Traumatic Brain Injury Attorneys – TBI
Common Testing: Will it Help With TBI Diagnosis?
Diagnostic workup of individuals sustaining traumatic brain injury has evolved dramatically in certain areas (neuro-radiology being the foremost) and yet has remained extremely static in other areas (standard neurological examination).
Family members, as well as victims, often learn of various tests purportedly administered following traumatic brain injury. Whether the tests were administered in a given case, and whether positive results were found, may not conclusively establish, nor rule out, the existence of brain injury. Nonetheless, brief description of common tests follows:
Clinical Neurological Exam
Debatably, the clinical neurological examination is the least effective test for all but the most severe cases of traumatic brain injury. The usual clinical approach to the study of brain function is the neurological examination. This includes a study of an individual´s “behavior” which comprises responses and motor patterns.
The neurologist examines an individual´s reactivity, his/her strength, the appropriateness of the individual's reaction to commands, questions, and other inquiries, and challenges to muscle groups. The neurologist examines the body, in general, looking for evidence of brain dysfunction that maybe evidenced through atrophied muscles, or due eye or retina deformation. When looking at behavior, the neurologist looks at patterns in gross terms. In short, if the neurologist can´t “see it”, or “feel it”, the conclusion is often reached that “it does not exist”.
One need not be an expert in traumatic brain injury to understand the extremely limited benefit of a standard neurological examination in cases involving mild to moderate traumatic brain injury. In fact, most individuals sustaining mild to moderate traumatic brain injury have virtually normal findings on clinical neurological exam.
GlASGLOW COMA SCALE
Clinical Neurological Exam
Often times administered by EMT personnel or paramedics during ambulance transport from the scene of an accident, the Glasgow Coma Scale rates
- a patient´s ability to open his/her eyes;
- motor responses to verbal/painful stimulus;
- verbal responses.
Glasgow Coma Scale: Scale Response Chart
The Glasgow Coma Scale is also used to rate coma victims, and an individual´s response, or lack thereof, may correlate, especially in severe cases, to cognitive deficits. Where the patient´s consciousness has been compromised, the Glasgow coma scale has proved effective for determining severity of injury. As indicated earlier, however, problems can arise where the victim is found to be under the influence of either pain medication or alcohol at the time of administration of the test.
|Glasgow Coma Scale Response Chart|
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|Examiner’s Test||Patient’s Response||Score|
|Spontaneously||Opens eyes normally||4|
|Speech||Opens to loud voice command||3|
|Pain||Opens eyes to pain||2|
|Pain||Does not open eyes||1|
|Best Motor Response|
|Command||Follows simple commands||6|
|Pain||Pulls examiners hand away on painful stimuli (localizes source)||5|
|Pain||Pulls a part of body away on painful stimuli (withdraws)||4|
|Pain||Flexes body inappropriately to pain(abnormal flexion)||3|
|Pain||Decerebrate posturing (abnormal extension)||2|
|Pain||No motor response to pain||1|
|Speech||Converses – orientated||5|
|Speech||Speaks – confused disoriented||4|
|Speech||Talks but makes no sense||3|
Glasgow Coma Scale: Severity Classification GCS
When evaluating injury severity, a GCS range of 3 to 8 is considered severe, 9 to 12 is moderate and 13 to 15 is mild. Coma has been defined as occurring when the GCS is equal to or less than 8.
|Severity Classification GCS|
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|Mild||13 or above||or||less than 20 min.|
|Moderate||9 – 12||or||within 6 hours|
|Severe||8 or less||or||greater than 6 hours|
As indicated above, the GCS creates a score on a continuum ranging from a minimum of three to a maximum of 15 points. Presumably, an individual can have a mild traumatic brain injury and yet still score 15 on the GCS. This is why the American Congress of Rehabilitative Medicines definition of mild traumatic brain injury allows for a GCS of 13 to 15. The GCS has been criticized by many, therefore, is having much more efficacy in the diagnosis of moderate to severe traumatic brain injury then in the diagnosis of mild traumatic brain injury.
Studies show that patients with a lower GCS score show poorer prospects for recovery. This is another important use of the GCS. Not only is the GCS used to evaluate severity, but it is also used as a predicting tool to determine outcome. Moreover, it can be used repeatedly over time as a prognosticating tool.
A complement to the GCS is the Glasgow Outcome Scale (GOS). The GOS provides five levels for evaluating outcome. The first is that of death due to brain damage. Generally speaking this will happen 48 hours after injury. The second is persistent vegetative state (PVS). The third is described as severe disability, which implies consciousness though individuals are dependent for daily support. The fourth state is described as moderate disability, which implies that the patient is disabled but is independent. The fifth state is described as good recovery, which implies a resumption of normal life. Note that the fifth state does not prognosis a return to the competitive workplace, however.
Criticism of the GOS primarily emanates from its simplicity. Individuals often cannot be categorized within the five listed categories. Discussion has occurred over time within the health care profession of expanding the five categories to eight, but even with eight listed categories, criticism exists.
While the GCS has been universally accepted as a standard measure for determining severity of injury in patients whose consciousness is comprised, it also has some inherent problems. Mentioned above are problems where the patient has been sedated or where the patient has been anesthetized or were intubated as a result of injury. Where any type of medical treatment results in the patient being unable to talk (such as a tracheotomy), or where the patient is unable to move limbs as a response to pain, the GCS will obviously be limited.
Rancho Los Amigos Scale
Levels of Cognitive Functioning This scale describes levels of function and is used to evaluate the progress of a patient and rehabilitative development. Most often, the “Rancho scale” is used to track improvement, for evaluating potential, for planning and placement purposes, and to measure outcome and treatment effects.
In essence, the Rancho scale measures eight levels of cognitive function. The scale was primarily developed for use by rehabilitation staff, and contemplates a course of improvement following head trauma.
- The eight levels of cognitive functioning of the Rancho scale are as follows:
- No response: (such as where 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 of activity).
- 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 more severely or 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 post traumatic 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/spacial, 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. Tests that may be utilized by a neuropsychologist may include, among others, the following:
- Halstead-Reitan Battery;
- Halstead Russell Neuropsychological Evaluation;
- Repeatable Cognitive-Perceptual-Motor Battery (Lafayette Clinic Repeatable Neuropsychological Test Battery);
- Luri-Nebraska Neuropsychological Battery;
- Neuropsychological Assessment Battery;
- Kaplan-Baycrest Neurocognitive Assessment;
- Wechsler Intelligence Scales;
- Peabody Individual Achievement Test;
- The Kaufman Brief Intelligence Test;
- Wide Range Achievement Test;
- Woodcock Johnston Tasks of Cognitive Ability;
- Stanford-Binet Intelligence Scale;
- Iowa Screening Battery for Mental Decline;
- Assessment of Individuals with Cognitive Impairment;
- San Diego Neuropsychological Test Battery;
- Repeatable Battery for the Assessment of Neuropsychological Status;
- Cambridge Cognitive Examination;
- Mini-Mental Status Examination;
- Disability Rating Scale;
- Katz Adjustment Scale;
- The Mayo-Portland Adaptability Inventory;
- Beck Depression Inventory;
- Thematic Apperception Test;
- Rorschach Test;
- The Zung Self-rating Depression Scale;
- Million Clinical Multi-axial Inventory;
- Minnesota Multiphasic Personality Inventory (MMPI/MMPI-2);
- Personality Assessment Inventory;
- General Memory versus Attention/Concentration;
- Auditory-Verbal Learning Test;
- California Verbal Learning Test;
- Complex Figure Test;
- Recognition Memory Test;
- Memory Assessment Scales;
- Wisconsin Card Sorting Test;
- Paste Auditory Serial Addition Test (PASAT);
- Reaction Time (RT);
- Forced-Choice Test;
- Portland Digit Recognition Test;
- Hopkins Recall/Recognition Test;
- Test of Memory Malingering (TOMM);
- Validity Indicator Profile (VIP);
- Word Memory Test (WMT);
- Rey 15-Item Test;
Obviously, there are hundreds of additional tests which may, under the circumstances of an individual case, be utilized by an appropriate neuropsychologist. Counsel representing individuals with traumatic brain injury must be familiar with the general tests given, the test purpose, the test parameters, and the methodology employed in grading any such test.