The Concussion Blog

Below is an excerpt from a dissertation from Don Brady, PhD, PsyD, NCSP wrote ten years ago.  Although the year of publishing might seem aged, there are pertinent and salient points to behold in this.  Without further ado…

TBI and Postconcussion:  Many Years of Controversy

Vague and inconsistent definitions of the constructs used to explain a [concussion] brain injury, coupled with confusion and misunderstanding of brain injury symptoms, create further problems in the study of sports-related concussion research.  Wills and Leathem (2001) amplify: “The quagmire created by the use of inconsistent, overlapping and poorly defined terminology relating to brain injury research is exacerbated in sport-related research” (p. 646).

Common synonyms for concussion include mild traumatic brain injury (mild TBI) and minor closed head injury (minor CHI) (Kelly, 1999). Other terms which have been utilized since last century to describe the concept of a mild brain injury include: spinal concussion, railway spine, railway brain, traumatic neurosis, nervous shock, traumatic hysteria, traumatic hysteroneurasthenia, spinal anemia, vasomotor symptom complex, litigation neurosis, compensation neurosis, accident neurosis, Erichsen’s disease, Friedmann’s disease, traumatic neurasthenia, the posttraumatic concussion state, the posttraumatic psychoneurotic state, traumatic encephalopathy, posttraumatic cerebral syndrome, posttraumatic syndrome, post traumatic nervous instability, postconcussion syndrome, postconcussive syndrome, postconcussional syndrome, posttraumatic stress  syndrome, and a persistent postconcussive syndrome (p. 32).

Gerstenbrand and Stepan (2001) also reported a variety of terms being used to describe minor brain injury: “mild head injury, mild injury, traumatic head syndrome, postbrain injury syndrome, mild concussion syndrome, postconcussional syndrome, traumatic cephalgia, posttraumatic syndrome, Commotio cerebri, light traumatic brain injury damage and mild traumatic brain injury” (p. 95).

Approximately 50% of persons who sustained a TBI experienced postconcussion syndrome (PCS), which manifested itself in various symptoms that were not present in the person prior to sustaining the concussion (Bazarian & Atabaki, 2001). Although controversy exists pertaining to the existence of PCS as a direct outcome of sustaining a minor TBI, more sensitive brain-imaging techniques such as SPECT, PET, and functional MRI have documented an organic basis for the symptoms (Bazarian & Atabaki, 2001).

The term postconcussion evolved from early conceptions of a concussion as an entirely reversible syndrome without detectable neural pathology.  As such, the prefix post literally meant after [the event] (Gasquoine, 1997). Agreement does not exist on how to conceptualize the concept of post concussion syndrome or even if the syndrome exists. According to Evans (1987), symptoms attributed to the effects of a concussion may also be called postconcussion syndrome. Rutherford (1989) advocated for the dropping of the prefix post, and thus called the collection of presenting symptoms the concussion syndrome. The author also argued and pointed out that since fractured ribs-related pain is not labeled “post rib fracture” pain, concussion-related symptoms should not be perceived as postconcussion symptoms. Furthermore, since some symptoms of a concussion and post concussion are similar, it is not easy to recognize when a concussion ends and the postconcussion syndrome begins (Wills & Leathem, 2001).

McClelland (1996) emphasized that PCS is not a simplistic concept and thus cannot be exclusively categorized within either a psychological or physiological framework. He also cautioned about applying a dualistic mind-versus-body approach to the syndrome. Robertson (1988) voiced similar concern regarding adherence to either/or views when he declared, “polarized opinions of causation [of PCS] are foolish” (p.413). He also reiterated Symonds’ 1942 perspective that it is extremely difficult to distinguish between an organic and psychological basis of concussion because the concepts seem to be closely woven together.

Strauss and Savitsky (1934) are credited with coining the phrase postconcussion syndrome (Evans, 1994), and they posited that not only may a concussion occur without a loss of consciousness, but that it has an organic basis. In their extensive 63-page review of the topic, they emphasized the importance of documenting clinical observations and of not quickly attributing vague or unusual findings to functional/psychological origins. The value of the clinical judgment was also highlighted in the following statement: “Results of tests and exact quotients cannot take the place of the opinion of an experienced clinician” (p. 912).

The authors also reported that some physicians, who had personally experienced concussions themselves, changed their beliefs regarding the origin of postconcussion syndrome from a psychological basis to a physiological basis. Discussions among various physicians also gave credence to the existence of PCS:  They reported similar clinical features and symptoms in their patients who neither conversed with other patients nor lived near each other. A more recent neurosurgeon’s personal experience with a concussion revealed that the doctor not only experienced long-term attending-to-task problems but also required more energy to complete various designated tasks (Marshall & Ruff, 1989).

Brown, Fann, and Grant (1994) advocated for “the DSM-IV and/or successors to create the diagnostic label of “postconcussional disorder” for the cluster of cognitive, affective and somatic symptoms which comprise this category since adequate scientific research exits to support this request” (p. 21). An examination of the DSM-IV R revealed this early recommendation was not accepted and that the status of a specific classification category for postconcussional disorder remains under review by the American Psychiatric Association.

As previously noted, symptoms attributed to the effects of a concussion may also be called the postconcussion syndrome (Evans, 1987, 1994). The neurologist’s descriptions of frequently observed symptoms of a concussion/postconcussion will be used as parameters for determining the symptoms of concussions in this research study.  A perusal of these symptoms revealed the existence of a wide spectrum of presenting symptoms for the effects of a concussion. The symptoms cited are:  “headaches, dizziness, vertigo, tinnitus, blurry vision, double vision, memory dysfunction, impaired concentration, personality changes, anxiety, depression, sleep disturbances, decreased libido, irritability, noise and light sensitivity, fatigue, and slowed information processing” (p. 49).   Although various symptoms that proceed from sustaining a mild brain injury have been acknowledged for some time, the theories utilized to explain the presence of symptomology have varied significantly (Packard, 1994). Consistent with the area of concussions, differing perspectives exist regarding the origin of the postconcussion symptoms.

Evans (1989, 1994) and Roberts (1988) elaborated on the notion of the PCS construct being entrenched in controversy for several hundred years.  Evans also stated that current controversies pertaining to concussions are comparable to injuries and their respective symptoms that persons reportedly sustained in railroad-related accidents during the mid to late 1800s in the United States and Europe (Caplan, 1995; Erichsen, 1997; Keller, 1995).  Reflected in the numerous terms utilized since the mid-1800s to describe the present day postconcussion construct, these controversies range from acknowledging to disputing the existence of the syndrome, and they include a debate as to whether its etiology is organic or psychological/functional.  Evans also pointed out that the physiological basis of the postconcussive syndrome is becoming increasingly well-documented by abnormalities found in pathologic, neurophysiological, neuroimaging, and neuropsychological studies. (1994, p. 5).

Postconcussion symptoms were once labeled accident neurosis as the symptoms were originally thought to be primarily related to secondary gain (Brown et al., 1994). After an extensive review of literature relating to mild brain injury studies, Brown et al. concluded post- concussional symptoms existed and that the “preponderance of the evidence favors the conclusion that concussed persons are at risk of developing cognitive, vegetative, and affective-behavioral sequelae, some of which affect day to day life” (p. 21). Levin, Benton and Grossman   (1982), as cited in Reitan and Wolfson (1986), pointed out that current available evidence regarding postconcussive syndrome favors the view of concussion as a severity continuum of diffuse injury (Reitan & Wolfson, 1986, p. 15). In an extensive literature review on concussions, Evans (1994) also pointed out that “the duration of posttraumatic amnesia and not brief loss of consciousness has been reported as predictive and not predictive of neuropsychological sequelae associated with a concussion” (p. 36). In the same vein, the significance of posttraumatic amnesia has received recent renewed attention in the sports related concussion field (Aubry, 2002; Giza, 2004).