No Loss Of Consciousness Is Required

• Muriel Lezak, Neuropsychological Assessment, 3rd, ©Oxford, 1995.
• Levin, Mild Head Injury,©Oxford, 1989.
• Kelly, James P., M.D. “Diagnosis and management of concussion in sports“. ©Neurology. 1997. p 575-580.
• September 8, 1999 JAMA.
• Reitan and Wolfson, Neuroanatomy and Neuropathology, A Clinical Guide to Neuropsychologists, 2nd Edition, ©Neuropsychology Press, 1992.
• Definition of Mild Traumatic Brain Injury , Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. J Head Trauma Rehabil 1993:8(3):86-87
• Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, ©American Psychiatric Association, 1994.

Unless your client is unconscious when first evaluated by medical personnel, the defense will argue that a brain injury cannot occur without a loss of consciousness, and perhaps a five minute loss of consciousness. Serious researchers have discounted this theory for decades, and as we enter the next millennium, there should be no room left for debate on this issue. But there will be, so it is paramount that you come into depositions and the court room fully armed with the best authority to refute this assertion.

A. Lezak. Primarily because of the ease with which I have obtained concessions as to its authoritativeness, I prefer to start this battle with Lezak. Lezak has a comprehensive treatment of this subject beginning at page 178:

Noting that the concussion syndrome covers a range of symptoms and severity, Gennarelli, (1986) suggests that there are two broad categories of concussion: mild concussion, without loss of consciousness and characterized by symptoms such as seeing stars, if the injury was focal, and or a short period of confusion and disorientation with or without amnesia for a brief time before and or after the event; and classic concussion, defined by reversible coma, occurring at the instant of trauma, which may be accompanied by cardiovascular and pulmonary function changes and neurologic abnormalities …

The neuropsychological sequelae of concussion without loss of consciousness do not differ in severity from those occurring when there is a brief comatose period ( Leininger, Grambling et al, 1990, Nemeth, 1991) (emphasis added) . In recommending that concussion be defined as “an acceleration/deceleration injury to the head” which is typically but not necessarily accompanied by amnesia, Rutherford (1989) has attempted to extend this diagnosis to the many cases of minor head injury in which behavioral sequelae are consistent with this type of damage, but loss of consciousness in questionable. 2

B. Jennett from Mild Head Injury. The second most predictable thing that the defense attorney will argue is that our clients did not have a brain injury because their Glasgow Coma Scale was 15. For that reason, my second authority in support of the No LOC required position is the statement by Dr. Bryan Jennett, the author of the Glasgow Coma Scale, from the book Mild Head Injury. Jennett states:

“The widespread adoption of the Glasgow Coma Scale has made it easier to classify severe injuries, but it was not intended as a means of distinguishing among different types of milder injury. Many of these patients are oriented by the time they are assessed and therefore score at the top of the Glasgow scale. Yet some of these patients have had a period of altered consciousness, either witnessed or evidenced by their being amnesic for events immediately following injury. Impairment of consciousness is indicative of diffuse brain damage, but there can also be marked local damage without either alteration in consciousness or amnesia;” Mild Head Injury, ©Oxford, 1989, page 24.

C. Sport and Concussion Guidelines. Invariably, it will be a defense neurologist who will be touting the theory that LOC is required. It is for this reason that I think the “Sport and Concussion Guidelines” can be very helpful, as they are promulgated by the American Academy of Neurology. See the presentation by Dr. James Kelley, earlier in this program for the current status of this work.

D. September 8, 1999 issue of JAMA. The September 8, 1999 issue of the Journal of the American Medical Association, JAMA, has three breakthrough articles on concussion. What is so significant about these articles is not so much anything new that appears therein, but having JAMA’s authoritative stamp of approval on the ongoing research into the permanency of brain injury, in absence of identifiable periods of unconsciousness.

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E. Reitan. Any expert who questions the authoritativeness of Ralph Reitan, the father of neuropsychology, does so at the risk of his/her own credibility. Reitan has this to say about LOC:

We should note that loss of consciousness and severity of brain damage correlate in certain ways, but their correlation is far from perfect. In fact, a significant degree of contusion or laceration of the brain may occur without loss of consciousness; in many instances the same occurs with severe penetrating injuries. The patient may feel dazed, mildly confused, light-headed, and have generalized motor weakness; such symptoms may even persist for an extended period of time.4

G. ACRM. The American Congress of Rehabilitation Medicine’s definition of mild traumatic brain injury has been sited at this conference for years, and probably will exist elsewhere in these materials. It continues to be perhaps the most comprehensive definition of this condition and does stand as clear authority as to the issues to be looked at in the acute stage with respect to a diagnosis of concussion.5

H. Other Authority. Additional authority that a brain injury can occur without a documented loss of consciousness is included in R.W. Evans, Neurology and Trauma, and the treatise Silver, Yudofsky and Hales, The Neuropsychiatry of Traumatic Brain Injury and the Evans, Prognosis of Neurological Disorders, Oxford, 1992. See also Greenfield’s Neuropathology, discussed at the page on Neuropathology.

NEXT: Neuropathology.

Understanding Subtle Brain Injury

The concussions that disable, are almost always more symptomatic at 24 hours, than at the 2-4 hour time frame when injured persons are evaluated in the emergency room. Brain injury symptoms escalate over the first 24 hours, because brain injury involves a cascade of events. It is critical that if you are still symptomatic the day after your injury, go back to the same Emergency Room, don’t wait for a doctors appointment. It is critical that the Emergency Room personnel see that the symptoms still persist or have gotten worse.

View Our Video Series on Concussions