lay public. By taking this very complex area of neuroscience that utilizes case histories and models, BHET makes it easy to understand this complex condition.
A major point of failure with clinicians treating TBI is their limited understanding of the hierarchical organization of the brain before and after injury and the subsequent recovery path that the brain follows during recovery. I have personally seen patients be harmed because of this misunderstanding. In fact, certain treatment modalities are often administered at the wrong time or stage of recovery because of a misunderstanding of the brain’s hierarchal organization and the process by which such disorganization is restored following injury. BHET was developed based on my experience as a neuroscientist working in the field of brain injury with a team of colleagues who I have come to respect and admire. In developing this method, I have been able to utilize my experience in leadership and business, the practice of neuroscience, knowledge of the human condition, and my understanding of how the nervous system works, in order to conceptualize and implement BHET.
Features of Cerebral Concussion and TBI
Key Elements that Define Concussion
ONE OF THE best definitions provided for concussion is based on a consensus statement provided at the 4th International Conference on Concussion in Sports held in November 2012 in Zurich. This very progressive definition evolved from the changing evidence that we now have on concussion. The definition is as follows: “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:
1. Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an ‘impulsive’ force transmitted to the head.
2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged” (McCrory 2013).
BHET defined: Concussion occurs when mechanical forces affect the brain in such a manner that it disrupts the structural and physiological hierarchical organization and the associated functioning of the brain to the point that the patient experiences signs and symptoms that we now know are characteristic of concussions. In TBI/concussion, signs are what the healthcare providers find and symptoms are what the patients report.
These signs and symptoms include the following:
• Physical or somatic – fatigue, dizziness, spinning sensation, headaches, sleep disturbance, and lack of energy. Headache is the most commonly reported symptom in TBI/concussion, followed by dizziness, vertigo, and fatigue. A hallmark reported somatic symptom suggesting a disruption in the brain cycle is difficulty falling asleep and staying asleep.
• Cognitive – mental fog, memory and attentional impairment, and word-finding and visual perception problems. The hallmark feature of TBI/concussion is the inadequacy in executive functions, manifested by diminished insight, speed of processing, trouble with social graces, and in one’s ability to shift from one set of cognitive tasks to another.
• Neurobehavioral – anxiety, OCD, depression, low self-esteem, disinhibition (loss of filter), fear, short fuse, and personality changes that could include aggression, emotional lability (inappropriate laughter or crying), impulsivity (lack of impulse control), and irritability (Riggio 2009).
• According to Riggo (2009), neuropsychiatric or neurobehavioral symptoms actually are correlated with the severity, type, and duration of the somatic symptoms. This issue of which comes first the chicken or the egg, i.e. the physical somatic symptoms causing the cognitive and behavioral symptoms or vice versa is critical to understand TBI and concussions and how to treat such conditions.
Signs and symptoms in the immediate and chronic phases Immediate:
• Impaired attention – vacant stare, delayed responses, inability to focus
• Slurred or incoherent speech
• Gross incoordination
• Disorientation
• Emotional reactions out of proportion
• Memory deficits
• Any loss of or alteration of consciousness
Within one hour to days:
• Persistent headache
• Dizziness/vertigo
• Poor attention and concentration
• Memory dysfunction
• Nausea or vomiting
• Frequent fatigue
• Irritability
• Intolerance of bright lights
• Intolerance of loud noises
• Anxiety and/or depression
• Sleep disturbances
Concepts on Classification – It is now commonly believed that a proper classification system is necessary for the allocation of resources, treatment, and for determining the severity, prognosis, and outcomes. However, due to our recent understanding from new pathological studies, imaging, and new emerging clinical evaluation and treatment methods, we now can revisit how we define and classify TBI and concussion.
For years, experts in the field of TBI/concussion have applied many classification systems to better define the condition. However, these systems that worked previously may not be as relevant given the new understanding we have of injury and the science of the body. Many of the very strict classification systems used in the past that supported research initiative and clinical evidence required the patient to have suffered LOC and in some cases hospitalization. In fact, many of the older publications on concussion stipulated that one had to have a loss of consciousness as a criterion for establishing a concussion. No wonder many physicians (including neurologists), attorneys, and sports medicine programs still hold on to that belief.
Here is a classification system utilized for concussion, based on the acute severity at the time of the injury, which has been utilized by the VA and Department of Defense.
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