. Note that there are many other neuropsychological risk factors that we have not yet talked about, which also need to be considered. 16

17 What are the typical causes of a claim of prolonged postconcussion syndrome? Mittenberg W., et al. (1992). Symptoms Following Mild Head Injury: Expectation As Etiology. Journal of Neurology, Neurosurgery, and Psychiatry, 55, pp PCS is dependent upon the extent to which the postconcussive individual attributes noninjury-related shortcomings to the injury (example, they overlook any history of preexisting headache, and attribute all current headaches to the MTBI). catastrophizing, avoidance, maladaptive coping, creating distress, stress, and disability. Question #7 Are these people faking? These data show base rates of malingering that approach or exceed 50%... Larrabee GJ. Assessment of Malingered Neuropsychological Deficits. Oxford, Question #8 What does neuropsychological consultation have to offer for such cases? Neuropsychological consultation does NOT offer Assessment of impairment from MTBI Because there is no credible basis for claiming that such impairment exists. Neuropsychological consultation offers Objective assessment of whether there is any type of cognitive impairment (there might not be) Neuropsychological consultation offers If there is significant impairment, the consultation might provide diagnostic clues (we know that the MTBI is not the cause of the impairment, so a neuropsychology consultation might help us develop alternative diagnostic hypotheses) 17

18 Neuropsychological consultation offers Objective assessment of whether the examinee s presentation is consistent with faking Psychology has extensively researched the phenomenon of malingering Many tests have been scientifically validated for the objective assessment of malingering for -cognitive complaints -mental illness -pain complaints Psychology has extensively researched the phenomenon of malingering Warning!!! Researchers are scared of being sued, therefore Almost all of the research is designed to miss many to most examinees who are faking This helps to insure that when a malingeringlike result is obtained, we are indeed probably dealing with someone who is faking But when a honest-like result is obtained, we cannot claim with probability that the examinee has been honest with us. Psychology has extensively researched the phenomenon of malingering Warning!!! Unscrupulous doctors will use inadequate tests so that they can claim that they tested for faking, when in fact these tests frequently produce honest results for people who are actually faking. Examples: Test of Memory Malingering (TOMM) Rey 15 Item Test Personality Assessment Inventory (PAI) Question #9 What can we do for someone with prolonged postconcussive complaints? Credible treatment for claims of prolonged PCS Cognitive behavior psychotherapy focused on: Teaching the patient to re-evaluate symptoms as possibly normal shortcomings Teaching patient to avoid over-reacting to such perceived symptoms Teaching the patient to avoid becoming stressed by such perceived symptoms NOTE: This psychotherapy approach is the ONLY scientifically validated specific treatment for PCS. Mittenberg W, et al. Cognitive-behavioral prevention of postconcussion syndrome. Archives of Clinical Neuropsychology, 1996, 11,

19 First Steps: First Steps in Analyzing a brain injury claim: 1. Determining severity 2. Objectively scrutinizing neuropsychology test results 1. Determining Severity Most brain injuries are of mild severity Mild brain injury is not associated with any permanent impairment, or even persistent impairment (everything seems to normalize within a week). Therefore, the first step involves determining whether this was a mild brain injury (or perhaps not a brain injury at all). First Steps: 1. Determining Severity Real life example: Brain Injury Claim File Review From California Brain Injury Claim: File Review From California 1.Determining Severity The adjustor sent me the records from the day of injury. Note: Arranging for a review of just this one day of records can usually eliminate the need for an IME, or for any treatment. Brain Injury Claim: File Review From California 1. Determining Severity In this case: The reported loss of consciousness lasted 20 minutes (30 minutes of less indicates mild). Glasgow Coma Scale at ER was 15 (13 and above indicates mild). No posttraumatic amnesia (24 hours or less of PTA indicates mild). There were some brain imaging findings, but they were not of a nature that warranted brain surgery. Brain Injury Claim: File Review From California Therefore, the case clearly involved a MILD traumatic brain injury, which means No permanent impairment No persistent impairment or problems can credibly be attributed to the injury Everything should normalize within a week (if it does not, then something other than the injury is responsible) 19

20 Brain Injury Claim: File Review From California The adjustor asked me to provide a fully referenced report enabling all parties to see that the conclusions from the previous slides were fact-based rather than opinion-based. Case reportedly settled quickly and easily. No need to authorize any further healthcare, and no need for an IME. First Steps in Analyzing a brain injury claim: 1. Determining severity 2. Objectively scrutinizing neuropsychology test results Objectively scrutinizing neuropsychology test results If neuropsychology testing has been administered to the claimant, arrange for those results to be reviewed by a competent and honest neuropsychologist Objectively scrutinizing neuropsychology test results by simply comparing the test results to the relevant scientific literature the reviewer can tell you, objectively, no opinions necessary, whether the results are consistent with brain injury or if instead the results are consistent with some other explanation (approximately 50% of the time, the results will be objectively more consistent with faking). Arrange for test results to be reviewed by a competent and honest neuropsychologist Such a review has several advantages over an IME: Less expense Review can be done by the best neuropsychologists, rather than by local neuropsychologists No one can accuse the reviewer of manipulating the test results No nonsense about observing or recording an evaluation First Steps: 2. Arrange for test results to be reviewed by an honest and competent neuropsychologist Real life example: Brain Injury Claim File Review From New York 20

21 Tracking Test Sorting Test Honest brain injury patients averaged up to 39 errors Examinees faking impairment averaged up to 79 errors Claimant s score 97 errors Honest mild brain injury patients averaged seconds Honest severe brain injury patients averaged 98.4 seconds Research participants faking impairment averaged seconds Claimant s score from his doctor 423 seconds Claimant s score from doctor hired by his attorney 960 seconds Malingering-like weakness AND strength Puzzles Test Brain Injury Fakers Claimant Average Severe Brain Injury Scientific Findings Analogies Test Brain Injury Malingerers Plaintiff Average Severe Brain Injury Scientific Findings Recovery continues for at least ten years Return to a normal life is probable Regaining the ability to work for a living is probable Severe Brain Injury Scientific Findings When a doctor predicts, within the first five years of the injury, a bleak outlook, that doctor is probably wrong. 21

22 Real life example: Severe Brain Injury Lawsuit from Alabama Severe Brain Injury Lawsuit Plaintiff attorneys claim that the plaintiff s impairment is permanent because it has been a year since the injury. Severe Brain Injury Lawsuit Defense attorneys actually believe this, and ask me to do an IME in order to determine severity of impairment. Severe Brain Injury Lawsuit I explain that there is no point in doing an IME to establish severity of impairment in a case that is one year post injury, because such patients continue to demonstrate improvement for at least ten years. Severe Brain Injury Lawsuit The defense attorneys cancel their request for IME, and ask me to provide a fully referenced report explaining that the plaintiff will most likely demonstrate continued improvement over the next decade, and eventually will be able to resume a normal life. Severe Brain Injury Lawsuit Settlement demand drops from $10M to $1M after plaintiff s attorneys read my report and the referenced scientific publications. 22