Jury Still Out On After Effects of Concussionby Lindsay Myers, MBA, MPH | May 14, 2014
Controversy surrounding Postconcussion Syndrome (PCS) dates back to the 1800s. 150 years on, contention still surrounds the lingering symptoms of insomnia, dizziness, irritability, depression, cognitive impairment and so on that affect between 30 and 80 percent of Americans following a mild traumatic brain injury (mTBI), or concussion.
The present day billboards of personal injury attorneys seeking auto accident victims as clients hark back to the late 19th century, when railways became a popular means of travel. During that time, railway accidents, and the number of physicians reporting on conditions such as “Railway Spine”, increased dramatically. Present day conditions of PCS and whiplash present similar symptoms, with etiology that is still the subject of debate. With billions of dollars of claims at stake, courtroom adversaries can pick and choose from a range of conflicting studies and theories.
In his book Post-Traumatic Neurosis, physician Michael Trimble notes that:
“In the nineteenth century and before, legal cases involved with personal injury were mainly to do with material injuries, such as loss of a limb or an eye, where objective evidence was unmistakable and quantifiable. With the advent of ‘concussion of the spine’ the situation changed, and the concept that the injured were victims of at best ‘shock’ and at worst spinal anaemia or meningitis became prevalent.”
In the late 1800s, the dominant theory involved organic lesions of the spine and brain. London surgeon John Eric Erichsen gave famous lectures in 1866, later republished in book format in 1875 as On Concussion of the Spine: nervous shock and other obscure injuries of the nervous system in their clinical and medico-legal aspects, in which he opined:
“The primary effects of these concussions or commotions of the spinal cord are probably due to changes in its structure. The secondary are mostly of an inflammatory character, or are dependent on retrogressive organic changes, such as softening, etc., consequent on interference with its nutrition.”
This view was challenged in the 1880s by London and Northwest Railway surgeon Herbert Page, who asserted that one of Erichsen’s spinal concussion cases was potentially suffering the effects of syphilis instead, and pointed to a lack of post-mortem data in the majority of spinal concussion cases. Dr. Page proposed that fear and shock played a role, suggesting psychological rather than organic causes in the large number of people who had been in relatively minor accidents yet remained symptomatic afterwards.
Among the many train crash victims was Charles Dickens, famous author of A Tale of Two Cities, A Christmas Carol, and Great Expectations. Dickens’ carriage did not go over the bridge, but was too close for comfort, dangling. He described “two or three hours work afterwards around the dead and dying surrounded by terrific sights”. Dickens suffered from symptoms including weakness and anxiety and being “not quite right within,” which he attributed to “the railway shaking.”
Later, Oppenheimer moved from the theory of “Railway Spine” to “Railway Brain”, like Erichsen attributing symptoms to an organic cause. Pioneering French neurologist Charcot suggested manifestations of hysteria instead. After World War II, as cars became popular, whiplash injuries multiplied, resulting in similar clusters of symptoms.
The Present Problem
According to the CDC, there were 2.5 million emergency room visits, hospitalizations, or deaths associated with traumatic brain injury, the majority of which were concussions, or “mild TBI”, in 2010. These numbers are understated, as they do not include those head injuries which did not involve a trip to the hospital. While causes vary and include falls, auto accidents, assault, occupational accidents, and sports, some of these, such as auto or occupational accidents, result in litigation.
Injury claims in the U.S. cost billions of dollars each year. Veronique de Rugy, a senior research fellow at George Mason University’s Mercatus Center indicated that despite medical advances which allow people to remain on the job, the number of Americans claiming disability has increased more than 6 fold.
Her report points to the fact that changing standards put more weight on self-reported pain and discomfort. Auto accidents follow a similar trend where the cost of claims is rising while the overall severity of injuries is declining.
The Coalition Against Insurance Fraud estimates that fraudulent claims cost $80 billion per year in the U.S. In a litigious society with so much money at stake, plaintiffs are often portrayed negatively by the media. In particular, those who are injured in ways that are not obviously disfiguring frequently are subject to great scrutiny and accusations of fraud. Types of fraud can include malingering, falsely assigning real symptoms to a compensable cause, or misrepresentation of diminished capacity following injury.
Diagnosis of PCS depends largely on self reporting. An observed loss of consciousness is not necessary, and common symptoms such as headache, irritability, loss of memory and the ability to concentrate, dizziness, and sensitivity to noise or alcohol do not lend themselves to objective, verifiable measurement. Some of these complaints are also highly prevalent in the general population.
Some explanations allow for the legitimacy of reported symptoms, while largely dismissing organic causes. Instead, other theories offered include psychogenic causes. Symptoms such as insomnia, dizziness, headache, and cognitive impairment can overlap with depression, anxiety, and post-traumatic stress disorder (PTSD). Studies have found premorbid depression common to almost half of those who develop PCS. Another study found that mild TBI was not a risk factor for PCS after adjusting for PTSD and depression. PTSD was found in other research to be the strongest predictor of PCS. (PTSD could also offer an explanation for what Dickens described following the train wreck).
Studies have found a link between persistent PCS and potential financial compensation. Evans reports that “on neuropsychological testing, there is a dose-response relationship between an increasing amount of potential compensation and an increasing rate of failure on malingering indicators, particularly in those who have suffered only mild TBI.”
Lithuania served as a testing ground, chosen for the fact that compensation for post-traumatic headache is unlikely there, and because the general population has fewer “expectations of persisting symptoms than in a Western society.” Among emergency room patients with mild headache injuries and loss of consciousness not exceeding 15 minutes, headaches disappeared within a month for the overwhelming majority of Lithuanian subjects- 96 percent of respondents. However this does not necessarily prove that American plaintiffs with PCS are faking.
Litigation Response Syndrome
While prospective studies of emergency room patients in other countries on the surface appear to support non-organic etiology, it is worth noting that studies of neurasthenia have found that cultural factors can influence the manifestation of clinical symptoms. Additionally, a group of stress problems known as Litigation Response Syndrome have been described, the symptoms of which mirror PCS.
People can become “so terrified and emotionally traumatized by the litigation that they appear to have mental disorders,” explains expert Paul Lees-Haley. When plaintiffs are followed by insurance investigators, subjected to intrusive depositions and compulsory medical exams conducted by strangers, must hand over their private medical records to insurance company employees, and are constantly bombarded with medical bills and legal documents, symptoms such as stress, insomnia, anxiety, and dizziness may ensue, but not be attributable to the actual injury.
However, since the litigation, and therefore the symptoms, did not occur prior to the injury, patients could reasonably believe that the injury caused the symptoms. This is also a plausible explanation for why these symptoms are so persistent in U.S., but not in places like Lithuania where litigation is less common.
Due to the subjective nature of the symptoms associated with PCS, and the substantial overlap with highly prevalent psychiatric and medical conditions such as headaches and depression, it is unlikely that the debate will be fully resolved in the near future. Research has increased as a result of the return of veterans with brain injuries and PTSD as well as increased awareness of sports related concussions, which should result in more refined studies of specific subsets of the population with PCS symptoms.
De Rugy, V. (August 7 2013). Social Security Disability Costs are Exploding. The Washington Examiner.
Evans RW (2010). Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: the evidence for a non-traumatic basis with an historical review. Headache, 50 (4), 716-24 PMID: 20456159
Lees-Haley, P.(1989). Litigation Response Syndrome: How Stress Confuses the Issues. Defense Counsel Journal, 110.
Rogers R, & Payne JW (2006). Damages and rewards: assessment of malingered disorders in compensation cases. Behavioral sciences & the law, 24 (5), 645-58 PMID: 17016811
Styrke, J. (2012). Traumatic Brain Injuries and Whiplash Injuries. Umea University Department of Surgical and Perioperative Sciences.
Trimble, M. R. (1981). Post Traumatic Neurosis. New York: John Wiley and Sons.
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