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Mild Traumatic Brain Injury and Postconcussion Syndrome: The New Evidence Base for Diagnosis and Treatment
This is the first neuropsychology book to translate exciting findings from the recent explosion of research on sport-related concussion to the broader context of mild traumatic brain injury (MTBI) and post-concussive syndrome (PCS) in the general population. In addition, it includes a Continuing Education (CE) component administered by the American Academy of Clinical Neuropsychology.
Traumatic brain injuries constitute a major global public health problem, but until now, MTBIs, which constitute up to 90 percent of all treated TBIs, have been difficult to evaluate and manage clinically because of the absence of a viable model. Dr. McCrea's book thus provides a welcome evidence base for all clinicians - including psychologists, neuropsychologists, neurologists, neurosurgeons, rehabilitation medicine physicians, physiatrists, and nurses - involved in the clinical diagnosis and treatment of MTBI, as well as attorneys involved in personal injury litigation and personal injury defense. Each section of the book ends with a helpful summary of the 'Top 10 Conclusions.' Instructions for earning AACN-administered CE credit are included.
Traumatic brain injuries constitute a major global public health problem, but until now, MTBIs, which constitute up to 90 percent of all treated TBIs, have been difficult to evaluate and manage clinically because of the absence of a viable model. Dr. McCrea's book thus provides a welcome evidence base for all clinicians - including psychologists, neuropsychologists, neurologists, neurosurgeons, rehabilitation medicine physicians, physiatrists, and nurses - involved in the clinical diagnosis and treatment of MTBI, as well as attorneys involved in personal injury litigation and personal injury defense. Each section of the book ends with a helpful summary of the 'Top 10 Conclusions.' Instructions for earning AACN-administered CE credit are included.
222 pages, Paperback
First published September 20, 2007
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December 28, 2025
An excellent summary on the topic of Mild Traumatic Brain Injury (mTBI) and the related issues in clinical practice and research that was a great primer for writing an essay on the links between mTBI and posttraumatic stress disorder (PTSD). Although this book was written in 2008, based on my reading and understanding of current research and discourse on the subject, it is still as relevant today.
McCrea, distinguishes between clinical and sports epidemiology research models - highlighting the benefits of the latter (he is heavily involved in these studies of mTBI and cites a lot of work he's been involved in). However, since sportspeople are some of the most motivated people to get back to their lives and the scene of injury post-mTBI (as opposed to the other main groups of those suffering mTBIs - as a result of domestic violence, car crashes and war), and likely to have lower risk of complicating psychosocial factors, it's worth considering that McCrea's leanings and conclusions are heavily influenced by the characteristics and experience of this group and may underplay the complexity of potential impacts of mTBI, whether directly attributable to the head trauma or not. Depending on how things are measured (a running theme in the research and discussion in this area), the minority of those experiencing mTBI with persistent symptoms is anywhere from 5% to 35%. Some researchers, including McCrea, tend to say the lower figures are more accurate and that this should be emphasised to reduce anxiety, which otherwise has the potential to interplay with symptoms and hamper recovery. Others argue that this significant minority need to be better understood so that appropriate clinical treatments can be developed.
There is a lot of discussion as to how to precisely define mTBI as it is diagnosed purely on clinical symptoms and indeed based on the absence of more stable biological characteristics present in moderate and severe TBI, such as observable damage to the brain. McCrea nicely summarises the issues this creates in understanding and attributing causation to symptoms that last beyond the acute period. His argument is that the longer that symptoms persist, the less likely they are to be directly related to the head trauma and associated physiological processes, and the more likely they are related to psychosocial factors or potentially other non-head-injury related disease processes. The now-obsolete diagnosis of Post-Concussion Syndrome (PCS), which accounts for patients who experienced mTBI and went on to develop persistent symptoms, is discussed and critiqued. I could see that his book may have been cited as strong evidence in favour of scrapping PCS.
Where the line is in distingishing between physiological and psychosocial is unclear and varies depending on the measures and definitions used - in fact, framing the question this way, as far as I can tell, is part of the problem. Regardless of how it's worded, it's a fascinating question on a philosophical level and one that has been discussed in reference to various other "mild" manifestations of other conditions in a book I read shortly after this one - The Age of Diagnosis by Suzanne O'Sullivan. McCrea's clinical advice at the end of the book is to provide mTBI sufferers with education about the high rates of recovery and the base rates of symptoms such as fatigue and brain fog in the general population, to reduce fixation on symptoms and enhance focus on recovery, a very similar approach to what O'Sullivan suggests. What O'Sullivan emphasises in her book which McCrea doesn't is the crucial (psychosocial) intervention of listening to patients and empathising with their experience, alongside the delivery of optimistic prognosis and education.
Overmedicalisation is something we are becoming increasingly aware of these days, which begs the question, what function does it serve in our society? In her book, O'Sullivan acknowledges that patients and clinicians are often looking for certainty, and cures (both of which seem increasingly hard to come by). It reminded me of another book I read recently, The Ascent of Humanity by Charles Eisenstein, who summarises how invested we have been for centuries in acquiring knowledge and developing technology as a means for bringing as much of the world as possible under our control, seemingly to stave off the intrinsic messiness and challenge of life. He highlights the negative impact and ultimate futility of this project on our individual and collective wellbeing. He doesn't suggest we abandon knowledge-seeking or technological development, but argues how important it is that we recognise the limits of our knowledge and the limits of application of a given technology, and crucially that our science and technology should be driven by the intention to nurture and make space for the challenge and complexity of life, rather than to control via reductionism.
Linking this back to patients with mTBI and persistent symptoms, sadly I think these patients are one of many examples of the canaries in the coalmine of society (with O'Sullivan giving examples of many others). These patients aren't making things up, and dismissing persistent symptoms as "purely psychological" or even psychosocial is, I think, unhelpful at best. As O'Sullivan, Eisenstein and many others have highlighted, we may understand more about what is going on with these patients by critiquing our societal structures than by either further interrogating their symptoms in isolation or outsourcing to psychology, by understanding what function these symptoms serve on multiple levels, from an integrative perspective. This discussion, however, was clearly beyond the scope of McCrea's book, which I can't fault it for.
McCrea, distinguishes between clinical and sports epidemiology research models - highlighting the benefits of the latter (he is heavily involved in these studies of mTBI and cites a lot of work he's been involved in). However, since sportspeople are some of the most motivated people to get back to their lives and the scene of injury post-mTBI (as opposed to the other main groups of those suffering mTBIs - as a result of domestic violence, car crashes and war), and likely to have lower risk of complicating psychosocial factors, it's worth considering that McCrea's leanings and conclusions are heavily influenced by the characteristics and experience of this group and may underplay the complexity of potential impacts of mTBI, whether directly attributable to the head trauma or not. Depending on how things are measured (a running theme in the research and discussion in this area), the minority of those experiencing mTBI with persistent symptoms is anywhere from 5% to 35%. Some researchers, including McCrea, tend to say the lower figures are more accurate and that this should be emphasised to reduce anxiety, which otherwise has the potential to interplay with symptoms and hamper recovery. Others argue that this significant minority need to be better understood so that appropriate clinical treatments can be developed.
There is a lot of discussion as to how to precisely define mTBI as it is diagnosed purely on clinical symptoms and indeed based on the absence of more stable biological characteristics present in moderate and severe TBI, such as observable damage to the brain. McCrea nicely summarises the issues this creates in understanding and attributing causation to symptoms that last beyond the acute period. His argument is that the longer that symptoms persist, the less likely they are to be directly related to the head trauma and associated physiological processes, and the more likely they are related to psychosocial factors or potentially other non-head-injury related disease processes. The now-obsolete diagnosis of Post-Concussion Syndrome (PCS), which accounts for patients who experienced mTBI and went on to develop persistent symptoms, is discussed and critiqued. I could see that his book may have been cited as strong evidence in favour of scrapping PCS.
Where the line is in distingishing between physiological and psychosocial is unclear and varies depending on the measures and definitions used - in fact, framing the question this way, as far as I can tell, is part of the problem. Regardless of how it's worded, it's a fascinating question on a philosophical level and one that has been discussed in reference to various other "mild" manifestations of other conditions in a book I read shortly after this one - The Age of Diagnosis by Suzanne O'Sullivan. McCrea's clinical advice at the end of the book is to provide mTBI sufferers with education about the high rates of recovery and the base rates of symptoms such as fatigue and brain fog in the general population, to reduce fixation on symptoms and enhance focus on recovery, a very similar approach to what O'Sullivan suggests. What O'Sullivan emphasises in her book which McCrea doesn't is the crucial (psychosocial) intervention of listening to patients and empathising with their experience, alongside the delivery of optimistic prognosis and education.
Overmedicalisation is something we are becoming increasingly aware of these days, which begs the question, what function does it serve in our society? In her book, O'Sullivan acknowledges that patients and clinicians are often looking for certainty, and cures (both of which seem increasingly hard to come by). It reminded me of another book I read recently, The Ascent of Humanity by Charles Eisenstein, who summarises how invested we have been for centuries in acquiring knowledge and developing technology as a means for bringing as much of the world as possible under our control, seemingly to stave off the intrinsic messiness and challenge of life. He highlights the negative impact and ultimate futility of this project on our individual and collective wellbeing. He doesn't suggest we abandon knowledge-seeking or technological development, but argues how important it is that we recognise the limits of our knowledge and the limits of application of a given technology, and crucially that our science and technology should be driven by the intention to nurture and make space for the challenge and complexity of life, rather than to control via reductionism.
Linking this back to patients with mTBI and persistent symptoms, sadly I think these patients are one of many examples of the canaries in the coalmine of society (with O'Sullivan giving examples of many others). These patients aren't making things up, and dismissing persistent symptoms as "purely psychological" or even psychosocial is, I think, unhelpful at best. As O'Sullivan, Eisenstein and many others have highlighted, we may understand more about what is going on with these patients by critiquing our societal structures than by either further interrogating their symptoms in isolation or outsourcing to psychology, by understanding what function these symptoms serve on multiple levels, from an integrative perspective. This discussion, however, was clearly beyond the scope of McCrea's book, which I can't fault it for.
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