1. Outcome of Mild Head Injury and Persistent Post-concussion Syndrome

2. Brain Injury and Law Worker’s Comp Law Tort of Emotional Distress
Worker must demonstrate injury or disability that arises out of and during the course of employment and is accidental
Need to establish physical or mental stimulus (e.g., extreme stress) that causes the mental injury
Sometimes hard to determine whether there was a preexisting condition
Tort of Emotional Distress
Relies on judicial proceedings exclusively, rather than administrative decision-making
Case law vs. statutory law
Damages set by a jury, rather than fixed schedule

3. Mild TBI and Forensic NP
Mild TBI most common type of case seen by forensic NP in personal injury setting (torts)
Many cases of mTBI or post-concussion syndrome don’t show acute injury characteristics consistent with TBI
mTBI refers to alteration of ongoing mental processing either due to loss of consciousness (59mins or less) or post-traumatic amnesia (not beyond 24hrs)
For non-complicated mTBI, expect full NP recovery ~3mo post-trauma
Larrabee & Rohling, 2013

4. Post-concussion Syndrome
Cluster of sx including:
memory/concentration difficulty
headache
vertigo
depression/anxiety/irritability/fatigue
blurred vision/photophobia
hyperacoustism
Cause is controversial
Cerebral dysfunction vs. psychogenic origin
Now more commonly seen as somatoform-esque
Incidence is unrelated to severity of injury or NP status
Issue is lack of specificity of PCS sx bc they tend to occur in everyday life
Mitterberg et al., 1992

5. Post-concussion Syndrome
Mittenberg et al. (1992) asked pts with TBI & healthy controls (who imagined they had a TBI) what symptoms they experienced/expected 6 mo following an injury
Number of sx TBI pts reported wasn’t significantly different from what controls expected
Headaches and visual difficulties were expected more often than they occurred
Irritability, fatigue, and difficulty with memory occurred more often than controls expected
However, there was a tendency of TBI to attribute premorbid sx to TBI
Mitterberg et al., 1992

6. Financial Incentives after Head Injury
Controversy in the field about whether financial incentives maintain disability and symptoms after closed-head injury
Mild head trauma w/post-concussion syndrome (PCS) has been called “compensation neurosis” that clears after settlement of litigation
Binder & Rohling, 1996

7. Financial Incentives after Head Injury
Meta-analysis of financial incentives on disability, symptoms, and objective findings
Reviewed 17 articles, total of 2,353 individuals
Found overall moderate effect size (0.47)
^ report of abnormality and disability in patients with financial incentives, even with less severe injuries
Monetary incentives are more powerful for mild TBI
Findings suggest that considering secondary gain is important in an NP eval, especially for mild TBI
Binder & Rohling, 1996

8. So What Symptoms are Legit?
Factors that can affect sx:
Severity of injury (e.g., length of coma, nonreactive pupils, mass lesions, CNS complications)
Time from injury to testing
Patient’s personal characteristics (e.g., mood, personality)

9. mTBI Post-Injury Outcomes
At one week post-trauma: domains with greatest effect size were WM, verbal and visual learning/memory
At 93 days: only WM was significantly different from 0
Larrabee & Rohling, 2013

10. NP Outcomes at 1-Year Post Injury
Head injuries requiring hospitalization are associated with NP impairments at 1-year post injury
Significant dose-response relationship
No one value or range of Impairment Index that can classify all TBI
Impairments are shifted about 25%ile points down from GT controls
Selective impairments in attention and memory start to emerge as head injury increases in severity
With ^ severity, most domains become affected
More reliable differences noted on measures like Finger Tapping, PIQ, and overall NP performance, rather than attention or memory only
Significant NP impairment due to a mild head injury is very unlikely
Dikmen et al., 1995

11. Should we be more stringent about test procedures to discriminate potential psychogenic PCS vs. organically-based PCS?
(e.g., should NP testing or trials for compensation only be done after 1-year, etc.)

12. Dangers of Incorrectly Diagnosing Impairments
Self-fulfilling prophecy
Patients believe they are incapable of getting better or lack control over progress
Potential mistreatment
Expensive or labor-intensive treatments that are unnecessary
Unnecessary management services
Bauer, 1997

13. Relevance to Forensic NP
Clinical eval of mental injury similar in torts and WC
Aside from assessing whether there is an injury, need to understand whether it was due to work or a result of the action by the defendant; also, need to comment on prognosis

14. “Deadly Sins” of Forensic NP in Brain Damage Cases (According to Dr
“Deadly Sins” of Forensic NP in Brain Damage Cases (According to Dr. Bauer in 1997)
It’s elementary
If a test result is abnormal, must mean the
person has brain damage
What you see is what you get
- Ecological validity of NP tests
3. Two deficits are worse than one
Taking each domain as an independent sample of
behavior; failing to interpret the overall pattern
4. All people are created equal
- All people should fall ≥ average

15. “Deadly Sins” of Forensic NP in Brain Damage Cases (According to Dr
“Deadly Sins” of Forensic NP in Brain Damage Cases (According to Dr. Bauer in 1997)
5. The proof is in the pudding
If neuroradiological evidence is absent,
just means NP is more sensitive
6. One man’s ceiling is another man’s floor
All NP data are subject to interpretation of the professional
7. You can use a wedge to putt from the fringe, as long as you blade it correctly
NP tests can be applied in all settings and whoever can administer/interpret
8. If the patient complains, it must hurt
All info that the patient reports must be true

16. “Deadly Sins” of Forensic NP in Brain Damage Cases (According to Dr
“Deadly Sins” of Forensic NP in Brain Damage Cases (According to Dr. Bauer in 1997)
9. What I don’t know won’t hurt me
NP data and interview are enough to infer past functioning
10. It’s all in the name
You can tell what a test measures by looking at its name
Three words to remember:
localization, localization,
localization
Every test has its own special location
in the brain