We are entering the end of a foundational era in concussion assessment and management research. Much research has been published over the past 10-15 years concerning concussion, and probably moreso than in any time in history. The research has raised more questions than answers. There is still no single recognized definition of mild traumatic brain injury or concussion among all experts. Much of the literature states that there are no measurable neuropsychological deficits one year post concussion (see that of McCrea et al. and Dikman et al., for some examples using randomized, controlled trials), and most show “full recovery” by 3 months. Much of the research has also shown that the contribution of demographic or psychosocial factors is quite significant and often stronger than effects of concussion. These can be sufficient to mimic or mask concussion effects. The research suggests that who you were before you experienced the concussion impacted how you reacted to the concussion. In other words, who you were before the concussion is never irrelevant to the assessment.
There have been single research studies using functional imaging to investigate and document brain changes after concussion; however, this does not necessarily indicate significant functional impairment.
Commonly, a concussion is defined as any period of loss of consciousness, any loss of memory for events immediately before or after the accident, any alteration in mental state at the time of the accident (i.e., disorientation, confusion), and/or focal neurological deficit(s) that may or may not be transient but where the severity of the injury does not exceed loss of consciousness of approximately 30 minutes or less, less than an initial GCS of 13-15, or posttraumatic amnesia of greater than 24 hours.
One challenge in studying concussion is the samples used. Many studies control for substance use, depression, anxiety, developmental history (ADHD, LD), and medical comorbidities. The reality is that many people with concussion may have these comorbidities. A biopsychosocial model of concussion is accepted by many neuropsychologists as an appropriate way to understand outcomes after concussion. That is, consideration of pre-injury variables, patient’s self-perception, personality, how the patient responds to adversity, coping skills, family reactions/support system, role expectations, sleep disturbance, other things the person has to adjust to (for example, musculoskeletal injuries) and involvement in litigation are on the table in terms of understanding outcomes.
Another challenge is that of management of closely spaced injuries. We do not have as much “good science” on those injuries spaced over a close interval, within several weeks.
Some of the important principles discussed after concussion include early identification of brain injury, protection from further injury, optimization of habits such as sleep, hydration, nutrition, graded exercise, return to work, education, and intervention types (pharmacologic, cognitive rehabilitation). Pre- and post-injury sleep disorders should be addressed, including obstructive sleep apnea, since these can impact brain functioning (as can chronic pain). Many neuropsychologists would agree that it is important to reinforce a normal recovery trajectory for people who have experienced a single mild concussion. Cognitive rehabilitation can be adopted in some cases for people with more moderate to severe brain injury, although the science has not yet caught up with implementation of attention and other brain training programs in this population and the application of this with people with concussion has not received wide support.
Neuropsychological assessment has been a particularly valuable tool after concussion, in terms of understanding diagnosis, prognosis, and treatment plan. This is an assessment of how one’s brain functions. In forensic cases, one may be remiss in not having a neuropsychologist’s assessment, as neuropsychologists are the foremost experts on application of the biopsychosocial model in understanding brain-behavior relationships. Within North Carolina, there are a number of neuropsychologists who are qualified to perform neurospychological assessment after concussion. Some of these can be found through the American Academy of Clinical Neuropsychology’s website: http://www.theaccn.org.