Brain Injury
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DIAGNOSING A TRAUMATIC BRAIN INJURYSan 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 situations.
Clinical Neurological Exam
Research suggests that clinical neurological exams are the least effective tests for accurately diagnosing brain injuries. Simply put, the clinical approach to TBI studies the victim’s responses to motor patterns, his / her “behavior.” This approach also involves a general examination of the victim’s body, which can reveal evidence of brain dysfunction.
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 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 and severe.
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.
Glasgow Outcome Scale (GOS)
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 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.
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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).
Oxford Test
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
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.
How Neurological Testing Works
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.
Approaches to Neurological Testing
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.
Assessment Batteries
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.
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