This article presents an alternative perspective on the issue of diagnosing and treating concussions, which has been discussed previously in OBPP pages.
Hopewell et al. (2025) argue that the impact of mild traumatic brain injury (mTBI) has been “minimized” and that symptoms requiring treatment remain in a subset of patients. Hopewell et al. claim that “over 50 years of research….has documented that at least 30% of concussion patients may actually show more persistent residual symptoms…” They cite as evidence a study from almost 50 years ago (which was not retrievable on research search engines) and a book from more than 35 years ago. Here we provide a more accurate summary of cognitive outcome research in concussion.
1. The authors incorrectly summarize research on cognitive outcome from mTBI:
Visibility for the idea that a subset of concussion patients do not recover was fostered in 1995, when Alexander (1995) published a review of mTBI in the journal Neurology, in which he concluded that “At 1 year after injury, 10 to 15% of mild TBI patients have not recovered” (p. 1256); however, examination of the two studies cited as evidence (Rutherford et al., 1979; McLean et al, 1983) show that they do not support this conclusion. In the Rutherford et al. (1979) study, 14.5% (n = 19) of the mTBI sample “still had symptoms after 1 year.” However, this subset was either in lawsuits and/or considered to be malingering; accurate conclusions regarding outcome cannot be obtained when samples include such individuals. Further, no cognitive testing was conducted; determination of cognitive dysfunction was instead based on self-report, which is well known to be frequently inaccurate when compared with the results of objective neuropsychological testing (Anderson, 2021; Bryant et al., 2023). In the McLean et al. (1983) study, the very small sample (n = 20) included cases of moderately severe TBI. Still, no cognitive deficits were found on testing at one month, although patients reported persisting symptoms.
Subsequently, six meta-analyses (Belanger et al., 2005; Belanger & Vanderploeg, 2005; Binder et al., 1997; Frencham et al., 2005; Rohling et al., 2011; Schretlen & Shapiro, 2003) documented that mTBI patients return to cognitive baseline by weeks to months post-injury. A recent analysis of studies published since the last meta-analysis in 2011 and that purported to show long term cognitive abnormalities from concussion revealed that they were methodologically substandard (Boone et al., 2025). Specifically, more than 50% of the studies did not: appropriately diagnose mTBI; employ prospective research designs; use standard neuropsychological tests; include appropriate control groups; provide information on motive to feign or use PVTs; or exclude (or adequately consider the impact of) comorbid conditions known to impact neurocognitive scores. In contrast, analysis of an additional 15 studies published during the same period that documented no longer term mTBI-related cognitive abnormalities demonstrated that they were more methodologically robust than were the former studies.
Consistent with the above research, the Diagnostic and Statistical Manual for Psychiatry – 5th edition – Text Revision (DSM-5-TR, 2022) concluded that:
“Neurocognitive impairments associated with mild TBI typically resolve within days to weeks after the injury, with complete resolution within 3-12 months post-injury….” (p. 709)
2. Persistent Post-concussive Syndrome has been removed from both the DSM-5 and the ICD-11:
The authors argue that post-concussion syndrome has not been eliminated from the DSM-5 and instead is encompassed by “minor neurocognitive disorder.” This is not accurate. The DSM-5 includes the categories of major and mild neurocognitive disorder which can be attributed to the umbrella term of “traumatic brain injury.”
The term “postconcussive syndrome” historically was used to describe chronic cognitive, psychiatric, and physical symptoms reported long after concussion. While the DSM-IV (APA, 2000) included reference to postconcussive syndrome in the index, the DSM-5 (APA, 2013) and the DSM-5-Text Revision (DSM-5-TR, APA, 2022) indexes do not. Likewise, while the International Classification of Diseases -10th edition (ICD-10) defines and describes postconcussional syndrome, the ICD-11 (WHO, 2019) does not. The removal of postconcussive syndrome from current diagnostic manuals is consistent with research showing that claimed symptoms occur at the same rates in concussed and non-concussed individuals (Wang, Chan, & Deng, 2006), and that so-called post-concussive symptoms are found in depression and other psychiatric conditions (Donnell et al., 2012; Garden & Sullivan, 2010; Iverson, 2006; McLean et al., 2009), sleep disturbance (Caccese et al., 2021), pain (Smith-Seemiller et al., 2003), and in non-brain trauma patients (van der Vlegel et al., 2021).
The DSM-5-TR (APA, 2022) cautions that if symptom reports persist more than 12 months after concussion, the clinician is to search elsewhere for the cause:
“Persistent symptoms after mild TBI or subsequent neurocognitive deterioration should trigger consideration of other potential causes of neurocognitive symptoms and functional limitations, including major depressive disorder, posttraumatic stress disorder (PTSD), anxiety disorders, substance use disorders, sleep disturbances, negative injury perceptions and poor expectations for recovery.” (p. 709)
3. The authors’ claim of long term non-cognitive symptoms following concussion is not supported:
The DSM-5 (APA, 2013) notes that:
“Other symptoms that may potentially co-occur with the neurological symptoms (e.g., depression, irritability, fatigue, headache, photosensitivity, sleep disturbance) also tend to resolve in the weeks following mild TBI.” (p. 626)
Research has shown no long-term headaches (Mickeviciene et al., 2004; Stovner et al., 2009; Nordhaug et al., 2019), vision changes such as light sensitivity (Marzolla et al., 2023) and convergence insufficiency (van Donkelaar et al., 2018; Del Rossi, 2021), dizziness/balance problems (Kaminski et al., 2017), fatigue (de Leon et al., 2009), sleep problems (Mickeviciene et al., 2004), and psychiatric symptoms (Panayioutou et al., 2010) following concussion.
4. DTI findings should not be used to document mTBI
Hopewell et al. assert that abnormalities on MRI Diffusion Tensor Imaging (DTI) place concussion into the category of mild complicated traumatic brain injury. However, this is not accurate. The DSM-5-TR (APA, 2022) specifically notes that determination of complicated mTBI is based on abnormalities detected in the acute post-TBI period on standard structural imaging (CT and MRI). Likewise, the American Congress of Rehabilitation Medicine diagnostic criteria for mTBI (Silverberg et al., 2023) indicate that neuroimaging evidence of traumatic brain injury involves “unambiguous trauma-related intracranial abnormalities on computed tomography or structural magnetic resonance imaging” (p. 1348).
Approximately 60% of normal individuals exhibit abnormalities on DTI (Weaver et al., 2018), and some studies show no greater rate of DTI abnormalities in mTBI patients than in normal controls (Dretsch et al., 2017), or if they do, rates do not differ from patients with orthopedic or other bodily injuries (Lippa et al., 2023; Wilde et al., 2019). DTI changes are known to accompany virtually any condition or exposure that can be identified in a person, including excessive social media use (He et al., 2018), smartphone dependence (Hu et al., 2017), video gaming addiction (Dong et al., 2012), air pollution (Kusters et al., 2024), post- COVID infection (Nelson et al., 2024), marijuana use (Robinson et al., 2023), borderline personality disorder (Ninomiya et al., 2018), and narcissistic personality disorder (Lou et al., 2023). DTI abnormalities are also observed in multiple medical conditions including hypertension (Burgmans et al., 2009), pre-diabetes (Liang et al., 2018), and elevated cholesterol (Lou et al., 2014). Thus, purported abnormalities on DTI imaging cannot be attributed to, or used to diagnose, concussion.
5. The concern with iatrogenesis in management of patients with concussion
Hopewell et al. recommend numerous treatments for mTBI patients, but recovery is spontaneous, and treatment may cause iatrogenic (i.e., treater-caused) harm. The American Academy of Neurology published guidelines in 2013 for “management” of concussion:
“Patients with mTBI/concussion may underestimate their preinjury symptoms, including many symptoms that are known to occur in individuals without concussion, such as headache, inattention, memory lapses, and fatigue. After injury there is a tendency to ascribe any symptoms to a suspected mTBI/concussion…Cognitive restructuring is a form of brief psychological counseling that consists of education, reassurance, and reattribution of symptoms…”
In other words, the “treatment” for concussion is to reassure, educate that individuals fully recover from concussion, and help patients reattribute claimed concussion symptoms to their correct causes (e.g., emotional or somatic conditions; Stenberg, Karr, Terry et al., 2020).
For patients who continue to perceive ongoing injury and symptoms, short-term cognitive-behavioral/psychoeducational approaches that focus on life re-engagement and expectations of positive progression (e.g., Simpson et al., 2021), and can include mild to moderate aerobic exercise (Haider et al., 2020), may be beneficial. However, additional treatment can in fact be harmful: the VA/DoD Clinical Practice Guidelines for the Management of Concussion/mild Traumatic Brain Injury (February 2016) caution:
“Some presenting symptoms may be attributed to the mTBI event by both providers and patients, even though the contribution of the original event to current symptoms is uncertain. This can place the patient into a category in which all of his or her symptoms are considered ‘mTBI symptoms.’ This attribution, and potential misattribution, of symptoms to mTBI can potentially place the patient at risk. When such a patient becomes ‘a TBI patient,’ providers may continue to view all of his or her symptoms through that prism. Unfortunately, some of the very programs that are intended to help patients with a history of mTBI may have the unintended consequence of reinforcing the concept that all of his or her symptoms are mTBI-related. When this happens, the patient may consider himself/herself as a ‘lifelong’ mTBI patient…” (p. 28).
Conclusion
Well-conducted research showing no long-term symptoms from concussion has enabled the field of neuropsychology to finally emerge from the “rabbit hole” of viewing concussion as a long-term condition requiring treatment, a rabbit hole which we do not wish to re-enter.
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Kyle B. Boone, PhD, ABPP
Board Certified in Clinical Neuropsychology
Correspondence: kylebboone@gmail.com
Tara L. Victor, PhD, ABPP
Board Certified in Clinical Neuropsychology
Correspondence: tvictor@csudh.edu