A person can experience headaches, dizziness, anxiety, memory problems, and major changes in daily function after a concussion while still receiving a normal MRI or CT scan.
That does not mean the symptoms are imagined. It means traditional imaging is designed primarily to show structure, while many concussion problems involve how the brain functions.
During this episode of Mind Matters: Navigating Head Injuries and Concussions, legal nurse consultant Kiley Como continued her conversation with Dr. Eric Reese of the Neural Connection about functional concussion testing, mental health changes, invisible injuries, and emerging research involving the vagus nerve.
Structural Imaging Has an Important Purpose
MRI and CT scans are valuable medical tools.
They may identify serious structural problems such as:
- Brain bleeding
- Tumors
- Skull fractures
- Blood vessel abnormalities
- Large areas of tissue damage
- Other medical emergencies
These tests are extremely important when a provider is looking for a dangerous condition that requires immediate intervention.
However, they may not reveal the functional changes associated with a concussion or mild traumatic brain injury.
A clear scan can provide reassurance that certain major structural problems were not found, but it does not necessarily explain how well the brain is processing vision, balance, movement, memory, or emotion.
The Difference Between Structure and Function
Dr. Reese compared brain imaging to looking at a car.
A vehicle may appear perfect from the outside, but that does not tell you whether the engine starts, the brakes work, or the transmission shifts properly.
To understand the vehicle, someone must test its function.
The same concept applies to the brain.
A provider may need to examine whether sensory information is entering the nervous system correctly and whether the brain is producing the expected response.
This may involve evaluating:
- Reflexes
- Cranial nerves
- Eye movements
- Balance
- Coordination
- Posture
- Memory
- Reaction time
- Symptom response to activity
These assessments can reveal problems that may not appear on a structural scan.
Making Balance Problems Measurable
Balance problems are common after concussions, but they can be difficult to describe objectively.
Traditional examinations may ask the patient to stand with their feet together, close their eyes, or change their head position while the provider watches for instability.
Newer testing platforms may measure the patient’s sway using force plates and specialized software.
Dynamic posturography can create a visual record of how the patient maintains balance under different conditions.
This gives providers an objective measurement that can be compared over time.
It may also help patients understand why they feel unsteady even when they appear normal to other people.
The Eyes Provide a Window Into Brain Function
Eye-movement testing is another useful part of a functional neurological evaluation.
Dr. Reese discussed video nystagmography, which uses specialized goggles and software to record eye movements.
The provider may examine:
- Involuntary eye movements
- Visual drifting
- The speed of eye movements
- The ability to focus on a stationary target
- The ability to move the eyes quickly between targets
- Patterns associated with dizziness or balance problems
These findings may help document how the nervous system is functioning on the day of the test.
Repeat testing can then show whether the patient has improved after several weeks of rehabilitation.
Mental Health Changes Can Follow a Brain Injury
Depression, anxiety, fear, irritability, and post-traumatic stress can develop or worsen after a concussion.
Dr. Reese compared a brain injury to pouring water on a laptop. It may be impossible to predict exactly which programs will continue working normally and which ones will begin malfunctioning.
The brain relies on complicated networks that regulate emotion, judgment, memory, attention, digestion, blood pressure, and other functions.
When an injury disrupts communication within those networks, the patient may begin experiencing emotional or psychological symptoms that were not present before.
Those symptoms are not necessarily separate from the neurological injury. They may be one of its effects.
Why the Brain Prioritizes Basic Functions
Dr. Reese described the brain as a multi-level house.
The lower levels manage automatic functions such as blood pressure, digestion, posture, and basic survival responses. The upper level supports executive skills such as reasoning, memory, planning, and emotional regulation.
When a problem develops in the lower levels, the brain may redirect more energy and attention toward managing those basic functions.
This can leave fewer resources available for higher-level tasks.
A survivor may then struggle with concentration, decision-making, emotional control, or memory even though those abilities were strong before the injury.
Moving Beyond the Chemical-Imbalance Explanation
Mental health conditions have often been explained primarily through chemical imbalances.
Dr. Reese said the full picture is likely more complicated.
Certain antidepressants may affect serotonin, but they may also influence inflammation and immune cells within the brain. Other treatments, such as transcranial magnetic stimulation, affect neurological circuits without directly providing additional serotonin.
This suggests that inflammation, brain networks, electrical activity, previous mental health conditions, genetics, and nutrition may all contribute to depression or anxiety after an injury.
There may be several possible treatment opportunities, including medication, cognitive behavioral therapy, neurological rehabilitation, nutritional support, and other specialized care.
The correct approach depends on the individual patient.
Why Neuropsychological Testing Can Help
When emotional or cognitive symptoms are significant, Dr. Reese may refer a patient for a neuropsychological evaluation.
This testing may assess areas such as:
- Memory
- Attention
- Processing speed
- Reasoning
- Emotional health
- Executive function
- Language
- Learning
Neuropsychological testing can help document the difficulties the patient is experiencing.
It may also reassure the survivor that the symptoms are real and worthy of treatment.
The evaluation does not provide every answer, but it can help the medical team identify limitations and create a more appropriate rehabilitation plan.
The Invisible Nature of Brain Injuries
One of the greatest public misunderstandings about concussion is the assumption that a person who looks healthy must be fully recovered.
A cast, wheelchair, or surgical scar provides visible evidence that an injury occurred. Concussion symptoms may remain hidden.
Friends, relatives, employers, and others may expect the survivor to function exactly as they did before.
The patient may hear comments such as, “You look fine,” or, “Why aren’t you better yet?”
That lack of understanding can increase isolation, anxiety, and self-doubt.
Dr. Reese described traumatic brain injury as a silent epidemic because many survivors struggle with serious limitations that other people cannot see.
Education Creates Greater Empathy
Public education should emphasize that concussions can affect much more than memory.
A survivor may struggle with:
- Bright lights
- Loud environments
- Crowded stores
- Driving
- Computer screens
- Emotional regulation
- Sleep
- Fatigue
- Headaches
- Balance
- Anxiety
- Social interaction
These limitations may vary from day to day.
Understanding the invisible nature of the injury can help family members, coworkers, and friends provide better support.
The survivor may not need to be treated as incapable. They may simply need patience, flexibility, and recognition that recovery is still taking place.
The Future of Vagus Nerve Stimulation
Dr. Reese is especially interested in research involving vagus nerve stimulation.
The vagus nerve is connected to the parasympathetic nervous system, sometimes called the “rest and digest” system. It helps balance the body’s stress response.
After a traumatic brain injury, some patients may remain in an extended fight-or-flight state. This can contribute to pain, inflammation, anxiety, sleep problems, and difficulty calming down.
Vagus nerve stimulation is already being studied or used for several conditions, including:
- Epilepsy
- Migraine
- Cluster headaches
- Anxiety
- Depression
- Post-traumatic stress
- Stroke rehabilitation
- Inflammatory conditions
Dr. Reese believes this area may eventually provide additional tools for concussion and TBI rehabilitation.
The research is still developing, and patients should not assume every commercial device has been proven effective for brain injury.
Functional Testing May Shape Concussion Care
The future of concussion evaluation may involve a combination of clinical examinations, objective balance testing, eye-movement analysis, neuropsychological testing, wearable technology, and advanced software.
MRI and CT scans will remain important for identifying structural emergencies.
Functional assessments may help answer a different question: not simply what the brain looks like, but how well it is working.
For concussion survivors, that distinction matters.
A normal scan should not end the search for answers when headaches, dizziness, emotional changes, memory problems, or other symptoms continue.
The next step may be a closer examination of how the nervous system is functioning and which parts of that system need rehabilitation.
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