Head Clash: concussion, mild, moderate or severe traumatic brain injury?

Head Clash: concussion, mild, moderate or severe traumatic brain injury?

If you pay any attention to the media, it would seem we have entered an age of prolific concussion and brain injury. The issue has been brought to the forefront, mainly through the coverage of concussions and their long term effects on sports people, with a focus on contact sports. But before we label the current incidences as a ‘concussion crisis’ with irrevocable consequences, it is important to know what a concussion actually is and how it differs from a mild traumatic brain injury (mTBI) or even a moderate to severe traumatic brain injury. Concussion and mTBI are often confused, even in medical literature, and the terms are often used interchangeably. However there are some important differences between the two.

According to the American Association of Neurological Surgeons, a concussion is defined as an injury to the brain that results in temporary loss of normal brain function. Concussions are usually caused by a blow to the head, acceleration or deceleration (whiplash), a projectile or an explosion. However this is not necessarily the criteria for a mTBI.

Dr Arthur Shores, a Clinical Neuropsychologist, points out the differences between the two medical conditions: ‘Concussion is the historical term representing low-velocity injuries that cause brain “shaking” resulting in clinical symptoms and which are not necessarily related to a pathological injury. In contrast, mTBI is part of a spectrum of injury severity that reflects a pathological injury. This is typically assessed by the Glasgow Coma Scale (GCS) and the Westmead PTA Scales (WPTAS and AWPTAS) that are widely used in emergency departments and brain injury units in Australia. The assessment of traumatic brain injury and classification of the severity of an injury is reflected both by the depth of disturbance in consciousness (coma), as well as the duration of post-traumatic amnesia (PTA).’

Mild TBI

The operational definition of mild TBI (Carroll et al, 2004) is defined by the World Health Organisation (WHO) Collaborating Centre for Neurotrauma Task Force on mTBI as follows:

‘mTBI is an acute brain injury resulting from mechanical energy to the head from external physical forces. Operational criteria for clinical identification include:

  1. One or more of the following: confusion or disorientation, loss of consciousness for 30 minutes or less, post-traumatic amnesia for less than 24 hours, and/or other transient neurological abnormalities such as focal signs, seizure, and intracranial lesion not requiring surgery;
  2. Glasgow Coma Scale score of 13–15 after 30 minutes post-injury or later upon presentation for healthcare.’[1]

Moderate to extremely severe TBI

Moderate TBI is defined by a disturbance in consciousness producing a GCS score of 9–12, and a period of persistent deficits in retaining new information and processing new memories (PTA) of 1–24 hours. Severe TBI is defined by a GCS of 3–8, and a period of PTA of 1–7 days. Very severe TBI is characterised by a period of PTA of 1–4 weeks. Extremely severe TBI is defined by a period of PTA of greater than four weeks. (Figure 1).[2]

Figure 1. Classification of traumatic brain injury severity.

Mild Moderate Severe Very Severe Extremely Severe
GCS

13-15

GCS

9-12

GCS

3-8

GCS

3-8

GCS

3-8

PTA

<1-24 hours

PTA

<1-24 hours

PTA

1-7 days

PTA

1-4 weeks

PTA

>4weeks

Concussion may be seen as a ‘minimal’ injury subset that falls below the threshold of mTBI (ie, GCS) score 13-15. This represents the majority of concussive injuries seen in sports (Figure 2).[3]

Figure 2. Sports concussion as minimal injury subset of mild traumatic brain injury.

McCrory-(2013)-Fig-jpg

 

 

 

 

 

 

Assessment of outcome

Recovery from a mTBI can vary, however generally speaking, the severity of the mTBI will have a direct impact on the likelihood of a positive recovery. Dr Shores states, ‘Concussion and uncomplicated mTBI generally lead to full recovery, however repeat concussions and complicated or more severe injuries can lead to long term functional impairment.’ Dr Shores advises caution and care when evaluating an injury, as there are dangers in both over-estimating and under-estimating brain injury severity, particularly based on duration of PTA. ‘Duration of PTA provides a guideline to the severity of brain impairment and has been shown to be a useful outcome predictor of cognitive-behavioural-social dysfunction, with longer duration of PTA predicting a worse outcome. A careful scrutiny of the results of existing measures is necessary in determining severity of the injury. In contrast to mTBI, Moderate to Very Severe traumatic brain injuries are expected to have more permanent neurocognitive disorder than would be expected in claimants with mTBI. Neuropsychological assessments are useful in determining the severity of the injury and evaluating the outcome,’ Dr Shores states.

If you need a neuropsychological assessment regarding a concussion or mTBI, please contact our experienced team at MedicoLegal Assessments Group.

[1] Carroll, L.J., Cassidy, J.D., Holm, L., Kraus, J., & Coronado, V.G. (2004). Methodological issues and research recommendations for mild traumatic brain injury: The WHO collaborating centre task force on mild traumatic brain injury. Journal of Rehabilitation Medicine, S43, 113-125.

[2] Neuropsychological Assessment of Children and Adults with Traumatic Brain Injury: Guidelines for the NSW Compulsory Third Party Scheme and Lifetime Care and Support Scheme, 2013, MAA, Editor. 2013, Sydney.

[3] McCrory, P., Meeuwisse, W.H., Echemendia, R.J., et al. What is the lowest threshold to make a diagnosis of concussion? British Journal of Sports Medicine, 47, 268–271.

 

A Pain in the Gut

A Pain in the Gut

The effect of pain medications on gastrointestinal function

Anyone suffering moderate to severe pain from an accident or injury will quickly want to address their problem. However prescribed and over the counter (OTC) pain medications can also often leave the patient with unwanted gastrointestinal side effects. Three of the most common drugs used in pain management are opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. Professor Brian Jones is a Gastroenterologist and Hepatologist at the Sydney Adventist Hospital. He has offered some insight into the side effects of these commonly used drugs.

Opioids

Opioid, or narcotic painkillers are strong pain relievers and are generally used only in cases of moderate to severe pain. They come in various forms and type, such as in-hospital injectable types including pethidine, morphine and fentanyl. They are usually used for short term pain relief, for example after surgery. Fentanyl also comes in a patch (for more long-term use as part of chronic pain syndrome management). Codeine is a common component in OTC analgesic drugs such as Panadeine (paracetamol plus codeine). Higher concentrations of codeine such as in Panadeine Forte require a prescription from a medical practitioner.

Opioids work by reducing the pain signals from the brain, which in turn reduces the feeling of pain in the body. Since opioids can have quite severe side effects and become tolerable to the body over time, the prescribing and management of opioids in a patient is necessary to avoid harmful long term effects.

Prof Jones states that opiods slow down the gut, which is the reason for some of the common abdominal side effects. One such side effect is opioid-induced bowel dysfunction (OIBD). Symptoms of OIBD include:

  • Constipation
  • Nausea and vomiting
  • Gastro-esophageal reflux
  • Abdominal pain
  • Bloating

Prof Jones also notes the addictive nature of opioids. “All opioids are highly addictive and there are strict regulations regarding their use. Codeine is illegal in some countries and its use and possession can attract hefty fines, even if prescribed by a doctor.”

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs temporarily relieve pain and reduce inflammation and swelling in the body. There are different types of NSAIDs, including aspirin, ibuprofen and naproxen. They can be available at both over the counter and prescription levels. NSAIDs are often prescribed to treat conditions which cause swelling, such as arthritis and other musculoskeletal disorders.

While each of the types of NSAIDs have different properties, they all work by blocking an enzyme which in turn reduces fever and inflammation in the body. But NSAIDs can also have significant side effects on the gastrointestinal system.

Side effects can range from mild to severe. NSAIDs can cause stomach upset and indigestion as well as ulcers and bleeding in the stomach and gastrointestinal tract. Long term use can also cause kidney damage, raised liver enzymes and high blood pressure.

Since ibuprofen and aspirin are two highly common over the counter NSAIDs, people are not always aware of the severity of side effect from long term or over-use of these drugs. Prof Jones states, “The NSAIDs are rapidly overtaking simple analgesics such as paracetamol, and they are used in a number of situations such as treatment of pain and fever in children, period pain in young females, and arthritis pain in older people. Again their use should be short-term only.”

Paracetamol

“Paracetamol is probably the safest analgesic on the market and available OTC,” Prof Jones states. It is a commonly used drug to help in the management of pain, however this does not mean that it is free from side effects. Paracetamol works in reducing pain and fever, and is used in many types of pain management.

Prof Jones warns against the damage caused by Paracetamol overdose. “Paracetamol can cause severe liver damage in overdose (deliberate or accidental) and lead to liver transplantation and even death. Care should be exercised with paracetamol use in larger doses (e.g. 12-16 tablets a day) particularly in heavy drinkers with predisposed liver injury from alcohol.”

Asking Questions

Prof Jones recommends the patient addresses these three important questions when dealing with analgesics:

  1. Why do I need painkillers in the first place?
  2. How long will I need them?
  3. Are there any non pharmaceutical methods that may be preferable?

He also warns that, “ongoing pain may be a manifestation of a more serious underlying medical condition and review by a medical practitioner may be indicated.”

If you are suffering pain from an accident or injury and need advice on medical reporting,
please contact MedicoLegal Assessments Group for expert advice.

The Traumatic Truth: Questions for MedicoLegal Reporting regarding PTSD

The Traumatic Truth: Questions for MedicoLegal Reporting regarding PTSD

Traumatic events can be unexpected and sometimes unavoidable. With 50-75% of people facing a traumatic incident at some point within their lifetime, attention needs to be given to treatment and recovery from both a legal and medical perspective.

Dr Glen Smith is a consultant Clinical and Forensic Psychologist who works with MedicoLegal Assessments Group. Recently, he presented to our clients on the topic of Post Traumatic Stress Disorder (PTSD), highlighting factors in diagnosis, management and questions to ask MedicoLegal reporting when having such cases assessed.

As stated above, Dr Smith pointed out the somewhat unsettling statistic that over half the population will experience trauma within their lifetime. He cited the most common potentially traumatic events as the sudden and unexpected death of someone close (35%) and witnessed death (27%). Interestingly, the lifetime prevalence of PTSD in females is higher than in males and is 5-10%[1].

As a result of suffering a traumatic episode, many people will suffer Acute Stress Disorder, however only a minority of this number will continue to suffer symptoms consistent with PTSD. It is therefore important to know the difference between the two conditions.

Dr Smith outlined the symptoms of Acute Stress Disorder, which mirror many of the symptoms of PTSD. Some of the more common symptoms included:

  • sleep disturbance
  • anxiety
  • emotional distress
  • appetite disturbance
  • sadness and guilt
  • re-experiencing the event in forms of memories and nightmares
  • avoidance and social withdrawal.

A presence of the more severe reactions can lead to a diagnosis of Acute Stress Disorder. These symptoms are most prevalent in the first two weeks after the traumatic experience, however would gradually resolve in time, often without need for formal treatment. Having said this, counselling should also be offered. For a diagnosis of Acute Stress Disorder, symptoms need to be present for at least three days, however should not be present for more than one month. If symptoms persist greater than a month, then the diagnosis of PTSD may be made.

This brings us to the diagnostic criteria of PTSD. Dr Smith referenced the DSM-5 and ICD-11 criteria for diagnosing PTSD from the Australian and New Zealand Journal of Psychiatry [2]. Unlike Acute Stress Disorder, symptoms were present for four weeks or longer and result in a functional impairment. Other symptoms included re-experiencing symptoms, active avoidance symptoms, hyperarousal symptoms (hypervigilance or exaggerated startle) and functional impairment.

An important consideration when seeking assessments for patients with PTSD is ‘Criterion H’. Dr Smith indicated that for a diagnosis of PTSD, the symptoms must not be attributable to substance use or a general medical condition. This is a particularly important question to ask when seeking medico-legal reporting, as substance abuse, particularly alcohol abuse, is frequently comorbid with PTSD.

Dr Smith subsequently outlined therapies used in the treatment of PTSD. He focused on the following in treating trauma and its symptoms, namely:

  • the development of new ways of coping with anxiety, including progressive muscle relaxation (PMR) and the slow breathing exercise
  • trauma focused psychological therapypharmacological treatment.

Questions for MedicoLegal assessments and reporting

Having explored the definition of PTSD and expanding on the treatments available for trauma patients, this leads us to the important questions that need to be asked when seeking MedicoLegal assessments and reporting. Dr Smith touched on questions of diagnosis, prognosis, causation and contributing factors to ongoing incapacity – all of which are highly relevant in the medical reporting of PTSD.

Diagnosis

In terms of diagnosis, it is important to ask:

  • Is this Acute Stress Disorder or PTSD?
  • Can it be diagnosed in the context of alcohol dependence?

Prognosis

In terms of prognosis, it is important to ask:

  • Has treatment been offered?
  • Was it appropriate and for an adequate duration?
  • Has the patient ceased alcohol consumption?

Causation

When seeking a report, the following factors relating to causation should be noted:

  • establishing the main or the substantial contributing factor required to establish injury
  • ensuring you refer to the criterion in terms of factors or causes constituting PTSD.

Ongoing Incapacity

Be sure to ask questions relating to ongoing incapacity, such as:

  • Is alcohol or any other factor contributing to the lack of improvement?
  • Is there an employment related exposure to traumatic incidences?
  • Is there a lack of motivation for treatment?

Finding the right doctor to produce your medical report is of critical importance when establishing a claim for PTSD. MedicoLegal Assessments Group (MAG) will provide you with the right doctor, in a timely manner, who is an expert in this field. For more information on how you can access the right doctor to assess your PTSD claim, please contact the MAG team.

[1] Phoenix Australia – Centre for Posttraumatic Mental Health.

Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. 2013.

Phoenix Australia, Melbourne, Victoria

[2] Meaghan L O’Donnell et al. Aust NZ J Psychiatry 2015; 49:315-316

Paralympic glory

Paralympic glory

Stop and pause to reflect for these wonderful athletes.
The Winter Olympic Games has finished up in Sochi, but our Paralympic athletes are preparing themselves to compete in two of the six disciplines scheduled at the Winter Paralympic Games. So who are they? And what will they have focused on in the run up to the Games?

The Australian team has a total of 11 athletes, including six alpine skiers, two sighted guides and, for the first time, three snowboarders. The experience level of the alpine skiing component of the squad is strong, with all but one of the athletes having competed previously at a Paralympic Games, and all athletes having won medals over the two most recent World Cup seasons. Victoria (Tori) Pendergast, Australia’s first female sit-skier, will make her Paralympic debut, while Cameron Rahles-Rahbula has come out of retirement to compete in his fourth Games at 30 years of age.

Rahles-Rahbula, a leg amputee, picked up two bronze medals in the slalom and super-combined events four years ago at the Vancouver Games, and will be no doubt be focused on pushing himself to his limits once again in his final Paralympic Games despite an injury yesterday while training on the downhill course.
As the Para-snowboard discipline makes its debut on the Paralympic program in Sochi, so too will Australian snowboarder Ben Tudhope. Tudhope, who was born with cerebral palsy and partial paralysis of his left side, will become the youngest athlete to compete for Australia at a Winter Paralympic Games when he lines up in the new discipline at just 14 years of age.

As expected, there is a lot that is involved in preparing an athlete for such an event. Of course, there are the endless hours of training that have to be put in to ensure that each of the athletes is fit and ready to perform at their peak – but there is also a long list of other, more obscure, factors that need to be taken into account.

Common challenges

Preparation for the Olympics for athletes, whether or not they have a disability, is a huge ordeal.
There is a long list of potential stressors that can have a detrimental impact on athletes’ stress and confidence levels leading up to the event. These include, and are not limited to:
•    the physical and psychological effects of long-haul flights
•    adjusting to new foods
•    sharing a room with others for long periods of time
•    poor sleep quality
•    abiding by team rules
•    home-sickness
•    fatigue and stress that may come with travelling to and from competition venues
•    always being in the company of others.

Unique challenges

Athletes with disabilities face all of these same issues when preparing for the Paralympic Games – but they can also be faced with a unique set of physiological and psychological challenges which have the potential to disrupt their preparation.

In order to combat this, it is essential that the medical and sport science support staff are fully familiar with each individual athlete’s inherent disability and related medical conditions. Further to this, athletes with an intellectual or visual impairment may require additional care and assistance to provide them with the best opportunity to experience a smooth transition into competition.

From a psychological perspective, for some athletes, merely entering a plane or finding their way around the team accommodation or competition venue can be a source of additional stress.
Visually-impaired athletes may require assistance to help them orient to their new environment. When on a long-haul flight, for instance, finding the way to the bathroom facilities and back in a darkened cabin can present them with a challenge that others may not encounter.

Due to the increased amount of cognitive effort that can be required, such experiences may impact upon the athlete’s overall stress and/or energy levels, which can impair performance.

Support staff can relieve some of this pressure by checking in with relevant athletes to see if they have any questions, or by simply ensuring that they feel comfortable in their surroundings.From a physiological perspective, for athletes who are missing limbs and/or wearing prosthetic limbs, good stump care is a key part of the preparation process. It can help to avoid possible infection and the impact this can have upon performance. The overall aim while travelling, as well as prior to competition, is to not place any unnecessary stress on their stumps. Athletes are advised to wear compression garments on their stumps to prevent unwanted swelling during long haul flights, particularly if they remove their prosthesis during the flights.
They should also be reminded to try to avoid excessive walking in the days leading up to their event to prevent unnecessary fatigue, as well as the risk of breaking down the protective outer layer of the skin.

The one universal, whatever the discipline, whatever the circumstances of the athlete, is the desire to achieve Paralympic glory – and for us, the desire to see top-level competition.

This article was co-authored with Caron Jander, a consultant occupational physician affiliated with the Australian Paralympic Swim Team. Dr Caron Jander is an occupational physician who consults at MAG Head Office. She was the ParaOlmpian Team Doctor.