This case involves a 49-year-old male biomedical engineer who was involved in a serious multi-car crash during a storm. At the time of the accident, the engineer was the driver and was not wearing a seatbelt. The engineer’s car was slammed into by another car and the engineer hit his head on the windshield. Following the accident, the engineer was diagnosed with a mild traumatic brain injury and required the care of various providers for physical and cognitive impairments. The engineer sought treatment for his traumatic brain injury from “non-traditional” specialists including chiropractors, acupuncturists, and massage therapists. He attempted to return to work various times following the car accident, but according to family and co-workers, he could not perform his tasks at the pre-injury level, struggling with memory, focus, and vision. He has been unable to work because of the neurological injuries from the car accident and remains on disability.
Question(s) For Expert Witness
- 1. How often do you diagnose and treat patients with TBI who have been treated by "non-traditional" specialists?
- 2. What are some "non-traditional" treatments for TBI? In your experience, what has the effect of "non-traditional" therapy been on patients?
- 3. What are potential cognitive impairments that can occur as a result of a TBI, both permanent and transient?
Expert Witness Response E-197529
I am able to evaluate cognitive disorders in individuals with a history of TBI. I have worked in a TBI acute care rehab unit, full-time for 9 years and have worked with around 200-300 patients with mild to severe TBI, as well as with their families. I have run group therapy for TBI patients and their caregivers for two years. Additionally, I have done psychotherapy/behavior management and psycho-education in private practice with post-acute TBI patients for 5 years. I have evaluated dozens of patients with TBI related cognitive impairment. I have spoken at professional conferences about TBI, and numerous other cognitive issues that arise in neuropsychological evaluations. A wide variety of cognitive and personality and behavioral changes are possible following moderate to severe TBI. Attention processing speed and executive functioning disorders, as well as disinhibited behavioral changes, are common but do not at all sum up the difficulties that can be seen. I do not know much about alternative treatments for TBI except that some exist (e.g., computerized cognitive remediation) and the research on their effectiveness is inconsistent. I do not know anything about the relationship between acupuncture and improvement in TBI. I could review what literature exists, but I suspect there is not much quality research to show efficacy except as these treatments can improve mood disorders that may accompany TBI. If the term mild TBI is being used synonymously with “concussion,” then I think the likelihood of ongoing cognitive impairment at this point in time is low. When individuals with concussion/mild TBI report complaints a year or more later it is typically due to emotional factors such as anxiety or a personal secondary gain. It is worth evaluating and reviewing the record carefully, to be fair, but typically concussion symptoms resolve within 4-12 weeks. If there is evidence of bleeding on imaging and/or loss of consciousness and post- traumatic amnesia, it is more likely that ongoing cognitive concerns could exist. I would need to review the medical records at the time of and immediately following the initial injury and perform an IME. I have performed IMEs confidently on individuals with TBI histories.
Expert Witness Response E-029894
I have conducted several hundred evaluations of individuals with TBI over the years, many of whom also pursued treatment with non-traditional specialists. Typical cognitive impairments following TBI include: Memory encoding and retention, sustained attention and processing speed, as well as the executive functioning and cognitive flexibility. As to whether these cognitive impairments are transient or permanent, this tends to be very idiosyncratic and depends on things like the severity of the injury, premorbid characteristics of the individual affected (i.e. age, education level, and others), and time since the injury. I have found that it is not uncommon for individuals to seek out non-traditional treatment, as it is often helpful in addressing particular post-TBI symptoms. Chiropractic treatment and massage therapy are commonly used. In my experience, these non-traditional treatments can be effective in treating particular symptoms following TBI, though they cannot address all the problems that individuals usually have following such injuries. I was recently involved in running a clinical trial that used a nutritional supplement that effectively addressed some TBI symptoms. I am able to perform an IME on the patient, and I have seen a number of similar cases.