Head injury occurs when the skull slams against a windshield, the ground, or some other object. Injury to the head or brain also can occur without direct impact to the head, as in severe "whiplash." The compression, twisting, and distortion of the brain inside the skull associated with this impact or violent movement has the potential to cause localized as well as widespread physical damage and electrochemical disruption throughout the brain. In addition, damage is often sustained to bone, muscle, and vertebral tissues of the cranial (skull and scalp) and cervical (neck and shoulder) structures. Thus, head injury is the general term that refers to potential injury involving the complex of cerebral, cranial, and cervical structures. Mild head injury, specifically, refers to trauma that results in no or brief loss of consciousness, typically less than about five minutes.

Post-concussion syndrome usually involves symptoms stemming collectively from injury to the cerebral, cranial, and cervical areas. Headache and other pain, dizziness or light headedness, memory and concentration difficulty, amnesia, sleep disturbance, frustration and irritability, periods of confusion or mental dullness, emotional and behavioral changes, loss of self-confidence, fatigue and weakness, tinnitus, visual distortions, and slow reactions are common characteristics following mild to moderate head injury. Post-concussion symptoms usually become rather intense soon after an injury. Many symptoms lessen or abate altogether with time—often within one year from the injury. Usually, there are no abnormalities on routine neurological examination, making post-concussion syndrome an often overlooked or under-diagnosed problem.

These and any other symptoms from head injury need to be sorted out and associated with the mechanism and anatomical nature of the injury. Potentially exacerbating or ameliorating factors need to be identified. Then, the whole matrix of injury mechanisms, symptoms, personal and medical history, diagnostic test results, successful and unsuccessful treatments, and emotional reactions needs to be understood. This understanding, complex as it usually is, forms the basis for predicting, prescribing, and achieving optimum clinical resolution. This is the role of the clinical neuropsychologist.

Sequelae and Intervention Following Head Injury

A mild head injury, such as from a fall, an automobile accident, or a work mishap, often brings the person to the attention of a physician or a hospital emergency room. If there are no complications or other injuries apparent, the person is checked over and sent home, perhaps with a prescription for pain relievers and a checklist to watch for any complications that might develop. Without timely, appropriate, and comprehensive follow-up diagnosis, education, and treatment, the lingering problems from uncomplicated head injury can mushroom into seemingly relentless frustration.

Underdiagnosis or misdiagnosis of the multiple cognitive, behavioral, and somatic complaints following head injury is common. Ultimate recovery and maintenance of a positive attitude toward recovery, as well as adjustment to the emotional trauma of the event that caused the injury, depend on early, appropriately intensive, and comprehensive intervention. Too often, symptoms are acknowledged by health care providers but are understated or minimized. The urge to get persons back to work too soon and without comprehensive understanding of the injury often creates emotional and cognitive obstacles and usually worsens the symptoms and outcome due to creation of stress, greater discomfort, chronic re-injury, and feelings of distrust and resentment.

Educating the patient, family, employer, case manager, and others involved in the lifestyle changes caused by brain injury is of extreme importance. Everyone needs to understand that even though no bones may be broken, no cuts sustained, and that the injured person may look and talk just fine, there is real injury. The complex injury involving cerebral contusion and diffuse axonal injury within the brain, trauma and stretching of cervical muscles and supportive tissue, abrasion within the cervical vertebrae, soft tissue injury to muscle and circulatory structures of the head, chronic muscle strain due to guarded behavior in response to pain, changes in cerebral circulation and perfusion, and potential neurochemical and neurotiming changes in brain function provides the foundation for a host of behavioral, emotional, and cognitive changes.

Diminished self-confidence, negative self-reference, inflexibility, desire for withdrawal, slower thinking, emotional unpredictability, and frustration intolerance stem from the complexity of injury. If the patient, family, employer and others do not understand the injury and its consequent dynamics, unreasonable expectations, charges of malingering, and inappropriate treatment will typically follow. Failure to understand and appropriately treat mild to moderate brain injury can result in prolonged and less than desirable ultimate outcome.

What Is A Neuropsychological Evaluation?

Neuropsychology is the scientific and clinical study of how the brain controls behavior and mental functions. This involves understanding how the brain influences emotions, personality, thinking, learning and remembering, problem solving, and adjusting to life’s demands. Neuropsychological evaluation is the application of objective psychological tests and other procedures that assess the array of functional strengths and weaknesses for diagnostic clarification and for treatment planning. Scientific and statistical techniques are used to infer premorbid (preexisting) characteristics of the individual and to provide an index of the extent and type of changes brought about by injury. Personality and emotional assessment usually accompanies neurocognitive assessment to determine impact of non-neurological factors on the clinical presentation. Prognosis for recovery and adaptability can be inferred based on objective test outcome, considered within the understanding of the complex matrix of relevant injury factors and personality/emotional variables.

By application of a wide range of psychological tests and procedures, mental functions sensitive to brain injury can be measured objectively. Based on an analysis of the profile of standardized scores and trained clinical observations of the individual’s mental processes, evaluation is made regarding: (1) structural brain condition, (2) deficiencies caused by brain trauma versus other conditions such as pain, emotions, personality, and pre-injury conditions that contribute to functional status, (3) strengths in cognitive and psychosocial skills, (4) comprehensive diagnostic understanding of the physiological, psychological, and cognitive impact of the injury, (5) extent of injury and prognosis for recovery, (6) specific treatment needs along with identification of barriers to and assets for recovery, (7) objectively-based prognosis for return to work, school, and other activities, and (8) foundation for life-care planning.

Diagnosis of head and brain injury must be made considering the patient’s personal capability and work history, psychological resources and weaknesses, mechanism of injury, neurodiagnostic assessment, and neuropsychological evaluation. Understanding head injury and its complex consequences requires collaboration among several health care specialists. The neuropsychologist must understand who the person was before the injury, what the potentially multiple neurological and somatic results are (from physician and laboratory reports), and what the resources are that will contribute to an optimum resolution. Integration of results from emergency room treatment, neurological examination, CT, MRI, PET SPECT, EEG, BEAM, non-neurological contributing factors, emotional reactions, quality of family and employer support, and multiple premorbid factors is typically accomplished by the neuropsychologist within the scope of the comprehensive neuropsychological evaluation.

Brief neuropsychological consultation is appropriate usually in the early stages following a brain injury. Too often, persons are not referred to the neuropsychologist (and then usually only later for full assessment) until the dysfunctional pattern of brain trauma or injury has become well established. Early consultation with the neuropsychologist, during the acute recovery stages, can provide invaluable assistance with patient and family education, early identification of potential problem areas, and therapeutic assistance.

A 1-2 hour interview, brief testing, and consultation in ways to improve attention, memory, other cognitive problems, and family adjustment can help avoid problems later. Providing immediate feedback, education, and behavioral counseling is clinically appropriate during early recovery. Planning recovery strategies can be more meaningful once the neuropsychologist has a handle on the nature of the injury, recovery course so far, patient and family resources, and barriers and assets for recovery.

Comprehensive neuropsychological assessment is warranted when recovery appears to be leveling off and yet when subjective problems remain. Issues of longer-term therapy, planning and timing for return to work or school, and methods for coping with permanent changes can be addressed two to six months following injury. Delineation of the final outcome, based on comprehensive understanding of the patient, provides the foundation for possible long-term disability, litigation settlement, and long-range life planning.

Neuropsychological treatment can be initiated at any time to help patients and families understand the complex consequences of brain injury, develop compensation strategies, deal with the emotional and behavioral changes, and help reconstruct a positive future. Often, the neuropsychologist will work concurrently with a physician in providing an appropriate mix of psychological and medical treatments. Cognitive treatment may be accomplished in either individual or group formats.

Appraisal of the Neuropsychological Evaluation

The following questions might be asked to determine the scope, thoroughness, and utility of the neuropsychological evaluation in cases of head and brain injury. Most, if not all, of these issues should be addressed in the comprehensive neuropsychological assessment report:

Achieving a comprehensive neuropsychological evaluation of persons sustaining head and brain injury is usually a complex and lengthy procedure. Accurate and objective data thoroughly considered in light of historical information, medical and neurological studies and treatments, psychological and emotional factors, financial and other stresses, and other relevant information will always yield an assessment that "hangs together." Successful case understanding means that all the angles have been considered and that integration has been achieved.