LOVES Chiropractors In spite of their Manipulative Personalities Because they make adjustments for that CONCUSSION FACTS The CONCUSSION INJURY LAWYERS at the Schmidt Salita Law Team want you to know the following facts about concussion injuries that result from motor vehicle collisi ID: 930710
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Slide1
Slide2Schmidt Salita
Law Team
LOVES
Chiropractors!!!
Slide3In spite of their
Manipulative
Personalities!
(Because they make adjustments for that!!!)
Slide4Slide5CONCUSSION FACTS
The CONCUSSION INJURY LAWYERS at the Schmidt Salita Law Team want you to know the following facts about concussion injuries that result from motor vehicle collisions:
Concussions are Brain Injuries.
90% of concussions occur without a loss of consciousness.
Most Concussions occur without a direct blow to the head.
Most Concussion victims are not aware that they have suffered a Concussion.
Most symptoms of a Concussion do not appear immediately but instead progress in a period of 3-30 days after the initial incident.
37% of the victims of Car Accidents have suffered a concussion.
Over 60% of concussions resulting from car accidents are not reported and are not initially treated.
Slide6CONCUSSION FACTS
Studies show that over half of all concussion victims that report to an emergency room are misdiagnosed or overlooked.
Studies indicate that as many as 73% of concussion have long term effects.
Concussions can cause long term lifetime disabilities and health problems.
Post Traumatic Amnesia is considered a more important indicator of brain injury severity than LOC.
The existence of Post Traumatic Amnesia lasting more than 24 hours is an indicator of
moderate
, rather than mild TBI.
Slide7MODERN MEDICINE IS STILL IN THE DARK AGES REGARDING MILD TRAUMATIC BRAIN INJURY!!!
For decades, we have neglected the consequences of Traumatic Brain Injury. Only recently, have we awakened to Chronic Traumatic Encephalopathy (CTE) in professional football players.
We remain in the Dark Ages in
every other
Brain Injuries outside Pro Football.
60% of the victims of TBI in motor vehicle collisions are being grossly overlooked!!!
Slide8CONCUSSIONS- THE SILENT EPIDEMIC.
Concussions have been labeled as “the silent epidemic”- 4 Reasons:
The symptoms are often initially “silent”, not apparent for both the victim and medical providers,
The symptoms often are not unique to concussions/similar to other medical conditions.
Many concussion victims do not seek medical attention (est. 50%).
Concussions are often overlooked by medical providers, EMT’s and law enforcement.
Slide9CONCUSSIONS- HISTORICALLY OVERLOOKED FOR CENTURIES
5
th
century BC-
Hippocrates identified concussions as “Commotio Cerebri”.
1518-
Autopsy studies brains of concussion victims provided evidence of brain tissue damage.
1953-
Dr. Courville summarized centuries of neglect of medical evidence of concussions.
1982-
Blockbuster report of 3 eminent brain injury experts (Levin/Benton/ Grossman) reveals significant neurobehavioral consequences of concussion injuries.
1986-
National Head Injury Foundation finds
“gross neglect”
regarding minor head injuries. Publishes “introduction for Professionals”. Including CTE Knowledge.
2002-
Dr. Omalu “discovers” evidence of CTE in brain autopsy of “Iron Mike”.
2003-
CDC declares MTBI to be a
“public health problem, the magnitude and impact of which is grossly
misundestimated
”
Slide102005-
Dr. Omalu publishes his findings in the Journal of Neurosurgery. NFL and its doctors vigorously dispute.
2009
- The CDC published
“Heads Up: Facts for Physicians About Mild Traumatic Brain Injury”
is an attempt to educate the medical community about MTBIs.
2011-
Minnesota Concussion Law
recognizes that concussions are being overlooked in youth sports and passes a law requiring education and assessment.
2013- American Medical Society for Sports Medicine estimates 3.8 million concussions annually, estimated to be only 50% of actual.2016-
The NFL and its highly paid doctors finally “give up” fighting CTE and pay $1 billion in settlement to NFL players.
2017-
The Emergency Medicine Research Group declared that deficiencies place concussion patients at risk for suboptimal care and resulting long-term cognitive dysfunction.
2018-
The CDC Report to Congress on Management of Traumatic Brain Injury in Children recognized “
limited understanding
” of long-term effects of brain injuries “of any severity”.
Slide11TRAUMATIC BRAIN INJURIES ARE A MAJOR HEALTH PROBLEM.
The CDC (2017) announced
2.8 million
TBI-related Emergency Department and, hospital visits. (75% were concussions-so-called "mild" TBIs),
Emergency Medicine experts show that 60% of concussions are misdiagnosed in the ER. (Myers-62.6%; Powell-56%) That means there are
3.5 million!!!
Experts estimate that over 50% of concussion victims don’t seek ER care. If so, there are over
7 million
concussions every year!!!
Sports Medicine experts say there are 3.8 sports related concussions annually, the majority not treated in hospital or ER. (BIAA)
The cost to society is estimated at $76.5 billion per year.(BIAA)
Slide12A CONCUSSION IS A TBI
It is almost universally accepted that a
concussion is a mild TB/.
It is almost universally accepted that
"mild" is not mild.
mTBis
can result is severe consequences. Both in terms of disabilities and secondary health-related conditions.
Studies show that consequences of mild
TBls
are more serious than from moderate to severe TBIs.
Slide1390% of TBI’s ARE CONCUSSIONS
Smith (U of Penn. Med. School) says
90% of TBIs are concussions:
On a relative basis, the incidence of mild TB/far exceeds the number of TBI-related fatalities and moderate/severe TBI’s, with some estimates suggesting
its frequency is at least 10 times more common than moderate and severe TBI.
Perhaps equally important, comparing the prevalence of patients showing
long-term impairment from mild TBI
to other diseases, concussions equal
Breast cancer, MS, and traumatic spinal cord injuries combined.
Slide14THE “RECOVERY” MYTH
MYTH: The medical community proclaims that nearly 90% of concussions “recover”.
Lezak
says,
“
I do not use the term “recovery” when discussing brain injuries. Damage that is severe enough to alter the level of consciousness even momentarily, or to result in even transient impairment of sensory, motor, or cognitive functions, is likely to leave some residual deficit.”
Perhaps the most statistically reliable study has reported that:
- 73% of those with symptoms lasting 3 months never recovered.
-67% of those who recovered did so in the 1
st
year.
-100% of those with symptoms lasting 3 years did not recover.
The Brain Injury Association reports that concussion victims have serious long-term consequences with a reduced life expectancy of 7 years with the following increased risk factors:
Slide15-3 times increased risk of a second concussion and 8 times for a third.
-22 times greater risk of seizures, with onset delayed many years.
(37 times more likely to die from seizures)
-49 times more likely to die form aspiration pneumonia.
-2 times increased risk of Alzheimer’s and dementia.
-5 times increased risk of various psychiatric diseases, obsessive compulsive disorders, anxiety disorders, psychotic disorders, mood disorders and depression.
Concussion victims are at risk for:
Slide16THE LATEST DEFINITION OF CONCUSSION.
There has been much confusion and disagreement about the definition of concussion. The latest is from the expert group of the international interagency initiative toward common data elements for research on traumatic brain injury and psychological health, supported by the national institute of neurological disorders and stroke (NINDS), the Department of Veteran Affairs and other prestigious and well- respected international media groups.
Their definition was this: “TBI is defined an alteration in brain function, or other evidence of brain pathology, caused by an external force.”
Their definition was this:
“TBI is defined an alteration in brain function, or other evidence of brain pathology, caused by an external force.”
Slide17THE MINIMUM CRITERIA FOR A CONCUSSION.
It is important that any of these signs will establish the existence of a concussion:
Any period of loss of or decreased state of consciences.
Any loss of memory for events immediately before (retrograde amnesia) or after injury (post- traumatic amnesia)
Neurologic deficits (weakness, loss of balance, change in vision, dyspraxia, paresis/
plegia
(paralysis), sensory loss, aphasia, etc.)
Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.)
Slide18DELAYED ONSET OF CONCUSSION SYMPTOMS-
MYTH
: Concussion symptoms present immediately and get better over a short period of time.
TRUTH
: The symptoms of concussions often develop over 7-10 days (Mayo) or even after weeks and months.
Often the victim is unaware of the concussion and doesn’t realize the condition until the attempt to return to activity.
Often there is a delay between the trauma and the development of symptoms.
Leidner
-Mauer-Morneau-NFL players. One sports study showed that 65% of footballers were no aware that they had suffered a concussion.
A concussion involves a “
metabolic cascade
” that develops over time. NEEDS DESCRIPTION HERE
Slide19METABOLIC CASCADE
Brain injuries involve both a shearing and tearing physical injury AND a “
metabolic
cascade
” often
lasting for weeks
.
The cascade involves an initial period of accelerated glucose utilization followed by a period of depressed metabolism.
Persistent increases of calcium can impair
mitochrondrial
oxidative metabolism and worsen the energy crisis, possibly leading to cell death. The result can be a “
secondary injury
” to the brain due to a
single insult
, as distinguished from a “
second injury
” due to a
second insult
.
This is a principal explanation for the delay onset of concussion symptoms.
Slide20Slide21THE MINIMUM CRITERIA FOR A CONCUSSION.
That simple definition is fleshed out by the importance of these clinical signs that will establish the existence of a concussion:
Any period of loss of or a decreased LOC.
Any loss of memory for events immediately before (retrograde amnesia) or after the injury (posttraumatic amnesia).
Neurologic deficits (weakness, loss of balance, change in vision, dyspraxia, paresis/
plegia
(paralysis), sensory loss, aphasia, etc.)
any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.)
Source: Menon et al,
Position Statement: Definition of Traumatic Brain Injury
, Arch. Phys. Med.
Rehabil
., Vol 91, November 2010.
Slide22RIVERMEAD
Slide23PRE- EXISTING CONDITIONS
We all have “idiosyncrasies”. We are all “quirky”. Some of us are extroverts and some introverts. Some are hyper-active and some hypo-active. Some are by nature happy and some sad.
A concussion tends to exaggerate the basic personality traits of “normal” people-taking these traits to a pathological level.
Slide24COMORBIDITIES
Cervical Spine Injury
: A concussion is a “whiplash of the brain”-occurs with a “whiplash of the cervical spine”. Best evidence of the severity of the brain whiplash is the evidence of the severity of the cervical injury-not the car damage.
Why do some concussions resolve and others become chronic, i.e. Post Concussion Syndrome with lasting effects? Theory: Chronic cervical pain, with symptoms of headaches and dizziness common to cervical injuries, interferes with the normal recovery process. See
The Role of the Cervical Spine in Post-Concussion Syndrome
.
2.
Post Traumatic Stress Disorder
: Studies show that Post Concussion Syndrome (PCS) and Post Traumatic Stress Disorder (PTSD) occur in combination with each other in ???? % of cases.
3.
Prior Concussion History
: The victim of a second concussion is 3 times more likely to have another. The 3
rd
concussion victim is 8 times more at risk.
4.
Prior /Current Migraine History.
5.
Prior/Current ADHD.
6.
Prior Emotional/Psychiatric Conditions.
Slide25DC SAFETY NET
The American Chiropractic Association says ,
“(Doctors of Chiropractic) can assume a major role in evaluating, diagnosing, and treating concussions, particularly head injuries that affect the spine and related extremities.
Chiropractic physicians should pursue education and credentialing offered online at HEADS UP, Brainline.org and BrainlineMilitary.org. Chiropractic colleges should provide postgraduate education and training, preparing chiropractic physicians to evaluate and manage patients with concussions and mild traumatic brain injuries.”
Slide26DC SAFETY NET
Reasons why Doctors of Chiropractic are in a special position to diagnose and treat concussion injuries:
1. DC’s typically see the patient after the symptoms have progressed and fully developed.
2. DC’s see that patient after the initial mental confusion has subsided and a more reliable history can be taken.
3. DC’s typically have a longer and more intimate relationship with the patient than the ER doctor’s 3-5 minutes cursory exam.
4. DC’s typically spend more time than the ER doctor.
5..DC’s have a better appreciation and understanding of the common connection between the cervical injury and the brain injury.
Slide27SCOPE OF PRACTICE
An ignorant few DC’s question whether diagnosis and treatment of concussion injuries falls within the scope of practice. They need to go back to school.
See American Chiropractic Association publication “
Mild Traumatic Brain Injury and Concussion
”
See
Position Statement on Sports Related Concussion in Athletics
, American Chiropractic Board of Sports Physicians (2014)
See
The Role of the Cervical Spine in Post-Concussion Syndrome
, Physician and Sports Medicine (2015)
A study showed that chiropractic students outperform medical students in concussion knowledge and understanding. See
Concussion Assessment and Management Knowledge Among Chiropractic Fourth Term Interns and Residents
, J. Can. Chiro. Assoc. (2016) 60(4);273-285
Slide28CAREFUL HX IS
VITALLY IMPORTANT
The history from a concussion victims is very important, yet very challenging. These pointers are important:
Patient’s recollection of LOC is usually wrong.
Duration of Post Traumatic Amnesia is extremely important-more so than the duration of LOC!
Patient’s cannot be expected to recognize and report the symptoms of concussion.
A careful, searching “close your eyes” history is important.
Slide29TREATMENT
Diagnosis/Recognition
: The majority of researchers acknowledge diagnosis/recognition as an important component of the treatment of any concussion injury. Without that, the patient experiences psychological trauma. “What is happening? Am I going crazy?”
2.
Removal from Stress
: Many respected experts proclaim that removal from stressful activities plays a very vital role in the recovery process.
Sleep Monitoring
: Sleep is good but not too much.
4. Treatment of the Individual Symptoms
: Post Concussion Syndrome is generally recognized as a “collection” of symptoms that need to be treated individually.
A. Treatment of the chronic pain;
B. Treatment of Sleep Disorder;
C. Speech/Memory Therapy;
D. Vision Therapy.
E. Psychological Therapy.
Slide30SCREENING TOOLS
The
SCAT5
-This is a standardized tool for evaluating concussion which is designed for use by physicians and licensed professionals which requires a minimum of 10 minutes in order to be correctly performed. It was developed by the Concussion in Sport Group to be used primarily with regard to sports-related concussions. It is considered a reliable screening and diagnostic tool.
The
ACE
-The Acute Concussion Evaluation (ACE) is a tool for medical providers which is recommended by the Center for Disease Control and Prevention to preliminarily assess for concussion injuries. It comes in two forms, one for use in emergency medicine and the second for use in primary care.
The
ImPACT
-The Immediate Post-Concussion Assessment and Cognitive Testing (
ImPact
) is a computerized assessment tool designed primarily for use in the sports training world. This system utilizes baseline testing which allows for a comparison of the victim’s pre-injury level of function to be compared against the immediate post-concussion level of function.
Slide31ICD 10 CODES FOR CONCUSSION
BASIC CODING FOR CONCUSSION/MILD TRAUMATIC BRAIN INJURY
S06.0x0 Concussion without loss of consciousness
S06.0x0 Concussion with loss of consciousness of 30 minutes or less
S06.0x0 Concussion with loss of consciousness of 31 to 59 minutes
S06.0x9 Concussion with loss of consciousness of unspecified duration
R 41.0 Post traumatic confusion/disorientation
R 41.1 Post traumatic amnesia-Anterograde
R 41.2 Post traumatic amnesia-Retrograde
R 41.840 Posttraumatic attention and concentration deficit
G 44.3. Post-traumatic headache
R42 Post-traumatic dizziness/giddiness/vertigo
Note: Loss of consciousness and amnesia can only be accurately determined by a carefully and searching history, using the “Close your eyes and think back” technique.
Slide32ICD 10 CODES FOR CONCUSSION
BASIC CODING FOR CONCUSSION/MILD TRAUMATIC BRAIN INJURY
R11 Post-traumatic nausea and vomiting
R26.81 Balance difficulty/unsteadiness
H93.11 Post traumatic tinnitus-right ear
H93.12
Post
traumatic tinnitus-left ear
G 47 Post traumatic sleep disorder
41.840 Post traumatic cognitive dysfunction- attention/concentration deficit
R 41.842. Vision problem-Visuo-spatial deficit/blurred vision/double vision/convergence deficit
F43.23 Anxiety/depression
R45.4 Irritability
G47.9 Sleep disturbance
R45.1 Agitation
R25.9 Involuntary movement/dystonia
Slide33Slide34Slide35The Chiropractic Safety Net-Help Is On The Way!!!
Slide36