Documenting Concussions and Concussive Injury

22 Jun 2017

One of the strange things about an injury to the head and brain is that the cumulative effect of even a small or minor injury matters. Medical science has not yet determined how to measure and evaluate the extent of an individual injury, nor how to evaluate a new injury in light of a series of old ones. Current methods of assessing thinking and memory are inaccurate, at best. But the science is growing, and it is important for the emerging understanding of traumatic brain injury that you are able to document a history of both diagnosed concussions and concussive injury to the head.

Documentation of an injury does not involve producing medical records or any sort of proof as such. This documentation involves writing a detailed list of incidents, with all of the information you can remember or get from others, such as family members, about the injury: how it happened and the effects on you after.

An older definition of significant head injury was an injury that resulted in unconsciousness. Doctors carefully documented how long a person was unconscious and any symptoms after, such as dizziness and headache. What we know now, through advances in science and brain imaging, is that any injury that involves a blast or blow of any degree can affect the brain, and a series of injuries over time can produce an effect long after the initial injury.

Many kids have an injury as infants and children due to accidents at home. Falling off the couch or bed as an infant, any injury needing stitches to the face or chin, falling off a top bunk bed, bike accidents, and similar accidental injury to young children may be significant and should be documented.

During the school years, any sports participation should be noted. Even sports such as track and field can produce head injury, as anyone who has even tripped over a hurdle can describe. Any significant sports injuries should be noted, particularly ones in which a student athlete was evaluated for a concussion. Any history of hunting as a child can be estimated as the number of times weapons were shot in the course of a season, and then the number of seasons. Any violent attacks on a child's face or head can produce head injury, and should also be documented. Boxing and tackle football should be carefully noted.

As adolescents, the type of injuries noted above should be documented, in addition to any car accidents or vehicle whiplash-type injury while riding motorcycles and ATVs. Riskier sports, such as paragliding and bungee jumping, should be documented. During boot camp and other military training, hours of weapons training and types should be carefully noted, as well as activities such as parachute training. Any fighting or boxing that involved blows to the face or head are significant and should be noted.

While in the service, both weapons training and exposure to weapons and concussive or blast injury should be noted. It is understood that in the chaos of combat, not every incident can be carefully evaluated and documented in a medical record. Your recollections and accounts are important and are taken as valid sources of information.

As we get older, balance can be affected, making it easier to have an accidental injury. Falls on the ice, or while walking the dog, can cause significant head injury. Motor vehicle accidents are significant. Any head injury sustained during an interaction with law enforcement or while under the influence of substances should also be noted.

This type of documentation can be important for your doctor and for the VA while assessing a claim. As science into the brain and methods of injury grows, the more information we can gather can help researchers who are trying to puzzle out the strange relationship of repeated concussive injury to traumatic brain injury and chronic traumatic encephalopathy.

For more information on Traumatic Brain Injury - Veterans, please contact us.