If you’re searching for answers and think you might have post-concussion syndrome (PCS), the path to diagnosis can be challenging. Few medical professionals are experts on the condition, and many lack the most sophisticated diagnostic tools. Many doctors will make a diagnosis based on concussion symptom history and a quick physical examination. Others will supplement their findings with imaging or computerized testing.
We understand that obtaining a post-concussion syndrome diagnosis can be both stressful and a relief, all at the same time. Many patients have been to more than one doctor before getting their diagnosis. To make the process a little easier, we’ve put together a post that explains what methods are in use today to diagnose PCS, what their strengths and weaknesses are, and how the best testing methods enable you to get better treatment.
If you’re experiencing symptoms that won’t resolve after a concussion, you’re not alone. And you’re not crazy. On average, our patients improve by 75% after treatment at our center specializing in neuroplasticity-based therapy. To see if you are eligible for treatment, sign up for a free consultation.
Ruling Out Other Causes
In order to receive a post-concussion syndrome diagnosis, you must have had a precipitating event — meaning you must have experienced some kind of head trauma, be it physical impact, whiplash, or heavy jostling. Were you in a car accident? Did you fall and hit your head? Did you have a bad experience on an amusement park ride?
Most PCS patients can point to a specific incident that causes their symptoms. Others may have had a series of head injuries rather than just one. However, it’s important to note that loss of consciousnessat the time of injury is NOT required for a concussion to occur. Many people mistakenly believe that their head injury couldn’t be a concussion because they didn’t lose consciousness. In reality, 90% or more of concussion patients do not experience a loss of consciousness.
If, however, you are experiencing some symptoms of PCS but did not have head trauma of some kind, it is unlikely that PCS is the cause.
Your doctor will need to know your medical history to make a PCS diagnosis and treatment plan. Some common symptoms of concussion can be caused by other conditions, and sometimes patients have post-concussion syndrome plus other difficulties. For example, we often see post-traumatic stress disorder alongside PCS. Depression and anxiety may stem from the injury, or they may have been pre-existing.
Think of it this way: Nearly 83% of patients suffering from post-concussion syndrome report mood or personality changes! It’s very easy for them to see a mental health professional first and completely miss the PCS diagnosis. But doctors also have to make sure that PCS — and not an underlying issue — is at the heart of those changes.
You can help your provider by making clear distinctions between symptoms you experienced before the traumatic event vs. after the injury. This can affect the outcome of your treatment, so it’s important to provide any information your physician requires to the best of your ability.
Post-Concussion Syndrome Tests Currently in Use
In this section, we cover five common diagnostic methods: the SCAT2, CT scans, MRI scans, qEEGs, and baseline testing. We’ll also highlight and explain which practices we think are best.
SCAT2 and Self-Reported Concussion Symptoms
Most doctors do not have advanced equipment at their disposal, so they rely on clinical expertise, the patient’s description of symptoms, and an in-person examination to make their diagnosis.
A common way to do this is to use the SCAT2, short for Sport Concussion Assessment Tool 2. But that doesn’t mean it can’t be used on non-sport-related concussions. It can be used to diagnose any mild traumatic brain injury. The SCAT2 is primarily used to diagnose the initial injury but may be used to help with a post-concussion syndrome diagnosis as well.
The Post-Concussion Symptoms Scale
The test begins with a PCSS, or Post-Concussion Symptoms Scale. The patient rates his or her symptoms on a scale from 0 to 6, where six is the most severe. The symptoms you can report on this test include:
Nausea or vomiting
Nervous or Anxious
“Don’t feel right”
“Pressure in head”
Fatigue or low energy
Sensitivity to light
Feeling like “in a fog”
Sensitivity to noise
Feeling slowed down
Trouble falling asleep
For the majority of concussion patients, these symptoms go away in six weeks or less. But for those with post-concussion syndrome, persistent symptoms become the norm. Most of the time, post-concussive symptoms that do not disappear in six weeks will not go away without treatment.
That’s because PCS doesn’t look exactly the same in each person; different regions of the brain may be affected in different ways. Treatment of post-concussion syndrome is most effective when it takes those differences into account (more on that later).
After determining patient symptoms, the SCAT2 has several sections that look at physical symptoms.
The test looks at physical information such as:
State of consciousness (if administered immediately after head trauma)
The test also gives healthcare professionals guidelines as to how the patient should perform if concussed or not concussed.
The SCAT2 has two sections that evaluate cognitive function. It isn’t in-depth and is meant to be a quick assessment of things such as difficulty focusing or remembering. It covers things such as remembering what the month and day is, remembering a group of words and numbers (immediate recall), and then later in the test, remembering the words again (delayed recall).
Overall Usefulness of SCATII
The SCATII was designed for use soon after a concussion but has been used to diagnose PCS as well. Unfortunately, that means it is not well-optimized for someone who has been experiencing post-concussion symptoms for a long time. That said, the PCSS (self-reported symptom scale discussed above) is a good starting point for any diagnosis effort.
CT Scans for Concussion
Doctors may order a CT Scan when a traumatic brain injury (TBI) is suspected. CT (or Computerized Tomography) scans are used to take 2D images of bones and organs that can be collated to produce 3D images. A CT machine uses X-rays that are rendered in a specific way by the computer.
CT scans by themselves cannot diagnose a concussion, but they can rule out other causes of your symptoms. For example, let’s say you were a backseat passenger in a car accident and your head slammed into the side of the car. If you suffered a skull fracture or your brain was bleeding from the impact, a CT scan would detect that. Or if you’ve experiencing PCS-like symptoms but don’t remember having brain trauma, a CT scan might reveal that you have a brain tumor causing those symptoms.
Because concussion symptoms don’t come from the kind of structural damage that a CT scan can detect, a CT scan cannot positively diagnose PCS. But it can rule out major injuries like the ones described above.
A major downside to CT scans is radiation exposure. Patients are often given a liquid called “contrast” that is used to help technicians get a better image. If you’re concerned about radiation from a CT scan, talk to your doctor about risks vs. benefits and whether or not there are alternatives to get the information they need.
MRI Scans for Concussion
It’s not uncommon for a concussion patient to wind up in the emergency department, waiting for an MRI (short for “magnetic resonance imaging”). And in some situations, getting an MRI makes sense (for example, if the treating physician wants to check for internal bleeding).
An MRI shows soft tissue, so it can confirm whether or not your brain is intact. It doesn’t show bone well, so it’s not a great diagnostic option if you think you fractured your skull, for example. Regular MRI scans are powerful diagnostic tools for serious issues such as strokes, aneurysms, tumors, bleeding in the brain, and so forth. Plus, they don’t come with any radiation risk.
That said, most of the time, a regular MRI cannot detect post-concussion syndrome. But functional neurocognitive imaging (fNCI), which is a special type of MRI, can detect brain damage sustained from a mild TBI.
The ability to pinpoint neuronal communication problems is very important for our patients' recoveries. In our research, we’ve collected thousands of both healthy and PCS-patient brain scans. Using this database, we’ve calculated what “normal” is for most patients. From there, we can see which regions of your brain are behaving the way they should — and which will need attention. Our team can use that information to tailor each patient’s treatment plan accordingly.
Note: If you think you have post-concussion syndrome, schedule a free consultation with our staff. They can help you understand if PCS is a likely cause of your symptoms and determine if an fNCI scan is the right next step for you.
EEG for Concussion
Some treatment facilities use a quantitative EEG (qEEG) to make PCS diagnoses. EEGs detect electrical activity coming from your brain (more specifically, from your neurons). Normal brains usually have certain patterns that injured brains may deviate from. qEEG is sometimes a helpful test, and sometimes not. Here’s why.
With any EEG, one of the main difficulties to overcome is noise. Since the electrodes sit on the patient’s scalp, they’re often placed over hair, which can interfere with the quality of the measurement. But even if you use qEEG on a bald patient, it won’t be able to evaluate the brain completely accurately.
Why? The electrodes detect too much signal from the surface and just below the surface of the brain. That makes it extremely difficult, if not impossible, to distinguish where the signal is coming from. So if concussion damage is affecting neurons deep within your skull, a qEEG probably can’t tell you whether there’s anything wrong with them. If the damage is closer to the skull, you may have better information.
Information gleaned from qEEG can support a PCS diagnosis. Unfortunately, that’s the extent of its helpfulness: a qEEG can sometimes indicate a problem, but not what that problem is, where the problem is, or how it is best resolved.
Some people — particularly athletes — will take a baseline test to assess their pre-injury cognitive abilities. A baseline test is often just a cognitive assessment (usually computerized) designed to establish the normal cognitive ability for a particular person. Some tests also include visual and balance/physical testing as well, making them more useful. If you take a baseline test and then sustain a concussion, taking the same test may reveal cognitive deficits caused by the head injury.
Sometimes, this information is helpful. If you show a decrease in attention span, memory, and conversation tracking that persists beyond a few weeks, then the test is something you can use to prove the effect your concussion had.
Unfortunately, baseline testing also has its limitations. It’s not uncommon for athletes to sandbag the test (i.e., intentionally doing poorly on the initial test so that they will be quickly approved to return to play after a future concussion, should they sustain one). In addition, baseline tests are not always administered in a consistent manner. If they are administered differently, then a change in results can’t be exclusively attributed to the concussion. Finally, a baseline test is only helpful if you took one before your head injury — something many people don’t bother to do.
While baseline tests are popular in sports medicine, their contribution to a post-concussion syndrome diagnosis is limited.
How We Test for and Treat Post-Concussion Syndrome
At Cognitive FX, we diagnose post-concussion syndrome with a combination of imaging, physical tests, cognitive tests, and self-reported symptoms.
Post-Concussion Symptom Scale (PCSS)
We use information from the PCSS to get a quick idea of how much symptoms are impacting the patient in their everyday lives. We also ask them about other symptoms and have a conversation about what they’ve experienced. We review their medical history and make sure PCS seems like a reasonable explanation for what they’re facing.
We also have patients perform some quick physical maneuvers to check their balance, reflexes, vision, and so forth. For example, you might have to balance on one foot with the other leg bent while your eyes are closed. Your clinician will be observing you to see what difficulties, if any, you have with the task. For vision, we might hold out two fingers and have patients track the movement with their eyes only. Many patients will become dizzy from that exercise!
These form the minority of the testing we do, in part because the cognitive effects of PCS can vary so much from person to person. For one person, even basic logic exercises and reading could be extremely difficult. For another, complex thinking is within reach — for a short time, before they exhaust themselves. These issues are better described by the patient than tested during a diagnostic visit.
Functional Neurocognitive Imaging (fNCI)
For every patient who pursues treatment at our clinic, we take one “before” and one “after” fNCI scan. Doing so accomplishes several goals:
It is an excellent method to confirm diagnosis of PCS
It shows us exactly which regions of your brain were affected by a head injury (so we can tailor treatment to your specific needs)
It allows us to quantify your improvement after treatment.
The scan gives us an insider look at how your head injury affected communication in your brain. We then use one week of targeted physical and cognitive therapy to encourage neuroplasticity. This treatment pushes the brain to establish (or re-establish) more efficient communication pathways that resolve or greatly lessen PCS symptoms. You can read more about the treatment and why it works here.
What About the Autonomic Nervous System?
The autonomic nervous system (ANS) controls all the processes you don’t think about: breathing, heart rate, blood pressure, vascular (blood vessel) constriction and dilation, your fight or flight response, and more. It’s a bit like your body’s operating system: It’s behind the scenes, making sure things are working the way they’re supposed to.
Many patients don’t realize that, after a concussion, your ANS may become dysregulated. As you can imagine, having an autonomic nervous system that’s “off” can lead to a variety of common symptoms.
But because the ANS is a system spread throughout your body, it doesn’t show up on normal post-concussion syndrome tests. Unfortunately, there aren’t many options for objective testing of ANS function. However, an experienced concussion specialist can work with you to discuss your symptoms and determine if your autonomic nervous system was affected by your concussion(s).
Have had some kind of brain trauma (be it a blow to the head, heavy jostling, or whiplash), and
Experience symptoms in multiple SCAT2 categories
...then there is a good chance you have post-concussion syndrome. However, it is not possible to know for sure without consulting a medical professional who has experience with post-concussion syndrome. (Note:many general practice physicians, sports medicine doctors, and even neurologists do not have the experience or knowledge needed to diagnose and treat PCS effectively — it’s important to find someone with a proven track record and clear specialization in the field).
If you’re experiencing symptoms after a concussion, you’re not crazy. Post-concussion syndrome is a real condition that has real solutions. It does not have to be permanent. If you think you may have post-concussion syndrome, schedule a free consultation with our staff. They will help you understand your diagnosis and treatment options.
About Dr. Alina Fong PhD
Alina K. Fong received her PhD in Clinical Neuropsychology with an emphasis in neuroradiology from Brigham Young University. She received the national American Psychological Association Clinical Neuropsychology Division 40 Graduate Student Research Award in 2004 for her research on "Cortical Sources of the N400 and 'The N400 Effect." Dr. Fong's interest in brain mapping soon turned to functional MRI, and since then, her research efforts have been focused on the clinical applications of fMRI.