ican Association of Neuropathologists de- scribes this condition as a progressive dis- order.4


Widespread news reports of this


finding have helped to raise public aware- ness of the potential consequences of con- cussions or MTBIs.


Centers for Disease Control: Comprehensive Study of TBI


The third development has emerged from the work of the U.S. Department of Health and Human Services’ Centers for Disease Control and Prevention (CDC). When Con- gress passed the Children’s Health Act of 2000, the legislation included instruc- tions requiring the CDC to focus attention on MTBI. As a result, the CDC formed the Mild Traumatic Brain Injury Working Group, composed of leading experts in the field. The Working Group has published sever- al guidelines (which have been periodical- ly updated) for physicians, patients, and coaches, and in 2003, it provided an ex- tensive report to Congress. (The most re- cent guideline, published in 2012, is titled “Returning to School After a Concussion, A Fact Sheet for School Professionals.”) This information is publically available on CDC’s website.5


Both the CDC and Defense Department findings have a high degree of credibility, since they are endorsed by respected fed- eral agencies. The CDC’s conclusions and recommendations are particularly valuable for both TBI victims and their representa- tives. The following contents from the CDC publications are particularly relevant to the many TBI victims with symptoms like those I described above:


• “In recent years, public health and health care communities have be- come increasingly aware that the con- sequences of mild traumatic brain in- jury (MTBI) may not, in fact, be mild. Epidemiologic research has identi- fied MTBI as a public heath problem of large magnitude, while clinical re- search has provided evidence that these injuries can cause serious, last- ing problems.”6


• “A concussion is a brain injury. All con- cussions are serious. Concussions can occur without loss of consciousness or other obvious signs.”7


• “Some symptoms may appear right away, while others may not be noticed for days or months after the injury, or until the person starts resuming their everyday life and more demands are placed upon them.”8


• “MTBI is caused by a blow or jolt to the head that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging find-


www.vtbar.org


ings, i.e., CT Scan, MRI. MTBI results in a constellation of physical, cogni- tive, emotional and/or sleep-related symptoms and may or may not involve loss of consciousness.”9


• “Unlike more severe TBIs, the distur- bance of brain function from MTBI is related more to dysfunction of brain metabolism rather than to structural injury or damage. The current under- standing of the underlying patholo- gy of MTBI involves a paradigm shift away from a focus on anatomic dam- age to an emphasis on neuronal dys- function involving a complex cascade of ionic, metabolic and physiologic events. Clinical signs and symptoms of MTBI such as poor memory, speed of processing, fatigue, and dizziness re- sult from this underlying neurometa- bolic cascade.”10


• “Diagnosing MTBIs can be challeng- ing as symptoms of MTBI are common to those of other medical conditions (such as post-traumatic stress disor- der [PTSD], depression, and headache syndromes), and the onset may occur days or weeks after the initial injury.”11


• “Research indicates that up to 90% of concussions do not involve Loss of Consciousness”12


• “Physicians should be aware that symptoms will typically worsen or re- emerge with exertion.”13


• “Sometimes people do not recognize or admit that they are having prob- lems. Others may not understand why they are having problems and what their problems really are, which can make them nervous and upset.”14


• “In general, recovery may be slower among older adults, young children and teens. Those who have had a con- cussion in the past are also at risk of having another one and may find that it takes longer to recover if they have another concussion.”15


Mild Traumatic Brain Injury Defined CDC’s Report to Congress recommend-


ed a conceptual definition of MTBI, drawn in large part from the American College of Rehabilitation Medicine (ACRM). It is simi- lar to the definition adopted by the World Heath Organization (WHO). This definition plays a key role in most MTBI cases. Al- though it is reasonably clear on its face, as I will discuss, it can be challenging to apply in many cases because of imperfect informa- tion. The definition is as follows:


[A]n injury to the head as a result of blunt trauma or acceleration or deceleration forces that result in one or more of the following conditions:


Any period of observed or self-report- THE VERMONT BAR JOURNAL • SPRING 2012 13


Proving a “Mild” Traumatic Brain Injury


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