injuries are considered concussions (Cassidy 2004, Numminen 2011). In most cases, concussion symptoms last for a few days but rarely beyond 10–30 days (McCrory 2013, Broglio 2014).
Patients whose symptoms last for more than 30 days experience more physical, cognitive, and neurobehavioral signs and symptoms (O’Neil 2013, Williams 2015, McCrea 2003, Nelson 2016). When concussion symptoms last longer than 3 months following the initial injury, the condition is labeled as post-concussion syndrome. In this case, there are usually neurophysiological and neuropathological injuries to the brain structures, causing the disorganization and disruption of brain and body cycles, as well as functioning (Silverberg 2011).
Patients with repeated concussions tend to suffer greater long-term effects of concussion and/or TBI.
For the purpose of this book, “concussion” is defined as a milder form of TBI where the patient may or may not experience an alteration in or loss of consciousness for a brief period of time that is generally less than 30 minutes and may have the associated signs and symptoms but no focal neurological deficits. Focal neurological deficits generally involve an impairment in the neurological function of one or more parts of the body after an injury (e.g., weakness on one side of the body). The term “Traumatic Brain Injury” will be reserved for the more severe forms of injury, where there is one or more of the following: significant alteration in or loss of consciousness generally for more than 30 minutes; focal neurological deficits; or abnormal findings on CAT scan or routine MRI related to the injury. Abnormal CAT and MRI scans are rarely seen in concussion, depending upon how concussion is defined in various studies.
Between 5–15% of concussed patients will have trauma-related positive findings on MRI (Ellis 2015, Morgan 2015).
More recent sequences (techniques) in MRI, such as diffusion tensor imaging (DTI), can show abnormal findings in concussion patients that were not previously documented using the CAT scan or the regular MRI sequences (Arfanalkis 2002, Niogi 2008, Wilde 2008).
We now have both anatomic and physiological tools to evaluate one’s brain function after an injury, and while many of these tools are yet in their early stages of development, they tell us quite a bit about how the brain actually works, when an injury occurs, and what happens during recovery. Positron emission tomography (PET) scans and functional MRI (fMRI) are promising, as they look at the metabolism of glucose to reflect the functioning of distinct areas of the brain. The fMRI utilizes cognitive paradigms during imaging to look at the functioning networks and their connections to various areas (nodes) of the brain to determine their relationship while performing certain tasks (Medaglia 2017).
While there are limitations in these methods, they are valuable in the detection of injury and in understanding the patterns of recovery when compared to a normal functioning brain.
Recently, various pronouncements have been made about the identifiable markers of concussion/brain injury, which are found in blood and cerebrospinal fluids and that can be measured in the laboratory following an injury. Undoubtedly, findings such as these will ultimately change the definition of concussion and TBI. What we now know is that the definition of concussion will continue to evolve as we learn more about the science of brain injury.
Note that “traumatic brain injury” or “TBI” and “brain injury” are often used interchangeably to describe all forms of injury, including severe traumatic brain injury and concussion. “Concussion” and “cerebral concussion” are also used interchangeably.
Words and Concepts that Truly Define the Hierarchical Brain
Defining certain concepts and categorically organizing such concepts in a meaningful way to effectuate diagnosis and treatment and predict outcomes is what BHET is all about. While there are various approaches to evaluate and treat TBI/concussion, the BHET method espouses that there can indeed be a right and wrong way to evaluate and treat persons who carry the diagnosis of TBI or concussion.
Structural Anatomy: Relates to the physical structures of the nervous system that are both microscopic (also referred to as histological anatomy) and macroscopic that can be seen with the naked eye (also referred to as gross anatomy).
Physiology: Deals with the biology of how all living organisms work in relation to physical and chemical processes.
Cognitive or Neurocognitive or Neuropsychological Functioning: Deals with the cognitive function of humans that allows us to behave in certain ways that express who we are, what we believe, what is important to us, and how we relate to each other. It involves how we communicate, understand, express emotions, learn, memorize, perceive, process information, and relate to others and the world around us.
Neurobehavioral Functioning: Relates to how we react to who we are, what we perceive others to be, and how we respond to a situation. For example, anger, depression, anxiety, paranoia, and obsessive-compulsive tendencies are more neurobehavioral and can occur as a result of physical and neurocognitive factors, the environment, injury, or genetic defects that impact our physiological, functional, and our structural order.
Psychosocial: Looks at how the psychological factors and the social environment impact the physical health and mental wellness of an individual and their ability to function in society.
The hierarchical approach takes into consideration the following concepts:
1. Understanding the normal working of the brain and the working of the brain following injury – Having knowledge of the normally working brain enables a comparative understanding of the levels of disorganization that occur following injury and the subsequent reorganization that occurs during the recovery process. Anatomical, structural, and physiological disorganization produces a certain symptoms complex. Patients are not only treated according to the level of signs (what the professional finds) and symptoms (what the patient experiences) but also based on an understanding of the anatomical, structural, and physiological disorganization that disrupts the hierarchical order of functioning. This disruption can produce a complex set of symptoms reported by the patient and signs noted by families, caregivers, and through a meticulous evaluation performed by qualified clinicians. In doing so, BHET focuses on determining the level and severity of injury at every stage of the recovery process in terms of the hierarchical organization. BHET utilizes realistic evaluation methods to properly classify those conditions.
2. Treatment Concepts – The simple principles of what to treat first, where to start, how one sign or symptom relates to another, what athe triggers of a sign or symptom are, how to proceed with and when to end a treatment modality, are all critical issues in TBI/concussion. It is essential to establish the order and sequence of administering a treatment modality after the condition has been properly staged and classified. Once the level of disruption is established, there is generally an attempt to match the available treatment modalities to the patient based upon the level established. While the levels cannot always be neatly defined, any effort to classify the disorder into a hierarchy will go a long way towards treatment planning. BHET also provides sensible, logical, and whenever possible consensual and evidence-based tangible treatment modalities that generally produce positive results. This facilitates an approach that determines what should be evaluated and treated in the appropriate sequence and manner for effective recovery. This model utilized to treat TBI has the level of hierarchical organization and reorganization following TBI/concussion as its focus. Addressing those issues utilizing the BEHT method has made the concepts meaningful. Clinicians must resist the urge to start treatment when they have no idea what they are treating but feel the urge to do something because of the suffering reported by patients and their families. Such issues of treatment will be addressed in the second volume of this book series.
BHET provides a framework that can be utilized for making critical decisions about staging, prognostication, and treatment. This book was designed to bridge a significant chasm that exists among the various
