Diagnosing a Traumatic Brain Injury
San Francisco Brain Injury Lawyer
Diagnostic testing for brain injury victims has evolved in some areas,
such as neuroradiology, and remained stagnant in others, such as standard
neurological examinations. Unfortunately, standard testing doesn’t
always lead to an accurate diagnosis, but it can prove beneficial in other
Clinical Neurological Exam
Research suggests that clinical neurological exams are the
least effective tests for accurately diagnosing brain injuries, especially severe cases. Simply put, the clinical approach to TBI studies
the victim’s responses to motor patterns, his / her “behavior.”
This might include a person’s strength and reaction to questions
and commands. This approach also involves a general examination of the
victim’s body, which can reveal evidence of brain dysfunction.
The problem with this approach is it assumes the injury does not exist
if the examiner cannot see or feel it. Sadly, the limited benefits of
this approach often neglect to diagnose persons suffering from mild to
moderate TBI. In fact, clinical neurological exams can yield “normal”
results for these individuals; however, the physical consequences and
side effects of a mild / moderate traumatic brain injury can be long lasting
Who administers the test? In most cases, paramedics or EMT personnel give clinical neurological exams.
The test may occur during ambulance transport. Often, results are measured
by the Glasgow Coma Scale, which identifies the victim’s ability
to open his / her eyes, respond to stimulus, and respond to verbal communication.
Glasgow Coma Scale Ratings
The Glasgow Coma Scale rates an individual’s ability to respond and
is designed to identify cognitive deficits. If the patient’s consciousness
is affected, the scale can determine the severity of the injury. Certain
factors, such as intoxication or medication can influence the accuracy
of the test.
GSC Severity Classification:
- Severe (3 – 9)
- Moderate (9 – 12)
- Mild (13 – 15)
The GCS creates a score between 3 and 15 points. In short, a lower score
means a severe injury. According to studies, individuals who score higher
on the GCS are more likely to recover fully. In fact, medical professionals
may repeat the GCS test throughout rehabilitation to gauge the patient’s
progress and projected recovery. To estimate recovery, doctors may accompany
the GCS with the Glasgow Outcome Scale (GOS).
The GOS provides five possible outcomes to a traumatic brain injury:
- Death (usually within two days of the accident)
- (PVS) Persistent Vegetative State
- Severe Disability
- Moderate Disability
- Good Recovery
Problems with the GCS / GOS
The GCS and GOS may be useful, but cannot always predict the extent of
an injury or the outcome of a recovery. An individual with a projected
“good recovery” according to the GOS may not be able to return
to work, for example. Additionally, the GCS is not helpful in situations
where the patient is sedated.
Rancho Los Amigos Scale
The Rancho Los Amigos Scale evaluates the patient’s progress during
recovery. Also called the “Rancho Scale,” this test categorizes
patients into eight levels of cognitive function:
No response - the patient is in a deep coma
Generalized response - inconsistent reaction and non-purposeful response to stimuli
Localized Response - inconsistent though specific reaction to stimuli or even following simple commands
Confused-Agitated - patient has decreased ability to process information but is in a heightened
state of activity
Confused, Inappropriate, Non-agitated - patient is able to respond fairly consistently to simple commands and
appears alert, though with increased complex city of commands a fragmented
response is shown
Confused-Appropriate - goal-directed behavior is evident but the patient is dependent on assistance
Automatic-Appropriate - within the hospital and home settings the patient is oriented and able
to follow a daily routine with minimal confusion but has shadow recall
Purposeful and Appropriate - patient is alert, oriented, recall is intact, and patient is aware of
responsive to environment
Criticism of the Rancho Scale is that the scale is not sensitive to differences
in levels of vocational potential and, as above, this scale implies a
similar rate of improvement for different kinds of functions which may,
or may not, be the case in each individual´s recovery.
Galveston Orientation and Amnesia Test (GOAT)
Clinicians most often use the GOAT to assess severe and moderately impaired
patients. In essence, this test is a short mental status examination.
It can be repeated as with the GCS. The vast majority of the questions
on this test involve whether the patient is oriented as to time, place,
and person. Two questions deal with anterograde and retrograde amnesia.
The GOAT is used to predict ultimate recovery in a patient and is also
used as an indicator of level of responsivity. The measurements obtained
using the GOAT questions dealing with anterograde and retrograde amnesia
establishes the relationship between severity of injury (GCS), and a patient's
long-term outcome (GOS).
This test was designed for measuring the duration of posttraumatic amnesia
and tests memory, demographics, and orientation. Each day, the patient
is tested as to his/her memory and ability to recall and recollect. When
the patient is able to score a perfect score 3 days in a row, the test
is concluded. Different scales have evolved out of the Oxford Test. Different
scales can be used to determine recovery and duration, thereby charting
improvement on different components of orientation and memory.
Neuropsychological testing is the
sine qua non for modern diagnostics of brain injury. It is proven reliable, accurate,
and unlike other testing and evaluative mechanisms, which compare patients
with the so-called "normal person", neuropsychological testing
evaluates whether a particular patient has himself/herself changed.
The rationale for this distinction is easily enunciated: As an individual
grows and matures, s/he develops and utilizes the most efficient pathways
in the brain. When traumatic brain injury occurs, many times those pathways
are severed or unable to properly transmit or receive information. Methods
of learning and behaving are altered. While this individual may still
be within the normal population range, s/he would surely be outside their
individual "pre-injury" range.
Neuropsychological testing allows competent professionals to reach the
conclusion, to a reasonable degree of scientific probability, that organic
brain injury has occurred. It further allows the professionals to pinpoint
areas of deficit, be they visual/spatial, memory, recall or other. Simply
put, neuropsychological testing is the most important testing most "mild"
to "moderate" traumatic brain injury patients will undergo.
Neuropsychological assessment is a method of validation, which measures
the ability of the nervous system to perform cognitive functions we minimally
need to exist. It measures compromise of functions against pre-morbid
capabilities. Neuropsychologists are psychologists with specialized training.
Neuropsychological assessment is an interface between science and practice.
A current debate in the field of Neuropsychology focuses primarily on approach.
Many neuropsychologists advocate the quantitative approach utilizing the
so-called "non-flex" Halstead-Reitan battery of testing. Still
others advocate the "flexible battery" approach. Statistical
accuracy is the issue. In a 2000 survey, it was found that only 15% of
the neuropsychologists surveyed used a fixed battery (the Halstead Reitan
or Lurie-Nebraska batteries).
Clearly, there are advantages and disadvantages to use of either a fixed
battery or a flexible battery approach. Utilization of a non-flex battery
can reveal objective data in as much as it is gathered without subjective
influence and all scores are subjected to the same variables. However
a fixed battery does not allow the clinician the freedom to address specific
diagnostic problems. The flexible battery does give the clinician the
opportunity to individually test and assess for certain problems which
may be present though missed under the non-flex approach.
Irrespective of approach, neuropsychological assessment is essential to
the proper diagnoses and treatment of most victims of traumatic brain
injury. Neuropsychological assessment batteries are utilized in order
to obtain an accurate diagnoses of the individual (though with the improvement
of neuro- imaging, discussed below, utilization of assessment batteries
for diagnostic purposes is not as important today as it was in the past).
Primarily then, neuropsychological assessment batteries are utilized in
order to obtain and determined a functional assessment of the particular
patient. Numerous formalized batteries have been developed for general
use while others were "personalized" to assess a specific need.
There are literally thousands of tests available to the neuropsychologist
depending upon the issues faced. In essence, it is the incumbent upon
the neuropsychologist to derive a battery that provides for an examination
appropriate to the given patient.
Proven Experience Handling Brain Injury Lawsuits
The San Francisco brain injury lawyers at Scarlett Law Group have recovered
multi-million dollar results for our clients. If someone you love is the
victim of an avoidable, catastrophic accident, contact our office today
for the legal guidance you need. Schedule a free case evaluation today.