Longterm outcome after traumatic brain injury : neurological status and adjustment

D.Litt. et. Phil.Head injury is the major cause of death for individuals under 35 years old in the United States of America, and a similar picture exists in South Africa. A major cause of traumatic brain injury is motor vehicle accidents. In addition, the advances in modem medical technology increase the chances for survival, for example, sophisticated medical diagnostic techniques such as computerised tomography (CT), and magnetic resonance imaging (MRI). Advances in emergency trauma and neurosurgical procedures have also increased the number of survivors following a head injury. The symptoms resulting from head injury include disturbed physical, cognitive, psychological and behavioural functioning. Long-term management of these symptoms is usually required. A body of evidence exists that demonstrates the value of rehabilitation during the first year of recovery from traumatic brain injury. Head injury cases often result in litigation in that the injured person may be entitled to compensation for the injuries sustained. Considerable forensic debate exists around the issue of whether the victim's symptoms are attributable to organic brain damage, or whether they reflect a pre-existing functional psychological state of psychiatric illness, or personality disorder. Further still, the individual may be 'malingering' or faking postconcussion symptoms of headache, dizziness, fatigue, memory deficit, impaired concentration, irritability, anxiety, insomnia, concern about bodily functions, and hypersensitivity to light and noise. Alternatively, a common diagnosis is traumatic neurosis with a psychogenic basis, and in the context of litigation is referred to as "compensation neurosis". Specifically, the issue of contention revolves around concussion, and mild or minor head injuries. This study proposed that both neuropathophysiological and psychosocial symptoms occur in the event of a traumatic brain injury. This view supports the traditional model that pain or the sequelae of head injury are not affected by compensation. Therefore, the objective of the study was that follow-up assessment after compensation pay-outs should produce similar results to the assessment results obtained during the litigation process. The hypotheses of the study were essentially confirmed. The neuropsychological error scores produced in the assessments during litigation, and two-to-four years after the completion of litigation were similar. However, similar to other studies, variations were evident. Four exceptions were demonstrated in that significant improvement was evident with regard to shotterm verbal memory delayed recall for paragraphs, and for immediate recall (without and after interference) in verbal memory for a word list. These improvements therefore pertain to verbal memory. The fourth improvement occurred with respect to manual dexterity and visual-motor work speed, although the improvement may be peripheral or primary (neurological). Further findings included that no gender differences were evident in the neuropsychological posttest scores. It was confirmed that individuals with a good Glasgow Outcome Scale rating showed less posttraumatic amnesia, a shorter time since injury, less additional injuries, and a lower compensation sum. It was also supported that individuals with a good Glasgow Outcome Scale rating showed less impairment on neuropsychological indices. However, an exception was that individuals with a moderate Glasgow Outcome Scale rating showed improvement on the neuropsychological index measuring immediate concentration, visual scanning, and visual-motor work speed. The qualitative data or psychosocial measures of severity and outcome produced a similar picture that the majority of subjects maintained their pretest status although some exceptions were evident. Within the medico-legal domain it was shown that, in general, concordance of severity was high amongst the medical experts for the plaintiffs and the defendents. However, their prognoses were indicated to be less accurate, and whilst their consistency in documenting diagnoses in the reports of the subjects was adequate, they were found to be inconsistent in documenting severity ratings and prognoses. It was suggested that improvements may be attributed to neurophysiological differences, non-participation in a rehabilitation programme, the interference and delay of rehabilitation, increased psychological reactions associated with litigation, and mechanisms of secondary gain which may by attributed to the other players, such as the family, the attorneys, the medical experts, among others, and not only to the individual or victim