You are here

Concussion S024

Document
Last amended 
25 October 2018
Current RMA Instruments
Reasonable Hypothesis SOP
92 of 2018
Balance of Probabilities SOP 93 of 2018
Changes from previous Instruments

SOP Bulletin 205

ICD Coding
  • ICD-9-CM Codes: 850.0-1
  • ICD-10-AM Codes: S06.00, S06.02
Brief description

Concussion refers to a temporary brain disturbance as opposed to more significant brain damage, which is covered by the companion Statement of Principles for ‘moderate to severe traumatic brain injury’. Though this is a temporary brain disturbance, it may also be labelled as a ‘mild traumatic brain injury’ though the use of the term ‘concussion’ is preferred.

The SOP covers the direct effects of injury only.  Any ongoing symptoms attributed to the concussion (e.g. beyond 3 months) need to be separately investigated.  The RMA has declared that post concussion syndrome is not a disease or injury.  Alternative diagnoses for any such symptoms need to be considered.

If the concussion was associated with munitions discharge, then the SOP for ‘physical injury due to munitions discharge’ could also apply.  A decision will then need to be made as to which SOP is appropriate in the circumstances of the case.

Confirming the diagnosis

See also the comments section, below.  The relevant medical specialist for this condition is a neurologist, but a report will generally not be required. 

Normally there is sufficient data on the contemporary military medical documents to establish whether the claim is a simple concussion or a more significant moderate to severe traumatic brain injury.  Neuropsychological testing will generally not be required or appropriate for this type of claim.

This diagnosis requires contemporary military medical documents which indicate:

  • A transfer of kinetic energy to the head and
  • Evidence of a temporary disturbance in neurological function which falls short of a moderate to severe traumatic brain injury as defined in that SOP. That is:
    • No loss of consciousness or loss of consciousness less than 30 minutes
    • No amnesia or anterograde amnesia less than 24 hours
    • Glasgow coma score of 13, 14 or 15 out of 15.

Note that the reported alterations in consciousness and memory can also occur as a psychological response to a severe psychological stress. Hence care needs to be taken when considering a claim that has potentially physical and psychological (psychiatric) elements.

The diagnosis of moderate to severe traumatic brain injury is straightforward. By contrast, accurate identification of concussion can be challenging because of the more subtle and transient signs of injury, the paucity of objective physical findings and the possibility that reported symptoms are due to something else, such as an acute stress reaction.

Additional diagnoses covered by SOP
  • Mild traumatic brain injury (direct effects only, claims for ongoing/persisting effects are not covered by this SOP)
  • Concussion due to an MVA, a fall, sport, explosion or any other cause.
Other SOPS that should be considered
  • Acute stress disorder
  • Moderate to severe traumatic brain injury
  • Physical injury due to munitions discharge
Conditions not covered by SOP
  • Headaches
  • Non-specific symptoms persisting after acute phase of mild head injury
  • Post concussion syndrome
  • Post traumatic stress disorder
Clinical onset

The clinical onset will be at the time of the head injury event (the transfer of kinetic energy to the head).

Clinical worsening

The concussion SOP, by definition, covers only short term effects.  Any contended ongoing manifestations need to be separately considered and determined.

Comments

The principal aetiological factor in the SOP is that of experiencing a significant force from a specified event prior to the clinical onset of the injury. The ingredients of this factor are:

  • Significant force – This is an analysis of the severity of the transfer of kinetic energy to the head. Obviously moving one’s head backward and forward whilst nodding in agreement to a colleague would not be regarded a significant acceleration or deceleration of the brain, but suffering the same manner of movement during a high speed motor vehicle crash would be considered as significant.
  • Specified Event:
  1. the head being struck by an object
  2. the head striking an object
  3. the brain undergoing an acceleration or deceleration movement without direct external trauma to the head
  4. a foreign body penetrating the brain
  5. an explosion or explosive blast.

Temporary neurological impairment

The expectation is that the veteran will not suffer any significant permanent impairment arising from a concussion.  If the veteran is presenting with significant symptoms following a transfer of kinetic energy to the head, then the delegate should also examine the companion SOP  ‘moderate to severe traumatic brain injury’ and the relevant psychiatric SOPs being 'Acute stress disorder' and perhaps 'post traumatic stress disorder'.

Possible areas of temporary neurological disturbanceNormalConcussion (Mild Traumatic Brain Injury)Moderate to severe brain injury
Transfer of kinetic energy to the head (and brain)+++

Glasgow coma score (15/15)

  • Eye response
  • Verbal response
  • Motor response
1513 or 14 or 15<13
Conscious state Normal

Zero to < 30 minutes of unconsciousness.

> 30 minutes loss of consciousness

Memory

Normal

< 24 hours of anterograde amnesia

> 30 minutes loss of consciousness

Disorientation in time place or person

Nil++

Confusion (inability to respond appropriately to questions)

Nil++

Seizure or convulsion

Nil++

Balance disturbance

Nil

+

+

Motor incoordination

Nil

+

+

Inappropriate behaviour

Nil

+

+

Difficulty concentrating

Nil

+

+

Dizziness or vertigo

Nil

+

+

Blurred vision

Nil

+

+

Double vision

Nil

+

+

Altered speech

Nil

+

+

Weakness (paresis) or paralysis in non-physically traumatised limbs or spine

Nil

+

+

Pins and needles (paraesthesia), burning or numbness in non-physically traumatised limbs or spine

Nil

+

+

Note that trauma to the head is an essential requirement of the brain injury SOPS. Note that unless there is concomitant evidence of a temporary neurological disturbance, there is no concussion. Note that the assessment of an episode of concussion requires contemporary documentation, not hindsight recall of an episode. Copies of the contemporary military medical documents and MACE (Military Acute Concussion Evaluation) documents would be required for an assessment of a concussion.

Note also that the presence of pain from a somatic injury can cause some of the symptoms such as poor concentration, and the use of analgesia to treat somatic pain such as parenteral morphine, inhaled nitrous oxide and inhaled Methoxy flurane or Fentanyl can also produce alteration in normal brain function. Hence there can be a confounding in the presence of pain and analgesia.

Headache, feeling faint, fatigue, tiredness, irritability, sensitivity to sound and light, and nausea are not specific enough to be considered a manifestation of neurological disturbance.

EventType of event Body region or systemSOP

Confirmed event of kinetic energy transfer to body

Munitions discharge

Psyche

Acute stress disorder - PTSD

 

  

Physically anywhere

Physical injury due to munitions discharge

  

Brain

Physical injury due to munitions discharge
Concussion (MTBI) OR
Moderate to severe traumatic brain injury
Seizures
Epilepsy
Subdural haematoma
Subarachnoid haemorrhage
CVA (intracerebral haemorrhage)

  Face

Physical injury due to munitions discharge
Fracture

Confirmed event of kinetic energy transfer to body

No Munitions discharge

Brain

Concussion (MTBI) OR
Moderate to severe traumatic brain injury
Seizures
Epilepsy
Subdural haematoma
Subarachnoid haemorrhage
CVA (intracerebral haemorrhage)

  Face

Fracture
Cut, stab, abrasion and laceration

Glossary:

Amnesia – memory loss

Anterograde – Proceeding forward in time.

Concuss – Latin term which literally means ‘with shake’.

Post concussion syndrome – A controversial term which is not considered a specific disease or injury by the Repatriation Medical Authority. As such the symptoms of which the veteran complains, should be the focus of the claim investigation, rather than the ‘post concussion syndrome’, in the same way that back pain is not a valid injury or disease, and requires the delegate to find an organic pathology which is causing the symptoms or to determine that there is no injury or disease present.

Retrograde – Proceeding backward in time.

an explosion or explosive blast

Whilst it is clear that an Improvised Explosive Device (IED) blast which occurred 2 km away would not affect the veteran, and that an IED exploding 5 metres away would affect the veteran, it is less clear in the interval distance.

A veteran in close vicinity to an IED discharge can suffer:

  • Primary effects of blast – Veteran’s brain suffering an injury indirectly by the blast pressure and velocity air waves set up by the distant IED explosion, impacting on the head and being transmitted across the structure of the skull and layers of the brain.
  • Secondary effects of blast – Veteran struck by missile set in motion by IED blast suffering an injury in the form of blunt or penetrating traumatic injuries. This missile could be an integral component of the device or collected by the blast wave.
  • Tertiary effects of blast – Veteran is thrown against an object by the blast suffering injury.

It is the primary blast effect which is difficult for compensation purposes, since there is no confirmatory tell tale injury signs of blast exposure. Note that it is the blast air pressure and air velocity at the air-skull interface which is the pathological stress driving a potential traumatic brain injury.

An explosion produces a travelling pressure wave with the peak pressure falling inversely with distance and is proportional to the square root of the mass of the explosive. A pressure wave passes through the air and additionally through the ground.  

Though in the military situation, the mass of explosive detonated may be unknown, the distance from the detonation is still of importance.

Further it is important to identify the nature of any blast shielding interposed between the detonation site and the veteran. A veteran dug into the ground will not suffer significant air blast but may suffer from a ground shock particularly if the walls of the gun pit or trench are too narrow.

A veteran riding in an armoured motor vehicle may be well isolated from the ground wave by the rubber tyres, and shielded from the air blast wave by the armour, but can suffer from tertiary injuries by being thrown about the vehicle during the blast, or struck by the vehicle during the blast. Note also that a local direct blast injury can occur if the body is touching the inside of the vehicle which is exposed to the blast.

Issues that may be relevant to determining whether there has been a significant force from an explosion

  • Nature of a blast source
  • Distance from the detonation.
  • Nature of the shielding between the veteran and the detonation source.
    • Any structures between the veteran and the explosion
      • Hill
      • House
      • Wall
      • Hedge
      • Other vehicles – nature of vehicles – smaller or larger than veteran’s vehicle.
    • Orientation of body – standing, sitting, lying
    • Wearing helmet/ no helmet
    • In a gully
    • In a gun pit/trench – half in half out; fully covered.
    • Inside vehicle; on observation point of vehicle with head outside vehicle; sitting outside vehicle.
  • Evidence of blast damage between the veteran and the detonation source:
    • Damaged vehicles; damaged walls
    • Fatalities
    • Damage to veteran’s vehicle
    • Fatalities and injuries to passengers of veteran’s vehicle.