Cognitive Difficulties

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The presence and persistence of cognitive symptoms following concussion can affect an individual’s ability to function in everyday life, including work, academic and social activities.1,2 Concussion is associated with disruptions in cognitive skills that include difficulties with attention/concentration, processing speed, learning/memory and executive function.3-6 In the acute phase of injury there are changes in cerebral metabolic activity and perfusion, particularly in the frontal lobes associated with cognitive changes.7-12 However,15%-33% of individuals3,6,7,13 experience persistent cognitive symptoms beyond the acute phase of recovery, which significantly disrupts their capacity to resume many pre-morbid activities.

It is important to document cognitive symptoms in order to characterize the nature of these symptoms and to track progress over time. When cognitive dysfunction does not resolve with treatment of potentially contributing factors or if cognitive symptoms persist past 1 month, practitioners should consider referral for neuropsychological assessment. This assessment could  aid in identifying the nature of cognitive strengths and challenges, setting goals for treatment, career and education planning, or provide information about independent functioning.7,14 Deficits identified on neuropsychological assessment may be amenable to specific rehabilitation strategies (e.g., compensatory cognitive strategies) as well as facilitation of more effective coping strategies and integration of cognitive compensatory strategies.14 This combination has demonstrated reductions in the presence of persistent symptoms.4,7,15,16

While there are currently no pharmaceutical interventions that are approved for use with cognitive symptoms post concussion, the off -label use of methylphenidate has been shown in some studies to positively impact certain cognitive issues17.

Introduction-only references:

  1. Vanderploeg RD, Curtiss G, Luis CA, Salazar AM. Long-term morbidities following self-reported mild traumatic brain injury. J Clin Exp Neuropsychol. 2007;29(6):585-598.
  2. Theadom A, Parag V, Dowell T, et al. Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. Br J Gen Pract. 2016;66(642):e16-23.
  3. McInnes K, Friesen CL, MacKenzie DE, Westwood DA, Boe SG. Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS One. 2017;12(4):e0174847.
  4. Hadanny A, Efrati S. Treatment of persistent post-concussion syndrome due to mild traumatic brain injury: current status and future directions. Expert Rev Neurother. 2016;16(8):875-887.
  5. Cooper DB, Bunner AE, Kennedy JE, et al. Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans. Brain Imaging Behav. 2015;9(3):403-420.
  6. Nordström A, Edin BB, Lindström S, Nordström P. Cognitive function and other risk factors for mild traumatic brain injury in young men: nationwide cohort study. BMJ. 2013;346:f723.
  7. Rabinowitz AR, Levin HS. Cognitive sequelae of traumatic brain injury. Psychiatr Clin North Am. 2014;37(1):1-11.
  8. Metting Z, Rödiger LA, Stewart RE, Oudkerk M, De Keyser J, van der Naalt J. Perfusion computed tomography in the acute phase of mild head injury: regional dysfunction and prognostic value. Ann Neurol. 2009;66(6):809-816.
  9. Bartnik BL, Hovda DA, Lee PW. Glucose metabolism after traumatic brain injury: estimation of pyruvate carboxylase and pyruvate dehydrogenase flux by mass isotopomer analysis. J Neurotrauma. 2007;24(1):181-194.
  10. Leddy JJ, Baker JG, Willer B. Active Rehabilitation of Concussion and Post-concussion Syndrome. Phys Med Rehabil Clin N Am. 2016;27(2):437-454.
  11. Wylie GR, Freeman K, Thomas A, et al. Cognitive Improvement after Mild Traumatic Brain Injury Measured with Functional Neuroimaging during the Acute Period. PLoS One. 2015;10(5):e0126110.
  12. Liu SW, Huang LC, Chung WF, et al. Increased Risk of Stroke in Patients of Concussion: A Nationwide Cohort Study. Int J Environ Res Public Health. 2017;14(3).
  13. McMahon P, Hricik A, Yue JK, et al. Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study. J Neurotrauma. 2014;31(1):26-33.
  14. Mani K, Cater B, Hudlikar A. Cognition and return to work after mild/moderate traumatic brain injury: A systematic review. Work. 2017;58(1):51-62.
  15. Tiersky LA, Anselmi V, Johnston MV, et al. A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury. Arch Phys Med Rehabil. 2005;86(8):1565-1574.
  16. Al Sayegh A, Sandford D, Carson AJ. Psychological approaches to treatment of postconcussion syndrome: a systematic review. J Neurol Neurosurg Psychiatry. 2010;81(10):1128-1134.
  17. Lee H, Kim SW, Kim JM, Shin IS, Yang SJ, Yoon JS. Comparing effects of methylphenidate, sertraline and placebo on neuropsychiatric sequelae in patients with traumatic brain injury. Hum Psychopharmacol. 2005 Mar;20(2):97-104. doi: 10.1002/hup.668. PMID: 15641125.
Assessment of Cognitive Difficulties
9.1

A patient sustaining a concussion should be evaluated for the presence of cognitive difficulties, and consideration taken to the impact of such difficulties on functional areas such as performance at work or school and completing tasks within the home and community, etc. This can be done through a focused clinical interview regarding symptoms and administration of a validated post-concussion questionnaire [e.g., Rivermead (Appendix 1.5), PCSS (Appendix 1.6) or SCAT5 (Appendix 3.1)] for the purpose of assessing and tracking symptoms.

Level of Evidence Not Applicable
Last updated  
9.2

Since certain comorbidities can exacerbate cognitive symptoms (e.g., ADHD, learning disabilities, anxiety or mood disorders, pain, fatigue, sleep disturbance, neuroendocrine dysfunction, substance abuse, existing medications) patients should be provided with education highlighting that their cognitive symptoms may be intensified and prolonged by these comorbidities.

Level of Evidence Not Applicable
Last updated  
9.3

A patient with a first-time concussion should be advised through early education, support and/ or assurance that a full recovery of symptoms, including cognitive functioning, is typically seen within as early as a few days up to 1 to 3 months post-injury.

*NOT AN ORIGINAL RECOMMENDATION - REPEAT OF 2.3

Level of Evidence Not Applicable
Last updated  
9.4

Patients who have cognitive symptoms that are not resolving and continue to interfere in daily functioning (e.g., school or work) beyond 4 weeks should be considered for referral for specialized cognitive assessment (e.g., neuropsychological assessment). The evaluation may assist in clarifying appropriate treatment options based on individual patient characteristics and conditions.

Level of Evidence Not Applicable
Last updated  
Treatment of Cognitive Difficulties
9.5

Evidence-based neurorehabilitation strategies should be initiated if:

  1. The individual exhibits persisting cognitive impairments on formal evaluation, and/or
  2. To facilitate the resumption of functional activities, work and school.
Level of Evidence Not Applicable
Last updated  
9.6

If persisting cognitive deficits are identified by neuropsychologists or other healthcare professionals, implement temporary work or school accommodations or modifications and provisions for assistance (e.g., implement schedules, avoid excessive anxiety, pace activities, etc.). See Section 12.

Level of Evidence Not Applicable
Last updated  
Appendix 1.5
Rivermead Post Concussion Symptoms Questionnaire
appendix-1-5.pdf
Appendix 1.6
Post Concussion Symptom Scale
appendix-1-6.pdf
Appendix 3.1
SCAT5
appendix-3-1.pdf
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

O'Neil ME, Carlson K, Storzbach D, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. VA Evidence-based Synthesis Program Reports. 2013.
Country: USA
Design: Systematic Review
Quality Rating: PRISMA: 18/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Waldron-Perrine B, McGuire AP, Spencer RJ, Drag LL, Pangilinan PH, Bieliauskas LA. The influence of sleep and mood on cognitive functioning among veterans being evaluated for mild traumatic brain injury. Mil Med. 2012;177(11):1293-1301.
Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *6 of the sections were not applicable

Cooper DB, Bunner AE, Kennedy JE, et al. Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans. Brain Imaging Behav. 2015;9(3):403-420.
Country: USA
Design: Systematic Review
Quality Rating: PRISMA: 10/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Oldenburg C, Lundin A, Edman G, Nygren-de Boussard C, Bartfai A. Cognitive reserve and persistent post-concussion symptoms--A prospective mild traumatic brain injury (mTBI) cohort study. Brain Inj. 2016;30(2):146-155.
Country: Sweden
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *5 of the sections were not applicable

Na KS, Jung HY, Lee SI, Kim SG. Mediating effects of cognitive effort and depression on intelligence, memory, and executive functions in individuals with mild traumatic brain injury. Psychiatry Investig. 2014;11(2):112-118.
Country: Korea
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *7 of the sections were not applicable

Dean PJ, Sterr A. Long-term effects of mild traumatic brain injury on cognitive performance. Front Hum Neurosci. 2013;7:30.
Country: United Kingdom
Design: Case-Control
Quality Rating: DOWNS & BLACK: 17/32 *5 of the sections were not applicable

Van Patten R, Keith C, Bertolin M, Wright JD. The effect of premorbid attention-deficit/hyperactivity disorder on neuropsychological functioning in individuals with acute mild traumatic brain injuries. J Clin Exp Neuropsychol. 2016;38(1):12-22.
Country: USA
Design: Case-Control
Quality Rating: DOWNS & BLACK: 16/32 *6 of the sections were not applicable

Twamley EW, Thomas KR, Gregory AM, et al. CogSMART Compensatory Cognitive Training for Traumatic Brain Injury: Effects Over 1 Year. J Head Trauma Rehabil. 2015;30(6):391-401.
Country: USA
Design: Randomized Control Trial
Quality Rating: PEDro: 6/11

Twamley EW, Jak AJ, Delis DC, Bondi MW, Lohr JB. Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) for veterans with traumatic brain injury: pilot randomized controlled trial. J Rehabil Res Dev. 2014;51(1):59-70.
Country: USA
Design: Pilot Randomized Control Trial
Quality Rating: PEDro: 6/11

Storzbach D, Twamley EW, Roost MS, et al. Compensatory Cognitive Training for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans With Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2017;32(1):16-24.
Country: USA
Design: Randomized Control Trial
Quality Rating: PEDro: 8/11

Theadom A, Mahon S, Barker-Collo S, et al. Enzogenol for cognitive functioning in traumatic brain injury: a pilot placebo-controlled RCT. Eur J Neurol. 2013;20(8):1135-1144.
Country: New Zealand
Design: Pilot Randomized Control Trial
Quality Rating: PEDro: 10/11

Armistead-Jehle P, Cooper DB, Vanderploeg RD. The role of performance validity tests in the assessment of cognitive functioning after military concussion: A replication and extension. Appl Neuropsychol Adult. 2016;23(4):264-273.
Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 16/32 *5 of the sections were not applicable