Diagnostic Assessment — Head - Concussion
Example 1 of 1 · fictitious patient (Veteran N)
Diagnostic Assessment
Head - Concussion
BOP Code: 93 of 2018 (Concussion)
RH Code: 92 of 2018 (Concussion)
ADF History
Veteran N, date of birth 14 June 1990, Australian Army, Infantry Soldier (Rifleman), enlisted 03 February 2009, medically discharged 18 November 2021. Operational service: Afghanistan, 08 October 2012 to 27 May 2013 (warlike); Middle East Area of Operations, 12 January 2017 to 30 July 2017 (warlike).
Occupational History
As an infantry soldier the veteran conducted dismounted and mounted patrols, live-fire range practices, close-quarter battle training and demolitions familiarisation. Infantry soldiers are regularly exposed to blast overpressure from their own and enemy weapons, falls while carrying loads of 30 to 45 kilograms over rough ground, vehicle movements on unsealed tracks, unarmed combat and contact sports, all of which carry a recognised risk of head impact and acceleration-deceleration injury to the brain.
Mounted infantry travel in protected mobility vehicles in which occupants are thrown against roof hatches, weapon mounts and internal fittings when a vehicle strikes an improvised explosive device or crosses broken ground at speed. Medical care forward of a role 2 facility is limited to a combat first aider or medic, and the operational tempo of the period frequently returned soldiers to patrol duties shortly after minor head injuries.
History
Veteran N, an infantry soldier in the Australian Army, sustained a concussion when the protected mobility vehicle in which he was travelling struck an improvised explosive device during warlike service in Afghanistan on 17 March 2013. He was returned to patrol duties within 48 hours without a graded return to activity, and his post-concussion symptoms worsened over the following months and were documented as significantly worse on 04 September 2013.
Timeline
- 20 Aug 2012 — Pre-deployment medical examination by the regimental medical officer recorded no history of head injury, no headaches, normal concentration and memory, and a normal neurological examination. Baseline computerised cognitive testing was completed and recorded as within normal limits. He was assessed as medically fit for deployment to Afghanistan. "neuro exam normal, fit to deploy"
- 17 Mar 2013 — During a mounted patrol in southern Afghanistan the protected mobility vehicle in which the veteran was the rear left dismount struck an improvised explosive device. The blast threw him upwards and his helmeted head struck the roof hatch frame, and he then fell against the side wall of the vehicle. A combat medic recorded loss of consciousness of about two minutes, confusion and repetitive questioning, with a Glasgow Coma Scale score of 14 at 10 minutes and 15 at 40 minutes. A Military Acute Concussion Evaluation score was 22 out of 30, with headache, dizziness, ringing in both ears and nausea. "IED strike, brief LOC, MACE 22"
- 18 Mar 2013 — At the role 2 facility a medical officer recorded post-traumatic amnesia of about four hours, from the blast until mid-afternoon, a normal neurological examination and a normal CT brain. He was diagnosed with concussion (mild traumatic brain injury) and advised to rest for 24 hours. Because of patrol strength requirements he was returned to his platoon the next morning and resumed foot and mounted patrols on 19 March 2013, carrying a full load. "concussion, CT normal, RTD next day"
- 22 Mar 2013 — Review by the combat medic at the forward operating base recorded persisting daily headaches, light sensitivity, poor sleep and difficulty concentrating during patrol orders. A Rivermead Post-Concussion Symptoms Questionnaire score was 18. No medical officer was available at the base, rest was not provided and repeat cognitive testing was not done. He continued patrols until the end of his tour on 27 May 2013. "ongoing headache, RPQ 18"
- 11 Jun 2013 — Post-operational psychological screening on return to Australia recorded persistent headaches, irritability, forgetfulness and reduced tolerance of noise. A referral to a neurologist and for neuropsychological assessment was made, but the referral was not actioned by the garrison health centre for almost five months because of staff shortages and a backlog of post-deployment reviews. "persistent headaches, referral not actioned"
- 04 Sep 2013 — The veteran presented to the garrison health centre with worsening headaches occurring daily and lasting most of the day, dizziness on exertion, two episodes of losing his way while driving to the barracks and a near-miss on the range when he forgot a safety drill. The Rivermead score had risen to 34. He was placed on restricted duties and excused from live firing and contact training. "worse headaches, RPQ 34, restricted"
- 30 Jan 2014 — A neurologist confirmed post-concussion syndrome following mild traumatic brain injury on 17 March 2013, with a normal neurological examination and normal MRI. Amitriptyline 10 mg at night was commenced for headache prevention, together with vestibular physiotherapy and a graded return to exercise. The neurologist commented that the early return to patrol duties and the delay in specialist assessment had probably prolonged and worsened his symptoms. "post-concussion syndrome, amitriptyline 10 mg"
- 12 Feb 2014 — Formal neuropsychological assessment showed reduced processing speed and working memory compared with his 2012 baseline, with intact general intellectual ability. The findings were consistent with persisting effects of concussion. Cognitive rehabilitation strategies were provided. "slowed processing, working memory reduced"
- 05 Aug 2021 — A medical employment classification review recorded persisting headaches three to four days a week, noise and light sensitivity, poor concentration and fatigue more than eight years after the injury, despite treatment. He was assessed as unfit for infantry duties and recommended for medical discharge, which took effect on 18 November 2021. "persisting symptoms, unfit infantry duties"
Symptoms
At onset the veteran had brief loss of consciousness, confusion and repetitive questioning, post-traumatic amnesia of about four hours, headache, dizziness, nausea, bilateral tinnitus and light sensitivity. In the days after the blast he had daily headaches, poor sleep, irritability and difficulty concentrating, which persisted while he continued patrols.
His symptoms became markedly worse by September 2013, with daily headaches, exertional dizziness, forgetfulness and episodes of disorientation. He now reports headaches three to four days a week, sensitivity to noise and light, slowed thinking, poor concentration, fatigue and irritability. He avoids crowded and noisy places and needs written lists to manage daily tasks.
Imaging
- 18 Mar 2013 — CT brain: "No intracranial haemorrhage, contusion or skull fracture. Normal study."
- 28 Jan 2014 — MRI brain with susceptibility-weighted imaging: "No structural abnormality, no microhaemorrhage and no contusion. Normal study."
Onset Date
The most likely date of onset of this condition is 17 Mar 2013.
At that date the veteran was on warlike service in Afghanistan with an infantry battalion task group, travelling as a dismount in a protected mobility vehicle on a mounted patrol. The vehicle struck an improvised explosive device, and the blast threw him against the roof hatch frame and the side wall of the vehicle. He lost consciousness for about two minutes and was confused immediately afterwards.
This date is appropriate because his pre-deployment medical examination of 20 August 2012 recorded no head injury, no headaches and a normal neurological examination, with normal baseline cognitive testing, and the combat medic recorded loss of consciousness, a Glasgow Coma Scale score of 14 and a Military Acute Concussion Evaluation score of 22 within minutes of the blast. Concussion is an injury, and its onset is the moment of the injury.
For the specified event factor, the factor requires the event to occur at the time of the clinical onset of concussion. The blast, the head striking the roof hatch frame and the side wall, and the acceleration and deceleration of the brain as the vehicle was lifted and dropped all occurred at the moment of onset on 17 Mar 2013. The injury met the definition of concussion and not of moderate to severe traumatic brain injury: loss of consciousness was under 30 minutes, post-traumatic amnesia was under 24 hours, the lowest Glasgow Coma Scale score was 14 and both CT and MRI were normal.
For the worsening, the period after onset runs from 17 Mar 2013 to the documented worsening on 04 Sep 2013. During that period he was returned to patrol duties on 19 Mar 2013 without rest or a graded return to activity, there was no medical officer at his forward operating base, repeat cognitive testing was not done, and the referral for specialist assessment made on 11 Jun 2013 was not actioned until November 2013. His Rivermead score rose from 18 on 22 Mar 2013 to 34 on 04 Sep 2013.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Concussion (mild traumatic brain injury) with persisting post-concussion symptoms (ICD-10-AM S06.02, concussion with brief loss of consciousness), under the Statements of Principles concerning concussion, Balance of Probabilities No. 93 of 2018 and Reasonable Hypothesis No. 92 of 2018.
Concussion is a mild traumatic brain injury caused by the transfer of kinetic energy to the brain from external forces, such as a blow to the head, the head striking an object, rapid acceleration and deceleration of the brain, or blast. It produces a temporary disturbance of neurological function, which may include brief loss of consciousness, confusion, amnesia for the event, headache, dizziness, nausea and visual disturbance, without the structural brain injury seen in moderate to severe traumatic brain injury. Most people recover within weeks, but a substantial minority develop persisting post-concussion symptoms, including headache, dizziness, fatigue, poor concentration, memory difficulty, irritability and sensitivity to light and noise. Early return to strenuous duty, repeated head impacts and delayed management increase the risk of prolonged symptoms.
The concussion was sustained in an improvised explosive device blast on warlike service in Afghanistan on 17 March 2013, was diagnosed the following day at a role 2 facility, worsened after an early return to patrol duties and delayed specialist care, and was confirmed as post-concussion syndrome by a neurologist on 30 January 2014.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
17 March 2013.
When did the veteran first present to a health / medical provider for this condition?
17 March 2013.
When was the condition confirmed / formally diagnosed?
18 March 2013.
When did the veteran first present to you (or your practice) for this condition?
21 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically by a medical officer at a role 2 facility on 18 March 2013 on the basis of a documented blast injury with the head striking the vehicle interior, loss of consciousness of about two minutes, confusion, post-traumatic amnesia of about four hours, a lowest Glasgow Coma Scale score of 14 and a Military Acute Concussion Evaluation score of 22 out of 30, with a normal CT brain. These findings meet the Statement of Principles definition of concussion: a mild traumatic brain injury from the transfer of kinetic energy to the brain from external physical forces, with a temporary disturbance of neurological function that does not meet the criteria for moderate to severe traumatic brain injury.
The persisting effects were confirmed by a neurologist on 30 January 2014, who diagnosed post-concussion syndrome, and by neuropsychological assessment on 12 February 2014, which showed reduced processing speed and working memory compared with his pre-deployment baseline. Serial Rivermead Post-Concussion Symptoms Questionnaire scores of 18 on 22 March 2013 and 34 on 04 September 2013 document the worsening. MRI with susceptibility-weighted imaging on 28 January 2014 excluded a structural injury.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 17 March 2013, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan, where the blast occurred and where he was returned to patrol duties without appropriate management. The Balance of Probabilities instrument applies to peacetime service, during which the delay in specialist assessment occurred after his return to Australia in 2013.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Concussion, No. 93 of 2018
Causative factors
Factor 9(1): experiencing a specified event at the time of the clinical onset of concussion; — MET
- On 17 March 2013 the protected mobility vehicle in which the veteran was travelling on duty struck an improvised explosive device. The event met every limb of the definition of a specified event: an explosion or explosive blast; the head striking an object, namely the roof hatch frame and then the side wall of the vehicle; the head being struck by an object, with loose equipment striking his helmet; and acceleration and deceleration of the brain as the vehicle was lifted and dropped. Loss of consciousness, confusion and a Glasgow Coma Scale score of 14 followed immediately, so the event occurred at the moment of clinical onset. He was a serving member performing his duties at the time, and the event arose out of his service.
Worsening factors
Factor 9(2): inability to obtain appropriate clinical management for concussion. — MET
- After returning to Australia on 27 May 2013 the veteran was referred on 11 June 2013 for neurological and neuropsychological assessment of persisting post-concussion symptoms during peacetime service, but the referral was not actioned by the garrison health centre for almost five months because of staff shortages and a backlog of post-deployment reviews. During that period he continued full infantry training, including range practices and contact training, with no restriction or graded return to activity. His Rivermead score rose from 18 to 34 by 04 September 2013, when he was placed on restricted duties, and the treating neurologist recorded that the delay had probably prolonged and worsened his symptoms. Applying Brew v Repatriation Commission (1999), this is an inability to obtain appropriate clinical management that materially contributed to the worsening of his concussion.
Reasonable Hypothesis — Statement of Principles concerning Concussion, No. 92 of 2018
Causative factors
Factor 9(1): experiencing a specified event at the time of the clinical onset of concussion; — MET
- The veteran experienced an explosive blast on warlike service in Afghanistan on 17 March 2013, when his protected mobility vehicle struck an improvised explosive device on a mounted patrol. At the same moment his helmeted head struck the roof hatch frame and the side wall of the vehicle, and his brain underwent rapid acceleration and deceleration. He lost consciousness for about two minutes and had post-traumatic amnesia of about four hours. The specified event occurred at the time of the clinical onset of concussion and arose directly from his operational service.
Worsening factors
Factor 9(2): inability to obtain appropriate clinical management for concussion. — MET
- On warlike service in Afghanistan the veteran was diagnosed with concussion on 18 March 2013 and advised to rest for 24 hours, but because of patrol strength requirements he was returned to foot and mounted patrols carrying a full load on 19 March 2013. His forward operating base had no medical officer, no graded return-to-activity protocol was followed, and repeat cognitive testing was not performed despite daily headaches, light sensitivity and poor concentration recorded on 22 March 2013. He remained on patrol duties until 27 May 2013. Under Brew v Repatriation Commission (1999), operational circumstances that prevent rest and recommended follow-up amount to an inability to obtain appropriate clinical management, and the documented rise in his Rivermead score to 34 by 04 September 2013 shows the resulting worsening.
The % contribution of the causes is 100% and significant.
Sequelae
The persisting post-concussion symptoms have led to chronic post-traumatic headache, vestibular dysfunction with exertional dizziness, and cognitive impairment with reduced processing speed and working memory. The concussion is also a recognised contributor to the veteran's later sleep disturbance and to the noise sensitivity documented alongside his tinnitus. Each of these is a sequela of the accepted concussion and may be claimed in its own right.
Unintended Consequence
Not applicable on the present record. The amitriptyline commenced on 30 January 2014 for headache prevention has been well tolerated, and no complication of treatment provided by or paid for by the Commonwealth has contributed to the concussion or its worsening.
Inability to Attain Appropriate Medical Management
MET. The veteran was diagnosed with concussion on warlike service on 18 March 2013 and advised to rest, but operational requirements returned him to patrol duties the next morning without a graded return to activity, without a medical officer at his base and without repeat cognitive assessment. After his return to Australia, a referral for specialist assessment made on 11 June 2013 was not actioned for almost five months, during which he continued full infantry training. His Rivermead Post-Concussion Symptoms Questionnaire score rose from 18 to 34 by 04 September 2013, and the treating neurologist attributed the prolonged course in part to these delays. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the circumstances of his service, both operational and in garrison, prevented him from obtaining the rest, monitoring and specialist care that were clinically appropriate, and that inability materially contributed to the worsening of his concussion.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 20 Aug 2012, Pre-deployment medical examination and baseline cognitive testing, Regimental Medical Officer
- 17 Mar 2013, Casualty card and Military Acute Concussion Evaluation, Combat medic, Afghanistan
- 18 Mar 2013, Role 2 medical record and CT brain report, Medical Officer and Radiologist, Afghanistan
- 22 Mar 2013, Forward operating base treatment record, Combat medic, Afghanistan
- 11 Jun 2013, Post-operational psychological screening, Psychologist, Garrison health centre
- 04 Sep 2013, Outpatient health record and duty restriction, Medical Officer, Garrison health centre
- 28 Jan 2014, MRI brain report, Radiologist
- 30 Jan 2014, Specialist consultation, Neurologist
- 12 Feb 2014, Neuropsychological assessment report, Clinical neuropsychologist
- 05 Aug 2021, Medical employment classification review, Senior Medical Officer
- Statement of Principles concerning Concussion (Balance of Probabilities) No. 93 of 2018, Repatriation Medical Authority
- Statement of Principles concerning Concussion (Reasonable Hypothesis) No. 92 of 2018, Repatriation Medical Authority
