A person can experience a concussion without striking their head, losing consciousness, or showing an abnormality on a routine CT scan.
That can make the injury difficult to recognize, especially when medical providers are focused on more visible problems such as neck pain, back pain, shoulder injuries, or broken bones.
During this episode of Mind Matters: Navigating Head Injuries and Concussions, registered nurse and treatment coordinator Kiley Como spoke with Dr. Gilbert Mbeo of the Brain Spine and Pain Institute about how neurologists evaluate concussions, why normal imaging does not rule out an injury, and how balance, eye-movement testing, and emerging blood biomarkers may help guide treatment.
A Concussion Is More Than the Impact
Dr. Mbeo explained that a concussion involves two important parts.
First, force must be transmitted to the brain. That may happen through a direct impact, such as the head striking a window or steering wheel.
It may also occur through rapid acceleration and deceleration. During a car accident, the head and body can move suddenly even when the skull does not strike anything.
Second, the person must experience some change in neurological function after the event.
That change may involve thinking, awareness, balance, vision, mood, sleep, or other brain-controlled functions.
Understanding both the mechanism and the symptoms helps the neurologist determine whether a concussion may have occurred.
The First Clues Often Come From the Patient’s Story
A concussion remains primarily a clinical diagnosis.
That means the provider begins by asking detailed questions about what happened and how the person felt immediately afterward.
Important statements may include:
- “Everything was a blur.”
- “I did not know what happened.”
- “I felt dazed or confused.”
- “I could hear people talking, but I could not understand them.”
- “I became dizzy when I stepped out of the car.”
- “My vision was blurry.”
- “My ears started ringing.”
- “I immediately developed a different kind of headache.”
The patient may not initially recognize these experiences as concussion symptoms.
They may be more focused on pain in the neck, back, knee, or shoulder and forget to mention how their thinking or awareness changed.
Mood and Sleep Changes Matter Too
Not every concussion symptom is physical.
Family members may notice that the injured person has become unusually irritable, withdrawn, anxious, or emotionally reactive.
The patient may also develop significant sleep problems.
They may struggle to fall asleep, wake repeatedly, or feel as though restful sleep has disappeared completely.
Pain can certainly interfere with sleep, but Dr. Mbeo explained that sleep disruption may also be part of the neurological changes following a concussion.
Asking about sleep, mood, and behavior can therefore reveal problems that might be missed during a basic physical examination.
A Normal CT Scan Does Not Rule Out a Concussion
Patients are sometimes told they do not have a concussion because their CT scan was normal.
Dr. Mbeo emphasized that this is a misunderstanding of what the scan is designed to detect.
An emergency CT scan is primarily used to look for serious structural problems such as bleeding in the brain.
A normal result is reassuring because it means the test did not identify an obvious emergency. However, it does not prove that the brain is functioning normally.
Most concussions do not produce abnormalities that can be seen on a routine CT scan.
The diagnosis still depends on the accident history, symptoms, neurological examination, and other appropriate testing.
There Is No Single Gold-Standard Concussion Test
Dr. Mbeo explained that there is currently no one test that can independently confirm or exclude every concussion.
The neurologist must combine several pieces of information:
- The mechanism of injury
- Immediate symptoms
- Ongoing neurological complaints
- Physical and neurological examination findings
- Balance function
- Eye movements
- Cognitive performance
- Available laboratory or imaging information
Objective tests can add weight to the diagnosis, but they do not replace the clinical evaluation.
They can also show which systems have been affected and help determine what type of rehabilitation the patient may need.
Emerging Blood Biomarkers
One developing area of concussion testing involves blood biomarkers.
Biomarkers are measurable substances that may provide evidence of injury or disease.
Dr. Mbeo discussed two proteins that have been studied in connection with brain injury:
- GFAP
- UCH-L1
He compared the concept to blood testing after a suspected heart attack. A doctor may look for proteins released when heart tissue has been injured.
Researchers are examining whether brain-related proteins can provide similar information following neurological trauma.
Dr. Mbeo stressed that concussion biomarkers are still developing and are not yet a universal stand-alone diagnostic test.
A negative result also would not necessarily prove that no concussion occurred, particularly when testing happens well after the injury. The body may have already cleared the measurable proteins.
A positive result, however, may provide additional objective information when considered alongside the patient’s history and symptoms.
Why Balance Testing Is Important
A patient may believe their balance is normal until it is formally tested.
At the bedside, a provider may ask the patient to stand with their feet together and close their eyes. Someone who felt stable moments earlier may begin swaying or struggling to remain upright.
More detailed testing may use a force plate to measure the direction and amount of sway under different conditions.
The patient may be tested with:
- Eyes open
- Eyes closed
- A firm surface
- A softer or unstable surface
- Different combinations of visual and sensory information
These tests examine how the brain combines information from the eyes, inner ears, muscles, and joints to maintain balance.
Test Results Should Lead to Action
Finding balance dysfunction is not simply about proving that a problem exists.
It helps the provider decide what to do next.
A patient with significant post-concussion balance deficits may benefit from vestibular rehabilitation or another form of balance-focused therapy.
This treatment may involve controlled head movements, gaze exercises, standing activities, walking tasks, or gradual exposure to situations that trigger dizziness.
The exact program should be based on the patient’s examination and tolerance.
Objective testing can also establish a baseline that allows the provider to measure progress over time.
Eye Movements Reveal Brain Function
Vision depends on more than the physical structures of the eyes.
The brain must control eye movements, keep images stable, track objects, shift between targets, and interpret what the eyes are seeing.
After a concussion, patients may report:
- Light sensitivity
- Double vision
- Difficulty reading
- Headaches during screen use
- Visual fatigue
- Blurred vision
- Dizziness in traffic
- Discomfort around moving objects
A basic bedside examination may involve asking the patient to follow a finger with their eyes.
However, subtle abnormalities may be difficult to detect without more sensitive equipment.
Video Testing Can Detect Subtle Abnormalities
Dr. Mbeo discussed tools similar to video nystagmography, which magnify and record eye movements.
These tools may reveal small jumps, irregular tracking, or other abnormalities that appeared normal during a basic examination.
Testing may examine the patient’s ability to:
- Follow a moving target smoothly
- Make quick eye movements between points
- Maintain focus
- Move the eyes horizontally or vertically
- Coordinate visual and vestibular information
These findings may help explain why someone becomes exhausted while reading, develops headaches in visually busy environments, or feels disoriented while watching surrounding traffic.
Visual and Vestibular Symptoms Often Overlap
The eyes and balance system work closely together.
When a person turns their head, the vestibular system helps keep the eyes stable so the environment does not appear to jump or blur.
A concussion may disrupt this coordination.
Someone sitting in traffic may suddenly feel overwhelmed when cars begin moving beside them. Another person may become dizzy in a grocery store because of bright lights, patterned aisles, and people moving in different directions.
These experiences can feel difficult to explain, but visual and vestibular testing may help identify the underlying dysfunction.
Objective Findings Can Validate the Patient
Brain injury survivors are often told they look fine.
When scans are normal and symptoms are difficult to describe, they may begin questioning their own experience.
Objective balance and eye-movement testing can provide validation.
The patient can see that the problem is not simply a lack of effort or imagination. The nervous system is responding differently than it did before the injury.
That validation may also help family members understand why the person struggles with activities that once seemed simple.
Diagnosis Should Guide Rehabilitation
The purpose of concussion testing is not merely to attach a label to the patient.
It should help identify the systems that need treatment.
Depending on the findings, the recovery plan may include:
- Vestibular rehabilitation
- Vision therapy
- Balance training
- Cognitive rehabilitation
- Headache management
- Sleep treatment
- Mental health support
- Cervical or musculoskeletal therapy
No single test or treatment is appropriate for every patient.
A person whose main problem is balance may need a different plan than someone whose greatest difficulties involve reading, memory, sleep, or emotional regulation.
A Careful History Remains the Foundation
New technologies may improve concussion evaluation, but they do not eliminate the need to listen carefully to the patient.
The neurologist must still understand the forces involved, what the person experienced immediately afterward, which symptoms developed later, and how life has changed since the injury.
A normal CT scan does not close the case.
When the history and symptoms suggest a concussion, a more complete neurological evaluation may uncover balance, visual, cognitive, or other functional problems that routine emergency testing was never designed to detect.
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