Beyond Cognition: Why Standard Concussion Tests Miss the Full Picture
Posted on September 23rd, 2026
Persistent post-concussion syndrome is not purely a cognitive disorder. Yet much of our current diagnostic framework treats it as though it were.
By Miguel (Mike) Pappolla
That is the central problem my colleagues and I addressed in a review we recently submitted for publication.
After a concussion, persistent impairment can be cognitive—affecting attention, memory, processing speed, or executive function. But it can also be non-cognitive, involving balance and coordination, eye movement control, headaches, autonomic dysfunction, sleep, hearing, or centrally mediated pain. In some patients, these non-cognitive problems are the major source of disability.
This becomes especially important when neuropsychological testing produces an almost normal cognitive profile and the patient receives a report stating that there is little or no evidence of cognitive impairment.
There are two problems with extending that conclusion too far:
Environmental & Cognitive Load Limitations
Standard neuropsychological testing is usually performed one task at a time, in a quiet, highly controlled environment. Many patients with persistent concussion symptoms do reasonably well under those conditions. Their difficulties emerge when the brain is placed under load: multitasking at work, following a conversation in noise, walking while thinking, reading while monitoring what is happening around them, or switching rapidly between competing demands. The literature shows that some deficits become apparent only under dual-task conditions.
We use a simple analogy in the paper: A patient with lung disease may have nearly normal oxygen saturation while sitting quietly and become short of breath climbing stairs. The resting measurement is valid, but it does not tell us what happens under exertion.
The quiet testing room may be the couch. Real life is the stairs.
Unassessed Neurological Systems
Even if cognition is almost normal, the patient may still be substantially disabled by non-cognitive neurological impairment. A person can have relatively preserved memory and attention while suffering from incoordination, vestibular dysfunction, abnormal eye movements, orthostatic intolerance, severe post-traumatic headaches, or central and nociplastic pain. Cognitive testing cannot exclude abnormalities in neurological systems it was never designed to assess.
This distinction has become particularly important because DSM-5 and ICD-11 withdrew post-concussion syndrome as a diagnostic category and reorganized persistent TBI consequences largely within neurocognitive diagnoses. That leaves an important gap for patients whose major disability is neurological but not primarily cognitive.
Our review also examines why estimates of persistent post-concussion syndrome vary so widely. Different diagnostic definitions applied to the same patient population have produced prevalence estimates ranging from 11.4% to 38.7%. The patients did not change. The definition did.
We therefore argue for a broader neurological approach. Cognitive testing is essential, particularly when interpreted with appropriate validity measures, but it is one component of the evaluation. Depending on the presentation, assessment may also need to include:
Vestibular and oculomotor function
Coordination
Autonomic regulation
Headache and pain mechanisms
Sleep, hearing, and mood
The paper has now been submitted as a review. I am sharing its central argument while it goes through the publication process, and I will post an update after publication.
Should an almost normal cognitive profile ever be used to conclude that a patient has no persistent neurological impairment after concussion?
#Neuroscience #TraumaticBrainInjury #TBI #Concussion #PostConcussion #Neurology #Neuropsychology #Neurophysiology #BrainInjury
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