Lay and Scientific Scrutiny of Concussion/Mild Traumatic Brain Injuries (mTBI)
Recent research into chronic traumatic encephalopathy (CTE) as well as concussions / mild traumatic brain injuries (mTBI) have thrust the impact of mild traumatic brain injuries (mTBI) forcefully into the light of active scientific research, especially as the issue of military concussions secondary to blast exposure has been increasingly researched. Escalating awareness of such injuries may also be seen in real time by millions on television while watching sports events and are addressed increasingly with athletic safety precautions such as those taken by the National Football League (NFL) to protect players. Note that confusion remains about concussion terminology as well as the symptom clusters (Class I – V) and that the terms concussion, mTBI for mild traumatic brain injury, and minor neurocognitive disorder are all used interchangeably.
The Tendency to Minimize Head Injuries
A review of the literature along with personal injury and workers’ compensation cases often demonstrates a tendency to minimize the effects of these injuries and to give the impression that “all concussions resolve quickly.” Even programs which tend to see large numbers of concussion patients may be inclined to promulgate the assertion that concussions are for the most part “minor injuries” and that “cognitive recovery generally occurs quickly” (Perotti 2024). This is in contrast to over 50 years of research which has documented that at least 30% of concussion patients may actually show more persistent residual symptoms (Amphoux et al., 1977; Levin, et al., 1989) especially when complicating factors such as post-traumatic stress and pain occur co-morbidly (Hopewell et al., 2024; Vasterling et al., 2012).
One extreme example of “minimization” can be seen from the experience of COL Kathy Platoni, who deployed as the Officer–in–Charge (OIC) of Teams Wilson and Phoenix, 467th MED DET (CSC), to Afghanistan. Despite increased blast exposure injuries, the units were simply handed “a few plastic cards to take with us that rated TBI symptoms” (Platoni, 2024). Soldiers were at risk therefore of returning from their deployments with minimal to no treatment or follow up after blast or improvised explosive device (IED) injuries, and at times with minimal or even no medical documentation, exemplifying perhaps the extreme of the minimizer position of “your concussion will just get better on its own and you don’t really need any treatment.”
However, as originally noted by Levin et al. (1982, 1987, 1989) there is increasing evidence that even mild traumatic brain injury causes axonal shearing injury of white matter microstructures that can affect the long-term cognitive, neuropsychiatric, and social domains of function. Palacios et al. (2020) also observed that the lack of reliable objective tools to measure this pathology may well present barriers to clinical translation. These authors stated explicitly that the common assumption, even among health care professionals, that such patients will return to premorbid levels of function shortly after the traumatic event, will too often result in these patients not receiving appropriate follow-up care after the acute injury. The authors also noted that traumatic brain injury involves multiple different time-varying pathophysiological effects, including diffuse axonal injury, diffuse microvascular injury, and neuroinflammation, all of which lead to neurologic dysfunction.
In general, the “minimizer” template is usually something similar to the contention that “concussions are minor injuries, and the patient was probably not seriously hurt anyway. The cognitive effects of concussion almost always recover spontaneously. Any persistent effects of concussion are most likely due to malingering or other psychiatric factors. In any case, the patient may not have demonstrated full effort in the first place during the formal evaluation.”
And finally, the claim is often made that any diffuse tensor and/or imaging objective findings (DTI) which document the concussion and place it into a category of “complicated” concussion as originally described by Levin et al. (1982, 1987, 1989) and the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM 5-TR; 2022), may not be specific to concussion, but may related to other types of injuries or illnesses.
Fifty Years of Research Documents Percentages of Persisting Post Concussion Symptoms
Specific research on concussion has now been done for over fifty years, starting essentially with the formal brain injury research center directed by Harvey Levin at the University of Texas Medical Branch, Galveston, continuing with Salazar’s (Salazar et al., 2000) work through the Defense Veterans Brain Injury Center (DVBIC) and other military treatment and rehabilitation programs up to and including the current conflicts which often involve blast exposure injuries (Hopewell et al., 2024). Such findings were also eventually incorporated into the official position of the military TBI task force on the role of neuropsychology and rehabilitation psychology in the evaluation, management, and research of military veterans with traumatic brain injury which was published in The Clinical Neuropsychologist (McCrae et al., 2008).
It is also noted that concussion is not a unitary injury but is actually a continuum which contains different clusters of injuries. These clusters have been designated by DVBIC as being Class I – uncomplicated concussions, Class II – concussions complicated by emotional factors, Class III – concussions complicated by medical factors (basically the Levin and DSM V-complicated concussions), Class IV – repetitive concussions (dementia pugilistica), and Class V – concussions which are more related to dissimulation or factitious in nature (Hopewell, 2010, 2025; Levin 2010). Conceptualizing these as “classes” of symptom clusters as opposed to “severity of injury” also helps with some of the confusion introduced by different authors and different lines of research over fifty years since Levin et al. first addressed these issues. This is similar to the Latin binomial nomenclature system which provides scientific names to biological flora and fauna and avoids confusion since the same flora or fauna may be called by several different names in different countries.
And finally, concussion/ mTBI is not characterized only by cognitive components. The Neurobehavioral Symptoms Inventory (NSI) for example, quantifies concussion/ mTBI symptoms into at least four symptom clusters of concussion – not simply the cognitive cluster. The other three categories, as demonstrated by Klein et al. (2011) and Vanderploeg et al. (2014) include vestibular, emotional, and somatosensory disturbances as well. However, as documented by Klein et al. (2011), factor scores provide the best validity, rather than total scores. As these authors note, “adding” the NSI scores are somewhat akin to adding one’s hat size, shoe size, and waist size, ultimately resulting in a meaningless number. Of particular note, persisting vestibular somatosensory symptoms are particularly indicative of post-concussive syndrome, as patients are not likely to be aware of symptoms such as dizziness, hyperacusis, and photosensitivity, and therefore to be prone to “malinger” these types of symptoms. The combination of concussion symptom inventories along with validity measures may be especially helpful.
The Error of Focus on Only Cognitive Functions
Neuropsychologists who focus only on cognitive issues may obviously miss such important sequelae of injury, some of which may be quite persistent. Sometimes, these hearing and vision injuries are either not immediately apparent or require additional testing to be diagnosed, according to Aker (2024) from the Defense Health Agency.
Military experts also note that often TBI patients are often informed they do not have hearing loss despite their perceived listening difficulties, which is why additional measures to establish auditory processing abilities are required. Auditory processing disorder symptoms may include struggling to understand speech in noisy settings; problems recognizing spoken words or keeping up with telephone conversations; finding it hard to tell the difference between words that sound alike; and feeling uncertain about where the words that one hears are originating. At times hyperacusis, or phonophobia is noted, in which noise cannot be tolerated.
The conclusion of these military studies was that vision (often photophobia), vestibular, hearing, and cognitive dysfunction often occur simultaneously as the result of concussion. State-of-the-art treatment of sensory deficits associated with TBI for best and quickest recovery depends on coordinated multisensory interdisciplinary rehabilitation such as rehabilitation centers documented by Hopewell (2025). However, this type of coordination may not occur if patients expect that “they will all get better” in a brief amount of time and that they are malingering or putting forth poor effort if symptoms persist, if only cognitive symptoms are assessed, and if further rehabilitation is delayed for months or years by insurance delays.
Diagnoses Have NOT Been “Removed From the DSM”
Some practitioners also appear to desire to minimize concussive injuries by asserting that “post-concussion syndrome” has been removed from the Diagnostic and Statistical Manual of the American Psychiatric Association since this was a research proposal in DSM – IV, but is not a formal diagnosis in DSM–V-TR. Far from “taking the diagnosis out of DSM”, the Diagnostic Statistical Manual V-TR currently describes this diagnosis as being a minor neurocognitive disorder (NCD). The DSM also differentiates between “Uncomplicated Minor Neurocognitive disorder” and “Complicated Minor Neurocognitive disorder,” essentially mirroring the DVBIC classifications as well as the constructs originally proposed by Levin et al. (1989).
Treatment Approaches for Concussion
- Education of the patient, the family, employers, and instructors is a significant treatment component for concussion and mTBI. Education should be provided to patients and their support system about the nature and common manifestations of concussion/mTBI as a critical aspect of intervention. Communication of health information from providers helps manage patient expectations and can prevent the development of post concussion/mTBI symptoms and/or reduce their duration, number, and severity.
- A multidisciplinary approach may be needed due to the different cognitive and non-cognitive aspects of concussion as well as classes of concussion. Services should be provided immediately after concussion with assessment of all systems affected. If ongoing treatment is needed, this should not be delayed for years as happens in some cases of legal and vocational disputes, thereby making “treatment of concussion” some three years after an initial injury essentially impossible. Support groups may also be as helpful as they are with more severe injuries.
- Treatment of somatic complaints (e.g., sleep, dizziness/coordination problems, nausea, numbness, smell/taste, vision, hearing, fatigue, appetite problems) should be based upon individual factors and symptom presentation.
- Medication for ameliorating the neurocognitive effects attributed to concussion/mTBI as a cognitive enhancer is generally not recommended. This is referencing the commonly used cognitive enhancers such as donepezil and memantine, etc., which are used in the progressive dementias. Antidepressants, selective stimulants such as modafinil, and medications for other purposes may still be appropriate for targeted symptoms, with the former often being used.
- Medications for other issues such as headaches, musculoskeletal pain, or depression/anxiety must, however, be carefully prescribed to avoid the sedating properties, which can have an impact upon a person’s attention, cognition, and motor performance.
- Cognitive management also consists of efforts to improve certain specific aspects of complex cognitive processes such as focused attention or speed of information processing, as well as cognitive organizational strategies and cognitive efficiency.
- Usually a graduated transition for work or school return, appropriate management of cognitive demands, and consultation with family, employer, or school authorities regarding the appropriate management of such environmental demands will be helpful.
- Psychotherapy helps restore a sense of meaning to the patient’s life in the face of either permanently or even temporarily altered functioning. Since the progress of emotionally coping with disability is critical to the overall rehabilitation process, continued individual, family, and group psychotherapy may be very helpful. Treatment of neuropsychiatric symptoms following concussion/mTBI should be based upon individual factors and the nature and severity of symptom presentation and may include both psychotherapeutic and pharmacological treatment modalities.
Conclusions
Our analyses document that the rates of the persistent symptoms from concussions have really not changed over the past 50 years, although many clinicians seem to minimize or be unaware of these injuries. The analyses also demonstrate a much-improved understanding of the interaction of both neurological and psychological factors, all of which contribute to symptom clusters, with a classification system introduced by DVBIC which helps group injuries clinically. Such research has demonstrated that far from being a rather innocuous injury which almost always recovers spontaneously, concussion remains a serious medical health issue in both civilian and military populations, and neuropsychologists would be well advised to acquaint themselves with the more persisting and serious effects of these injuries. With increasing members of psychologists in the military also being credentialed to prescribe medications, increasing treatment options are also becoming available for this serious public health hazard.
References
Aker, J. (2024). How hearing and vision problems can be related to brain injury. MHS Communications. The Official Website of the Military Health system. https://health.mil/News/Dvids-Articles/2024/03/22/news466774
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Hopewell, C.A., Klein, R., and Adams, M. L. (2024). Psychiatric correlates of combat trauma in military personnel: PTSD And TBI TESI statistical analysis. Operations Iraqi and Enduring Freedom. Combat Stress Magazine. The American Institute for Stress. Winter, 12 (4), 34 – 53. https://www.stress.org/combat-stress-magazine/
Hopewell, C.A. (2010). Troubleshooting the role of the neuropsychological evaluation. Invited address, Defense Veterans Brain Injury Center, Washington D.C.
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MAJ [RET] C. Alan Hopewell, MP, PhD, ABPP, BSM
Board Certified in Clinical Neuropsychology
Correspondence: alanhopewell@cahopewell.com
CPT Robert Klein, PhD
Correspondence: kleinpsych@gmail.com
LTC Chris Atkins, MSW
Correspondence: counseloratkins@gmail.com
Laurence Perotti, PhD
Correspondence: peteyskid63@charter.net
COL (RET) Kathy Platoni, PsyD, DAAPM, FAIS
Correspondence: drrunt@woh.rr.com