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Identifying and Treating Concussion/mTBI in Service Members and Veterans
A Course for Civilian Health Care Providers from BrainLineMilitary.org
How to Diagnose a Concussion/mTBI
When you see a patient who has sustained a concussion/mTBI, you're going to make your diagnosis primarily based on patient history. (Remember, concussion/mTBI injuries are not typically visible with standard brain imaging techniques.) Under most circumstances, the concussion/mTBI will have occurred a long time before you actually see the patient, which can affect how much detail your patient can recall. As mentioned previously, concussion/mTBI is diagnosed by one or more of the following signs immediately after a traumatic blow or jolt to the head:
- Loss of consciousness for less than 30 minutes
- Loss of memory for events before or after the injury resolving within 24 hours
- Alteration of consciousness (confusion, disorientation, or dazed feeling) resolving within 24 hours
IMPORTANT: While a loss of consciousness is sufficient for a diagnosis of concussion/mTBI, it is not necessary.
Up to 85% of traumatic brain injuries are mild. A TBI is classified as mild if the alteration of consciousness (including amnesia) has resolved within 24 hours of the trauma. If the patient lost consciousness, the period of unconsciousness must be less than 30 minutes for the designation concussion/mTBI.
Symptoms of Concussion/mTBI
As a civilian health care provider, you won't be seeing a veteran until some time after the initial trauma. It may be months before a service member seeks help, and he may not associate his symptoms with an injury during combat. So you should be prepared to recognize the most common signs and symptoms associated with concussion/mTBI that can linger months after trauma to the head:
- Dizziness, balance, and coordination problems
- Cognitive deficits (e.g., issues with concentration or memory, getting organized)
- Fatigue and/or insomnia
- Emotional changes, including irritability, depression, and anxiety
Watch a short video of Adam Anicich, an Iraq war veteran who sustained a concussion/mTBI. Here he describes his symptoms three to six months following his injury:
VIDEO: Changes in Temperament
Changes in Temperament
"I started to notice that there was differences in my personality, differences in my behavior, differences in my level of temperament "
Critical: Taking a Detailed Case History
If your patient's symptoms lead you to suspect a concussion/mTBI, it can be helpful to determine if your patient served in the military. If so, ascertain if your patient experienced a blast, vehicle crash, or fall any trauma that might have caused a concussion/mTBI. (Please remember that these injuries also happen away from the field of battle on base or off duty.) If you discover a possible triggering event, then making the diagnosis requires assessing your patient's level of consciousness and symptoms in the past, right after the trauma. This can only be accomplished by getting a good case history or chronology of the incident.
To take a good case history, allow your patient to narrate the story; but question him or her in sufficient detail to uncover any gaps in your patient's memory or consciousness following the trauma. Remember from an earlier page that two of the diagnostic criteria are a loss of consciousness and loss of memory.
Watch this short demonstration of how to take a case history with Dr. Wendy Law, clinical neuropsychologist at the Walter Reed National Military Medical Center, and a Marine Corporal who sustained a concussion/mTBI in Afghanistan:
VIDEO: Dr. Wendy Law How to Unearth What Happened at the Time of Injury
How to Unearth What Happened at the Time of Injury
Diagnosis of TBI is based on what happened at the time of injury. It is often hard for service members to remember the moment-by-moment details.
NOTE: The name of the service member is not included to protect his confidentiality.
Making Your Diagnosis
Once you have the patient's history, carefully consider the criteria of diagnosing concussion/mTBI from the previous pages. It is evident that your patient has sustained a concussion/mTBI if he or she reports loss of consciousness or blacking out (even for a few seconds but less than 30 minutes). Post-traumatic amnesia (not remembering a period of time before or after the event) is easily identified too, but distinguishing alteration of consciousness (AOC; confusion, disorientation) is challenging at times. AOC should not be confused with a normal psychological response to stress, such as feeling startled or stunned by a sudden event.
Once you have determined your diagnosis, you can assess the current symptomatology by using two clinical tools:
- The Neurobehavioral Symptom Inventory (NSI) Form is a validated measure that captures information on 22 common subjective complaints which may occur following TBI.
- The PTSD Checklist (PCL) is a 17-item, self-report measure of the 17 DSM-IV symptoms of PTSD (or acute stress disorder depending on the length of time following the TBI).
The combination of both of these questionnaires is useful in identifying the critical needs of your patient and guiding the treatment plan.
Following the assessment, you should perform a neurological exam, documenting any abnormal findings (or refer as appropriate). The key aspects are vision, hearing, cranial nerves, muscle strength and sensation (pinprick, light touch, temperature, proprioception), balance and coordination, reflexes, and cognitive assessment (e.g. mini-mental status exam). Note the service member's behavior, appearance, and speech along with your focused evaluation.
Neuropsychological testing and bloodwork are often recommended as part of the comprehensive examination depending on the symptoms that the service member or veteran endorses. You will be able to use these findings in the treatment section.
Concussion/mTBI and Neuropsychological Symptoms
Concussions can cause neuropsychological symptoms, affecting memory, attention, and other aspects of cognition. The most common cognitive symptoms reported by patients or family members are problems with memory, attention, and processing speed (slowed thinking). Patients occasionally have insight into such changes, but it's frequently beneficial to ask their loved ones to get an independent perspective on how the patient has changed after the injury.
Though the majority of individuals will recover from the direct effects of concussion/mTBI within three months of injury (with many showing full recovery within days of the injury), some continue to have symptoms beyond three months. The symptoms for most of these people tend to vary in intensity and type over time, showing a waxing and waning pattern that is not typical of permanent injury to the brain.
In these instances, complaints of forgetfulness, poor attention, and slowed thinking may be due to other complicating conditions that developed at or around the time of injury (sleep disorders, for example). Treating these residual symptoms may help resolve the neuropsychological issues.
Some service members may have sustained multiple concussions. It's important to determine if that's the case — for example, was the individual exposed to a number of blasts? Sustaining multiple concussions can require more time for recovery after each subsequent injury. What is not clear from the literature is if multiple concussions increase the severity and duration of symptoms.
The military takes the issue of cumulative concussions very seriously. Service members receive a mandatory evaluation after any event that could possibly cause a concussion/mTBI. Additionally, those who have sustained three or more concussions must receive a more detailed evaluation before being cleared to return to combat.
Watch Dr. James Kelly, head of the National Intrepid Center of Excellence, talk about the military's protocol for caring for service members who sustain three or more concussions:
VIDEO: New Military Protocol for Three or More Concussions
New Military Protocol for Three or More Concussions
Soldiers who have sustained three concussions will receive a more detailed, mandatory evaluation before returning to combat.
*Note: The video interview with Dr. Kelly was shot in August 2010. Some information may have changed.
For more on this topic, please review BrainLine Military's cumulative concussions page.
Concussion/mTBI and PTSD
Concussion/mTBI frequently co-occurs with PTSD (post-traumatic stress disorder) in this population.
Watch this short video with Dr. Michael McCrea of the ProHealth Care Neuroscience Center and Research Institute:
VIDEO: PTSD & mTBI: Teasing Out the Differences for Treatment
PTSD & mTBI: Teasing Out the Differences for Treatment
"The dilemma that the clinician faces is trying to split that hair as to determining whether or not this military person in front of me in clinic has primarily post-traumatic stress disorder or primarily the lingering effects of mild traumatic brain injury "
So when evaluating a patient for concussion/mTBI, consider the possibility that your patient may have PTSD, or PTSD and concussion/mTBI. If your patient has PTSD (with or without concussion/mTBI), making the diagnosis is valuable because evidence-based treatments are available.
Here is a brief overview of PTSD treatments from the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
The signs and symptoms of concussion/mTBI and PTSD overlap considerably, so use the following chart to learn the symptoms that can help you discriminate between concussion/mTBI and PTSD for patients who have only one or the other.
Reference: Stein MB, McCallister TW (2009). Exploring the convergence of post-traumatic stress disorder and mild traumatic brain injury. Am J Psychiatry; 166:766-776.
Regardless of the cause of the symptoms, treating the symptoms themselves is the right approach.