This is the second of a series of blogs on Winning Strategies for Handling a Mild to Severe Brain Injury Case.
We first discussed the anatomy of the brain, including the structure of neurons. Here we will discuss the ways that our brain can be injured and the implications that flow from the various kinds of injuries.
The brain is very delicate and is considered to be the consistency similar to that of gelatin. If a brain is suddenly jolted or banged or twisted, it will cause a traumatic impact that ripples through the entire brain and can cause complications. The brain is made up of billions of neurons that can be damaged by trauma to a person’s head.
Some of the ways damage can occur to a human’s brain is as follows:
Mild Traumatic Brain Injury or Concussion
The term mild traumatic brain injury is used interchangeably with the term concussion. A concussion is caused by a blow or jolt to the head that disrupts the function of the brain. Unlike more severe traumatic brain injuries, the disturbance of brain function from a concussion is caused more by dysfunction of brain metabolism rather than by structural damage. The current understanding of the neuropathophysiology of a mild TBI involves a paradigm shift away from a focus on anatomic damage to an emphasis on neuronal dysfunction involving a complex cascade of ionic, metabolic and physiologic events. After an impact causing a concussion, there is an increase in glucose metabolism, and then a subsequent reduced metabolic state. These events interfere with the neuronal function in the brain and may lead to cell death after the injury.
Diffuse Axonal Shear
In a diffuse axonal shear injury many of the nerve cell pathways (axons) may be torn apart or stretched. This can cause a loss of connection between brain cells and can lead to a breakdown of overall communication among neurons in the brain. Information processing may be disrupted. A diagram demonstrating the process of axonal shear appears below:
Coup – Contre-Coup
A coup contre-coup injury to the brain occurs when there is a sudden impact to the head, which causes the brain to first slam into one side of the skull wall, then bounce off that wall and slam into the wall on the opposite side of the skull. Read more of this article »
This is the first of a series of blogs on Winning Strategies for Handling a Mild to Severe Brain Injury Case.
To begin, an understanding of brain anatomy is essential to gain some knowledge of what happens to the brain after a traumatic brain injury. It is one of the responsibilities of counsel in a traumatic brain injury case to educate the judge and jury on the anatomy of the brain.
Interestingly, the brain is not a hard muscle-like substance, but rather a soft gelatin-like organ that sits within a rough and bony skull. The brain is covered by three thin protective layers called the meninges. The space between the meninges and the brain is filled with a clear liquid called cerebral spinal fluid. This fluid works to keep the central nervous system healthy. The brain is innervated by a sophisticated system of blood vessels which carry blood to and from the heart.
Within these two hemispheres there are four lobes – frontal, parietal, temporal, and occipital, and each lobe is responsible for specific functioning. The brain stem and cerebellum also play a significant role in the brain’s functioning.The outermost and largest part of the brain is called the cerebrum and it controls things like thoughts and actions. It has a wrinkled surface and is divided it into two halves, known as the left and right hemispheres.
- Frontal Lobes – deals with reasoning, planning, self-control, some speech and emotion functions, and problem solving. The frontal lobes also play an important part in memory, intelligence, concentration, and are responsible for executive functions.
- Parietal Lobes – are involved with movement, and also help people to understand signals received from other areas of the brain such as vision, hearing, sensory and memory. A person’s memory and sensory information received give meaning to objects and “put it all together”.
- Occipital Lobes – found at the back of the brain, receive signals from the eyes, process those signals, allow people to understand what they are seeing, and influence how people process colours and shapes.
- Temporal Lobes – are located at around ear level, and are the main memory centre of the brain, contributing to both long-term and short-term memories. The temporal lobe is also involved with understanding what is heard, and with the ability to speak. The left temporal lobe is involved in verbal memory and aids in understanding language, where the right temporal lobe is involved in visual memory and helps people recognize objects and faces.
- Brain Stem – is responsible for maintaining the body’s most basic functions such as breathing, heartbeat, and blood pressure.
- Cerebellum – it is divided into two halves, with the main function of controlling and regulating the body movement of the muscular skeletal system.
The brain and nervous system also consist of billions of tiny cells called neurons. Neurons are the “communicators” and each neuron has three main parts:
- Cell body: the central station that sends out impulses
- Axon: long, slim “wire” that transmits signals from one cell body to another via junctions known as synapses
- Dendrites: networks of short “wires” that branch out from an axon and synapse with the ends axons from other neurons.
The neurons receive and transmit information in a relay where electrical impulses alternate with chemical messengers. The electrical impulses flow through nerve cell pathways along the axons and dendrites. Neuro-chemical transmitters leap the synaptic gaps between each neuron’s axon and the other neurons with which an axon makes contact. Each neuron is its own miniature information center which decides to fire or not fire an electrical impulse depending on the thousand or so signals it is receiving every moment.
Stay tuned for the next part in the blog series on the ways a brain can be damaged.This is a basic overview of the anatomy of the brain. It is important that lawyers understand the functions of the brain to better understand how injury to a particular area of the brain can impact your client.
The Chief Coroner for Ontario has just released the Office of the Chief Coroner’s Pedestrian Death Review.
In 2010 there had been a rash of pedestrian deaths. The review was initiated after Patrick Brown of McLeish Orlando LLP and enviromental lawyer, Albert Koehl gathered a coalition of interested groups and requested a review of cycling and pedestrian deaths within the province. Last summer, the Toronto Star posted Patrick and Albert’s request and later that fall, after several meetings, the review was launched. The purpose of the review was to examine the circumstances of the deaths that occurred from January 1, 2010 to December 31, 2010 and make various recommendations. The report itself was dedicated to the 95 Ontarians who lost their lives in preventable pedestrian collisions in 2010.
The review resulted in 26 recommendations covering many areas and includes:
• Reduced speed limits in residential areas and amendments to the Highway Traffic Act
• Adopting ‘Complete Streets’ aprroach to ensure the roadways are designed and maintained for all users including pedestrians and cyclists
• Installing side guards on heavy trucks
• Creating more pedestrian crossings, longer times to cross, and developing a “walking stratedgy for Ontarians”
• Educating drivers on the scenarios that can lead to a pedestrian collision
• Increasing enforcement
Read more of this article »
The majority of people who suffer mild traumatic brain injury recover within three months. However, up to 10 to 15 percent of people who suffer mild traumatic brain injury continue to have symptoms three months later. Research has shown that early diagnosis and management of mild traumatic brain injury greatly improves a patient’s outcome and reduces the impact of persistent symptoms.
Unfortunately, until now there have been no standardized guidelines that doctors or healthcare providers in Ontario could use to identify mild traumatic brain injuries early on or to treat individuals who suffer persistent symptoms following mild TBI. To respond to this concern, the Ontario Neurotrauma Foundation appointed a team of medical experts, doctors, healthcare providers, and mild traumatic brain injury survivors from across Ontario, Canada and outside the country. The team reviewed and vetted relevant clinical guidelines published in the last 10 years, and consolidated this information into one standardized guideline. The results of this process are the Ontario Neurotrauma Foundation’s Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms.
These guidelines will improve patient care by providing healthcare professionals with uniform, evidence based, best practice recommendations to effectively identify and treat individuals who suffer persistent symptoms following mild TBI. As part of Brain Injury Awareness Week, McLeish Orlando commends the work of the Ontario Neurotrauma Foundation and the project members who contributed to these guidelines in order to improve the care and quality of life for individuals living with the potentially devastating effects of mild traumatic brain injury.
Click here to read a brief summary of the guidelines for assessment and management in each of the 13 areas listed in the guidelines.
Recent research on concussions in children now indicates that even the mildest concussions need to be treated with “brain rest” to avoid injuries that can possibly have long-lasting effects on children.
Dr. Ellemberg, a neuropsychologist at the Université de Montréal is conducting the world’s first large-scale study of the effects of concussions on children. His five-year study will research concussions in more than 200 children.
Dr. Ellemberg states “The traditional view has been that children’s developing brains would recover faster from injury than adults’ brains. But we’re finding evidence that a child’s brain could actually be more sensitive to the effects of concussion”.
Dr. Ellemberg cautions that his results aren’t a call for kids to avoid sports and other activities. Rather, he says, it’s time for parents and coaches to be aware of concussion symptoms and give young brains a chance to heal.
“If we take the proper precautions after a concussion we can significantly reduce the impact of the concussion on the brain,” says Dr. Ellemberg.
Any blow to the head, face or neck, or somewhere else on the body that causes a sudden jarring of the head may cause a concussion, such as being hit in the head with a ball, falling off a bike or being checked into the boards in hockey.
The symptoms of a concussion may include:
• Dizzy or disoriented
• Headaches, nausea or vomiting
• Ding or buzzing sounds immediately after injury’
• Seeing stars on impact and later double or blurry vision
If you suspect that your child has sustained a concussion, your child should stop playing the sport right away. The most important treatment for a concussion is rest. Like any physical recovery, the invisible mental recovery must also occur and this takes time. That means not exercising, bike riding, playing video games or working on the computer. Children may have to stay home from school because schoolwork may make their symptoms worse. Children who go back to school or resume activities before they are completely better are more likely to get worse and to have symptoms longer.
A child who has been diagnosed with a concussion should see a doctor immediately if symptoms get worse, such as:
• being more confused;
• worsening of a headache;
• vomiting more than once;
• not waking up;
• having trouble walking;
• experiencing a seizure; or
• behaving strangely.
Problems caused by a head injury can get worse later that day or night. A child should not be left alone and should be checked on through the night. If there are any concerns about a child’s breathing or sleep, wake her up. Otherwise, let her sleep. If she seems to be getting worse, see a doctor immediately.
For more information visit the Canadian Paediatric Society website at http://www.cps.ca/english/statements/HAL/HAL06-01.htm
The Financial Services Commission of Ontario (FSCO) Panel selected to review the definition of Catastrophic Injuries has released their report.
To those consumers not familiar with this, see my previous blog “Catastrophic Impairment under a Microscope.” It was anticipated that the review of the definition would give rise to maintaining or granting greater access to medical and rehabilitation benefits to those suffering catastrophic injuries. The last set of changes made by the Ontario Government in September 2010 saw many accident benefits slashed in half or eliminated for the less seriously injured. These cuts were made in order to ensure that the system was financially able to protect those suffering from the more disabling catastrophic injuries. Therefore it was extremely alarming to see that the FSCO Review Panel has recommended new changes which will make it more restrictive for the seriously injured victims to meet the catastrophic definition.
If implemented, a large portion of these victims will be denied the designation and suffer greatly with the reduced benefits. The changes prevent the injured person from having psychological injuries combined with physical injuries when conducting the assessment. As well, they propose to get rid of the GCS score as a designator for those suffering brain injuries. The brain injury victim will no longer be able to qualify based on the early GCS score, but would rather be subject to a longer and more detailed assessment. An assessment which will delay benefits from flowing and costs significantly more.
This means that many people who suffer serious brain impairments, psychological injuries and physical injuries will be denied access to meaningful benefits in the future. The funds normally spent to get the seriously injured victims better or allow them to live with dignity will simply remain within the insurance companies. Of course, this will in turn increase the profitability of the insurance industry and put higher demands on the public health system.
However, the panel is only the first step in the review. The recommendations are not yet law. FSCO and the Government also requested submissions from the legal and medical communities. The deadline of May 13, 2011 has now passed. The response by these communities has been loud and clear. The recommendations are premature, flawed and ought not to be implemented.
A panel of prominent medical specialists in field of traumatic injuries have taken objection to the recommendations. This panels’ review was endorsed by the Alliance of Community Medical and Rehabilitation Providers of Ontario. The medical outcry is of no surprise, since the recommendations now being made are at complete odds with a 2001 Medical Panel Review. The September 2001 Review was supported by the insurance, legal and medical communities.
The major legal organizations have also stood up and indicated that these recent recommendations ought not to be implemented. They include the Ontario Bar Association, The Advocates’ Society, and the Ontario Trial Lawyers Association.
Based on the resounding objection, one can not imagine the Government giving any weight to the proposed recommendations. What is interesting is that in the submission made by the Alliance, they understand that over half of the panel making these recommendations had been at one time consultants with the Insurance Bureau of Canada.
What is really driving these recommendations?
Voice your Opposition to the Panel’s Recommendation and put people before profits. Send an email to your local MPP today before it is too late!
MPP Dwight Duncan is considering drastic changes to the definition of Catastrophic Impairment under the standard auto insurance policy based on the Report of the Catastrophic Impairment Expert Panel to the Superintendent of the Financial Services Commission of Ontario. The changes being considered will make it much more difficult for seriously injured accident victims to be able to access the care and treatment they require.
These changes ought not to be made for the following reasons:
1) The bar is being set too high - the medical panel assumed that to be considered “Catastrophic”, you have to have an injury that is essentially the same as being wheelchair bound. This will prevent many seriously injured accident victims who would qualify under the current definition for benefits from being able to get necessary treatment and care.
2) The Medical Panel’s work is not complete. This Panel, despite its limited membership, limited resources and rushed timelines, is recommending, and the Government is now considering, drastic changes even though their work is not yet done.
3) We have 15 years of experience with the current definition of Catastrophic Impairment. The Government is considering adding 4 new, complicated tests, and eliminating the one that is the most simple and the easiest to use (the Glasgow Coma Scale). They are considering adding a requirement that people MUST be accepted into an inpatient hospital rehabilitation program, when there are very limited beds available. All of this will throw our system into disarray, and create disputes and costly litigation.
4) The definition of catastrophic is not a medical decision, it is a policy decision based on three considerations: fairness to the most seriously injured people in the Province; affordable premiums for the motoring public; and reasonable profits for insurers. Benefits for all non-catastrophic victims were drastically cut in September of 2010. As a result, auto insurers in Ontario are poised to make significant profits which will relieve any upward pressure on premiums. In fact, insurer profitability has already begun to dramatically rebound before the effect of the September changes have begun to take hold.
The Financial Services Commission of Ontario (www.fsco.gov.on.ca) has now commenced a review of the “Catastrophic Definition”. The outcome of this review will have a dramatic impact on the victims who suffer severe disabilities in car crashes. For those deemed to be “catastrophic”, it can mean the ability to access essential services to live independently and with dignity. For those that are not, it can mean a life of limited help, despair and a stalled recovery. The stakes are very high!
The FSCO has now appointed an Expert Medical Panel to make recommendations regarding the definition and the assessment process. Careful attention will be made on people suffering traumatic brain injuries, paralysis, spinal cord injuries, severe mental and psychological disorders, and those suffering from multiple broken bones.
Many lawyers, doctors, rehabilitation professionals and treating providers are looking forward to the review. It is hoped that it will finally address the many holes that are within the system. Holes that have resulted in many seriously disabled victims being left out in the cold when it comes to basic care services and rehabilitation treatment. Treatment that will help them get better and integrated back into society and the workforce.
The last changes made by the Ontario Government to the insurance system was in September of 2010. These changes saw a drastic reduction in benefits to those suffering less severe injuries. The intent was to eliminate and drastically reduce benefits flowing to people suffering minor injuries. By cutting the flow, it would mean insurance companies would not have to raise auto insurance premiums to the driving public. It was also seen as a way of making sure greater benefits could flow to the more seriously disabled victims. As some would say, soft tissue injuries would have to take a back seat to the seriously injured.
Although the review process is to look at ways of making the present system better and more efficient, some fear that it will be used as a vehicle by the insurance industry to make it harder for people to be deemed “catastrophic”. This of course would mean people who otherwise would have up to two million in benefits available to meet their needs, would be reduced down to a bare bones package that is exhausted normally with one to two years. This of course cannot be the intent of the review. The review ought to ensure greater access is given to the seriously injured. Substantial savings have already been afforded to the insurance industry as cited in my previous blogs. To now go after the seriously injured and seek to reduce their benefits is just wrong.
Many are confident that the medical panel, FSCO and the Ministry will ensure these seriously injured persons are protected. An expansive approach with the definition must be done. A definition that recognizes all serious injuries. A definition that takes into consideration the collective impact of all injuries on the disabled. It should never be forgotten that there are no windfalls that happen when one is deemed “catastrophic.” Even if someone is found to suffer a catastrophic injury, they still must prove the need for benefits. It simply does not mean money falls on to their lap and they keep it. The money goes to rehabilitation, home modifications, mobility aids, and attendant care. The disabled person still must prove they need the services ( the wheelchair ramp, the wheel chair lift, the helper to get dressed etc.). If they don’t prove it, they don’t get it. If the definition is expanded, it simply means those who need it can access it beyond the temporal and monetary caps of $3,500 or $50,000 as set out in my previous blogs.
If the panel or FSCO or the Ministry seek to tighten up the definition, which would be contrary to the intent of the review, then many severely disabled individuals will be shut out from accessing the rehabilitation and medical help needed to live with dignity and independence. Of course further restriction would simply mean greater savings to the insurance industry. This time however, it will be on the backs of the severely disabled.
Scientists have discovered a DNA-based drug that could prevent the crippling damage that leads to permanent paralysis, if it is taken within several hours of a spinal cord injury.
Most spinal cord injuries do not cause a complete rupture of the cord. However, the body recruits large amounts of sodium to the injury site to ward off a perceived calcium attack. This recruitment mechanism cannot be turned off and floods blood vessels in the area, causing the cells to explode. The loss of blood vessels, starves spinal cord neurons of oxygen, and the neurons themselves succumb to excess sodium and explode.
The new drug will stop the sodium recruitment process and prevent the damage if it is taken within hours of the injury. So far, researchers have not found any side-effects as a result of the drug.
The new finding regarding Chronic Fatigue Syndrome lends new hope for effective treatment
People suffering from chronic fatigue syndrome are often accused of being lazy or even faking an illness.
However, researchers have found evidence that chronic fatigue syndrome is caused by a virus, closely related to the HIV virus. This finding raises hope that the virus might be treatable with medications currently being used for AIDS patients.
Judy Mikovits, the senior author of the study calls Chronic Fatigue Syndrome “a true human infection.” The virus, known as XMRV, was found in virtually all of the 101 chronic fatigue sufferers that she tested. She says that she is thrilled with this finding because it gives legitimacy to victims of the syndrome.
“We’re delighted because the stigma that’s gone on with this, the idea that it’s somehow psychiatric or you are unable to handle stress…would be gone.”