Traumatic brain injury (TBI) results when an external force is applied to the head, leading to injury to brain structures and/or disruption of chemical and physiologic brain functions. The most widely accepted taxonomy classifies brain injuries by severity. Severity is classified based on whether structural abnormalities are visible on imaging, duration of loss of consciousness, duration of altered mental status, duration of post-traumatic amnesia, and Glasgow Coma Scale (GCS) score.
In mild TBI (mTBI), imaging demonstrates normal brain structures. If loss of consciousness occurs, it lasts less than 30 minutes. Alteration of mental status, including feeling dazed, confused, and disoriented, lasts for up to 24 hours. Post-traumatic amnesia, the inability to reliably form new memories, also lasts up to 1 day. GCS scores range from 13 to 15.1
Forces causing mTBI can result from several mechanisms. Direct blows occur when the head forcibly hits an object or when an object hits the head. Acceleration and deceleration forces, which can occur with or without actual contact between the head and an object, result when the head moves rapidly quickly in one or more directions. Lastly, blast-related injuries are caused by transmission of force, via pressure waves accompanying blasts, to and through the brain.1
Epidemiology including risk factors and primary prevention
An estimated four million people sustain TBI annually in the US and 40 million internationally. Mild TBIs comprise nearly 90% of these cases, or 3.6 million in the US and 36 million internationally. The most common causes in the US are falls (over 40%), crashes involving motor vehicles, bicycles, or other forms of transportation (10-15%), and striking or being struck by objects (15%). There are also nearly 300,000 sports-related mTBIs per year.2
The Defense and Veterans Brain Injury Center estimates that more than 468,000 TBIs occurred among U.S. Service Members between 2000 and 2022. The vast majority (over 80%) of those injuries are classified as mild.3
Primary prevention of TBI includes, at the core, avoiding situations where injury is likely to occur. When primary prevention is not possible or feasible, appropriate safety strategies should be implemented. For example, it is not possible to avoid all transportation, but individuals can significantly lower the risk of injury by using seatbelts and car seats, abstaining from alcohol and drugs while driving, and avoiding distracted driving. Interventions aimed at optimizing gait and preventing falls can also be beneficial. Athletes should use updated and appropriate safety equipment, including helmets, and should employ techniques that minimize head impacts.2
Forces applied to the head can cause rapid acceleration and deceleration of the brain. The movements can be linear, rotational, or occur in some combination. Axons, neurons, blood vessels, and other fragile brain structures are stretched and sheared during the jostling and its aftermath. Neuronal membranes, and various portions of the vital blood brain barrier, are affected. Aberrant ionic flux results in abnormal intracellular and extracellular concentrations of crucial ions such as calcium and magnesium. When excitatory amino acids like glutamate are in high concentrations inside neurons, energy mismatches lead to problems ranging from cellular dysfunction to widespread ischemia. Clinical symptoms ensue.4
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Immediate symptoms of mTBI include disorientation, headache, blurred vision, dizziness, sleep disturbance, memory, attention, and other cognitive difficulties. Typically, symptoms peak immediately following the incident, begin to recede within hours, and are gone within days to weeks. Recovery can be complicated by vestibular abnormalities and oculomotor changes, which can each lead to worsening headaches and overall function but are largely treatable once they are diagnosed. Even in the face of these issues, eventual return to full activity and function is expected after mTBI.5
Specific secondary or associated conditions and complications
Second Impact Syndrome: Second Impact Syndrome can occur when an individual sustains a second mTBI prior to full recovery from the first. The second injury seems to overwhelm the brain at a time when the brain is healing and vulnerable. Rapid brain swelling, along with characteristic dangerous bleeds, can lead to massive ischemia and even death. Individuals should not participate in any risky activities until they have fully recovered from a prior traumatic brain injury.6
Chronic Effects of mTBI: There may be risk associated with sustaining multiple TBI events over an individual’s lifetime. It has been postulated that changes in brain architecture can result from cumulative effects of exposure to multiple, and repetitive, head impacts. The structural changes may in turn increase the risk that a neurodegenerative process, with significant cognitive and neuropsychiatric consequences, may occur. To date, however, studies have been small, lacking in control groups, and retrospective. Additional research regarding this important area of mTBI care is underway.5,7
Essentials of Assessment
Mild TBI is characterized by a plausible mechanism of injury (such as a blast, acceleration-deceleration, or blunt trauma) and subsequent disturbance of consciousness or focal neurological deficit that developed immediately after the injury (such as loss of consciousness, altered level of consciousness, confusion, and amnesia).
Other relevant items to include in history can include the duration and severity of the loss of consciousness, post traumatic amnesia, or alteration of consciousness, associated symptoms (such as headache, dizziness, weakness, dysesthesias, vertigo, nausea, slurred speech, photophobia), any treatment that had been implemented and what the response was, prior head injuries and severity if known, current and prior psychiatric diagnoses, educational attainment, occupational history, sleep history, and psychosocial risk factors (such as substance use).1,4
The physical examination should be used to not only identify neurological and cognitive deficits secondary to the mTBI, but to also identify other potential causes of the injury (such as checking orthostatic blood pressures in a fall due to suspected syncope). The clinician’s exam should include but is not limited to
- Neurological Exam with a focus on mental status changes, cranial nerves
- Vestibular Exam to identify changes in balance or ocular motor symptoms
- Vision Exam with a focus on visual field changes, acuity changes, and binocular vision
- Head and Neck Exam for areas of tenderness or signs of intracranial hemorrhage (Battle Sign, Raccoon Eyes) or cerebrospinal fluid leak (sudden drainage out of ears/nose).
Several physical exam assessments have been found to be useful in the assessment of concussion Tools such as the Sport Concussion Assessment Tool (SCAT 5) and the Child SCAT 5 are widely available and easy to learn and implement. Other assessments to consider are the Vestibular/Ocular Motor Screening (VOMS) Assessment and the Military Acute Concussion Evaluation which was updated in 2018 to include the VOMS. These assessment tools can assist clinicians and other members of the care team identify symptoms and signs of a recent mTBI.1,8,9
Non-specific symptoms like headaches, dizziness, and cognitive changes, can also be a harbinger of other, more urgent conditions. Symptoms suggestive of an acute neurological condition such as continued alerted consciousness, progressively declining neurological status, pupillary asymmetry, seizures, repeated vomiting, diplopia, worsening headache, unusual behavior, irritability, slurred speech, unsteadiness, weakness, or numbness, warrant urgent imaging and additional evaluation.1
Sleep disturbances are also common after mild traumatic brain injury. Sleep issues can include insomnia, circadian rhythm sleep-wake disorders, and obstructive sleep apnea. Screening for sleep disturbances, with tools including the Insomnia Severity Index, Epworth Sleepiness Scale, and Pittsburgh Sleep Quality Index, should be included in an assessment of concussion and, if positive on initial screening, follow-up assessments should occur. A 2-week sleep diary can provide helpful information to identify trends as well. If the clinician has a high suspicion for sleep apnea, a sleep medicine consult is warranted. Appropriately diagnosing and treating sleep disorders can help minimize their effect on other common symptoms, such as headache and impaired cognition, after mild TBI.10
Using symptom checklists, such as the Neurobehavioral Symptom Inventory (NSI) and Rivermead Post-Concussion Symptoms Questionnaire, can be helpful in identifying symptom burden in patients. Patients should also be screened for depression and anxiety, with measures like the Patient Health Questionnaire (PHQ) and General Anxiety Disorder (GAD), respectively. These can add value in characterizing the perceived severity of symptoms and prompting further history gathering and diagnostic assessment.1,11
Mild TBI has the potential to affect function, at least in the short term. Changes in vision or cognition can affect the individual’s ability to complete activities of daily living and instrumental activities of daily living. The affected individual would then require assistance with these activities. Support may be required for complex tasks like driving and bill-paying during the initial phases of recovery.
Despite much research about identifying specific biomarkers of mTBI, in recent years, no truly reliable test is yet available. TBI is a complex and evolving process over time, and no one clinical biomarker sufficiently reflects the ongoing pathophysiology. Several promising options include Neuron Specific Enolase, Ubiquitin C-terminal hydrolase-L1 (UCH-L1), S100B protein, and Glial Fibrillary Acidic Protein (GFAP). In 2018, the FDA approved the use of GFAP and UCH-L1 for clinical use in adult patients with mild TBI to determine the need for CT scan. Most likely, a panel of biomarkers will eventually be utilized to capture damage to not only neurons, but also to astroglia cells and oligodendrocytes, that will be able to measure the changes in these cells over time.11,12,13
Laboratory investigations into potential cofounding factors (such as alcohol or other substance abuse, causes of syncope, hypoglycemia, and others) should be considered by clinicians.
Evaluating for neuroendocrine abnormalities can help detect subtle changes that can affect recovery and function. Laboratory tests that evaluate the pituitary-hypothalamic-adrenal axis, include stimulating factors and hormones, can be helpful in diagnosing these abnormalities.1
Evaluation of mTBI does not universally need to include imaging such as computed tomography (CT) magnetic resonance imaging (MRI). Decision trees such as the Canadian CT Head Rule (CCHR), New Orleans Criteria, or the Pediatric Emergency Care Applied Research (PECARN) decision rule can be used in the acute setting to discern if intracranial hemorrhage or other acute pathology is suspected. Risks of obtaining CT, including significant radiation exposure, need to be weighed against potential utility of the clinical information to be obtained.
Imaging should be considered if the individual is elderly, is on anticoagulation, had a seizure, has nausea or vomiting, has any focal symptoms, had mechanism of injury that involves significant levels of force, symptoms seem out of proportion to the reported injury, or the individual is not able to participate in exam reliably due to intoxication or another factor.4,14
Advanced imaging techniques such as perfusion imaging and diffusion tensor imaging have shown promise in helping the presence of injury even weeks to years after injury. These and related techniques, then, may help provide clarification, but are not yet validated for routine clinical use in the diagnosis of TBI.14
Supplemental assessment tools
In patients who have persistent symptoms, supplementary cognitive, visuo-motor, or vestibular testing may be of value in guiding further treatment options. Batteries such as Repeatable Batter for the Assessment of Neuropsychological Status (RBANS) or Immediate Post Concussion Assessment and Cognitive Testing (IMPACT) may be of benefit in determining whether to proceed with full neuropsychological testing.15,16
Formal testing with a neuropsychologist, Neuropsychological Assessment (NPA), provides qualitative and quantitative information about domains including cognition and psychological functioning. NPA results can help guide diagnosis and treatment decisions, particularly in cases where there are overlapping symptoms (mental health, traumatic brain injury, other conditions affecting memory and thinking, and other medical conditions).17
Advanced visuo-motor and vestibular tests such as Vestibular-Evoked Myogenic Potentials can be helpful to distinguish between central and peripheral causes of persistent balance or oculomotor symptoms.9
Symptoms that are seemingly out of proportion or exam findings that do not fit the clinical picture should be followed up with further validity testing.18
The vast majority of people who sustain mTBI make a full recovery. One number that has been cited often in past was that 10% of people with mTBI have symptoms three months after injury. However, that number is not supported by quality studies. A recent prospective study, TRACK TBI, which followed 3000 patients and compared them to controls who had injuries but not mTBI, confirmed that some patients experience persistent cognitive problems following mTBI. At least 50% of patients who were followed after their initial emergency room (ER) visit for mTBI demonstrated functional deficits on the Glasgow Outcome Scale Extended (GOSE) at 12 months after injury. In fact, 53% of patients who’d had mTBI reported at least some ongoing functional limitations at 12 months. Some confounders and limitations include the fact that many people with mTBI do not visit the ER and that the GOSE may not be a robust measure of function. Even with those limitations, it is worth noting that some individuals have persisting symptoms after mTBI and these symptoms can benefit from intervention.19
Predictors of prolonged symptoms, or not achieving full recovery by three months post-injury, include older age at injury, lower socioeconomic status, increased symptom burden, pre-injury mental health problems, post-injury psychological distress, history of prior brain injuries, premorbid chronic pain, and other medical conditions.19
Accommodations to school and work environments can determine the success or failure of community reintegration efforts. Accommodations may include additional time for tasks, quieter work areas, opportunities for breaks and rest, tutors, and assistance in taking notes and completing assignments. Patients with photosensitivity benefit from light protection and glare-reducing interventions. Clinicians should act as advocates, insisting that appropriate accommodations are implemented and supporting patients as they increase function to pre-injury levels.
Social role and social support system
Individuals with mTBI, especially those with military-related and sports-related mTBI, often simultaneously face multiple challenges as they recover. In addition to coping with typical symptoms including irritability, impaired memory, and concentration, they may have to adapt to new social roles requiring flexibility. The mTBI-related symptoms can impair their ability to be flexible. Well-informed and sympathetic family members, friends, teachers and employers can provide key emotional and functional support during the recovery period.
Litigation and compensation-seeking behaviors are known risk factors for poorer outcomes. When litigation or compensation issues are present, then, clinicians need to be aware of them. At the same time, the clinical focus should be on the goal of full functional recovery. Patients should receive education and therapies that strive toward that very achievable objective.18
Rehabilitation Management and Treatments
Available or current treatment guidelines
VA/DOD Clinical Practice Guideline: Treatments should be geared toward the symptoms the individual reports and exhibits. The treatment plan should be personalized for the individual. Prescribed courses of medications and therapies should be time-limited, with goal being transition back to community-based activities as soon as possible. The VA/ DOD Clinical Practice Guideline for the Management of Concussion- Mild Traumatic Brain Injury provides recommendations for treatment.1
Ontario Neurotrauma Foundation Standards for Post-Concussion Care: Uncertainties faced by clinicians in mTBI care often involve evaluation and diagnosis. Related issues include whether and when to image and what follow-up is best. These are addressed in the widely respected Ontario Neurotrauma Foundation Standards for Post-Concussion Care, most recently updated in 2016.20
CDC Guideline for Pediatrics: Pediatric mTBI can be particularly challenging for clinicians. Children at different developmental states have varying normal examinations and differing responses to injury. Clinicians need to be vigilant to optimize recovery but also need to avoid being overly cautious, perhaps ordering tests that are not needed and could cause some harm. Children also have unique needs when it comes to returning to school and sports. Teachers, coaches, parents, caregivers, and other family members need to partner with the medical team and provide a consistent approach as children recover from mTBI. The CDC Pediatric Mild TBI Guideline provides a general roadmap through this process.2
Return-to-School: Children should be gradually returned to school activities. They may require periods of rest as their cognition and other symptoms improve. If they have headaches or neck pain, they should have help carrying their books or backpacks. If they have visuomotor symptoms, they should be allowed periods of visual rest. The amount of time they spend on school activities, including homework, should be slowly increased as tolerated.
Return-to-Play: Recommendations for optimal timing of returning to activities have varied from prolonged rest to early activity. This variation has left room for confusion and heterogeneous practice patterns. The CDC guidelines regarding safe return to sports and activities have brought standardization to this challenge. The return-to-activity guidelines are widely used and have been adapted by groups from all major collegiate and professional sports associations to the Department of Defense. The guidelines can also be readily adapted to any individual’s daily life.
Individuals start with 24 to 48 hours of relative physical and cognitive rest. Then they can start Step 1, which involves limited activity, but not doing actions that provoke symptoms. If there are no symptoms with this step after 24 hours of being there, they can progress to step 2, which involves light aerobic exercise. If there are no symptoms after 24 hours, progress to step 3, or sport specific exercise. This can include running and similar activities, but no resistance training and no head impacts. If there are no symptoms after 24 hours, progress to step 4, non-contact training drills. This includes some resistance training and more difficult drills. If there are no symptoms after 24 hours, progress to step 5, or normal activities but not quite at a game level. If there are no symptoms after 24 hours, progress to step 6, normal activity. If symptoms do occur, they should return to the highest level they achieved without symptoms, and then start progressing again.2
Berlin Guidelines: Sports-related mTBIs present challenges of their own. Questions often arise regarding optimal assessment and evaluation, safe return-to-play, and best practices for treatment. These and related questions are addressed in the Consensus Statement on Concussion in Sport, which was drafted at the 5th International Conference on this topic. The conference was in Berlin, and the recommendations are widely known as the Berlin Guidelines.21
At different disease stages
New onset/acute: During the days following and up to a week post injury, individuals can rest and start light activity when they feel up to it. Symptoms should be addressed.
Headaches and dizziness can be addressed with medications, cervical stretches in collaboration with physical therapy (PT), and interventions aimed at improving sleep, diet, and relaxation.22
Cognitive fogginess should improve with time and rest.
Sleep issues can respond well to normalization of schedule, some daytime activity, and optimizing environment for sleeping at night.
Subacute: During the weeks following injury, symptoms tend to steadily improve. Individuals return to more of their normal activity. Symptoms addressed in collaboration with interdisciplinary team.
Dizziness and disequilibrium can improve with from vestibular, visual, and proprioceptive exercises in collaboration with PT, occupational therapy (OT), or vision therapists.
Sleep disturbances can be addressed with education regarding sleep hygiene and related issues. Specific therapies include cognitive behavioral therapy for insomnia, medications to help with sleep initiation and sleep maintenance.
If behavioral or psychological symptoms occur, whether they are new following this injury or are of a long-standing nature, mental health practitioners can help develop and implement appropriate treatment plans.
Cognitive symptoms can be addressed with therapies aimed at optimizing function in the setting of the symptom. Compensatory mechanisms, and widely available technology, can be used as cognitive orthotics in the short term when they are needed.
Chronic/stable: Beyond 90 days post injury, the brain has returned to normal metabolic and physiological functioning and symptoms have generally resolved. In some cases, perhaps 10% of people with mTBI, symptoms persist following three months.
Therapies such as PT, OT, and vision therapy, can continue if they appear to be helping. Clinicians evaluate for other potential causes, such as a new condition or undiagnosed injury, for the ongoing symptoms. Psychological support, for the patient and family, can also be crucial.
If cognitive symptoms persist, neuropsychological tests can be used to help discern the specific problem that the individual is experiencing and can also provide guidance for subsequent treatment planning.
For persisting sleep disturbances, treatment should be geared to the specific problem. For general insomnia, behavioral modification is the first line treatment. This can begin with implementing healthy sleep practices and can increase to Brief Behavioral Therapy for Insomnia or Cognitive Behavioral Therapy for Insomnia. In cases of circadian rhythm sleep-wake cycle disorders, treatment can include strategically timed naps that are less than 30 mins and at least 7 hours before bedtime or short wavelength (blue) light therapy. For obstructive sleep apnea, positive airway pressure therapy is considered the mainstay of treatment. Sleep specialists can help with assessing and treating these and other complex sleep issues.10
Pharmacological treatments for severe symptoms: Medications can be helpful, particularly when symptoms are ongoing, severe, or significantly affecting function. Medications, which generally complement effects of therapies and behavioral interventions, are prescribed in the lowest doses and for shortest time periods possible. Clinicians can take advantage of manifold mediation effects to limit overall exposure. Valproic acid, for example, can treat both emotional lability and headaches. Clinicians need to be particularly attentive to potential adverse effects which can be subtle or atypical in this population. Careful risk-benefit review is warranted.
Headaches: The most common presentation of pain after mild TBI is headache. Medication treatment is geared toward the headache type. Post-traumatic headaches are most commonly classified as tension type headaches or cervicogenic headaches. Other headache types, including migraines, cluster-type headaches, neuritic/ neuropathic pain, medication overuse headaches, and combination headaches, also occur. Non-steroidal anti-inflammatory agents (NSAIDs) can help treat migraines, headaches with muscular or cervical joint involvement, and tension-type headaches. Acetaminophen can also help with musculoskeletal and tension-type headaches. It is important to avoid using as needed medications for prolonged periods, since medication-overuse headaches can result. Post-traumatic migraines can be addressed with serotonin-receptor agonists, also called triptans.1,22
Beta-blockers, such as propranolol, can help prevent headaches, but can worsen impaired cognition and fatigue. Tricyclic antidepressants, such as nortriptyline and amitriptyline, can be helpful, particularly when there is a neuropathic component to the pain, but can also lead to dizziness, fatigue, and gastrointestinal symptoms. Anticonvulsant medications, including valproic acid and topiramate, can also be used, with caution for potential side effects including fatigue, cognitive effects, and weight gain.1,22
Muscle relaxants, including cyclobenzaprine, whose mechanism is akin to a tricyclic antidepressant, and tizanidine, an alpha-agonist, can help address muscle tightness that can underlie cervicogenic and tension-type headaches. Of note, these medications can worsen cognition.1,22
Mood: Issues with depression, anxiety, irritability, and emotional lability can respond to medication treatment. Selective serotonin receptor inhibitors (SSRIs), including sertraline and citalopram, are commonly used to treat depression and anxiety following TBI. Serotonin/ norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine can also be helpful, particularly for anxiety. Mood-stabilizing medications, including the antiepileptic agent valproic acid, can help with irritability and emotional lability. Clinicians need to monitor carefully for side effects such as weight gain and other metabolic changes. Patients’ suicide risk also needs to be evaluated and monitored during the treatment course.23
Sleep: Disturbances in the sleep-wake cycle are common after mTBI. Insomnia, hypersomnia, and other abnormalities can occur. Headaches and mood issues can contribute. Sleep problems can exacerbate other symptoms, notably cognitive impairments and headaches, and can constrain overall function. Medication choices for sleep after mTBI are limited by potential adverse effects. Benzodiazepines have been associated with impaired neurological recovery after brain injury, so medications like clonazepam and lorazepam should be avoided. Newer non-benzodiazepine medications like zolpidem may be helpful in inducing sleep, but there is little data for them after TBI. Trazodone, a serotonin modulator that is commonly used to treat sleep issues after head injury, may help with sleep maintenance. Melatonin may help with resetting the circadian rhythm.10
Cognitive symptoms: Common cognitive issues following mild TBI include impaired attention and concentration, memory issues, and general feeling of mental cloudiness. These issues can improve with effective treatment of sleep or mental health issues. If cognitive symptoms persist, stimulant medications can often be helpful. Methylphenidate, a commonly prescribed stimulant, works by inhibiting norepinephrine and dopamine reuptake. Side effects can include worsened restlessness, impaired sleep, and loss of appetite. Other stimulants, including the combination product amphetamine/ dextroamphetamine, and other formulations of stimulants, including short-acting or extended release, can have benefits as well.Modafinil and armodafinil, whose mechanisms are believed to mimic effects of sympathomimetics, are stimulants which can help address fatigue. They may help with memory and other aspects of cognition in some cases but have the potential to interfere with normal sleep.23
Coordination of care
In mTBI, a biopsychosocial approach can be quite beneficial. Coordinated interdisciplinary treatment targeting the individual’s symptoms, and their potential underlying causes, can yield significant gains in function. The patient and family are key players. Team members include physiatrists, PT, OT, speech therapists, psychologists, neurologists and psychiatrists, vocational rehabilitation specialists, and social workers. Community contacts, including teachers, coaches, and work supervisors, can also play important roles. Attaining interdisciplinary goals that are developed with the patient can lead to a constructive combination of symptom resolution, community re-entry, and optimal quality of life.
Patient & family education
From prevention through recovery, education is paramount to effective mTBI care. Education needs to be both standardized, based on reputable data, and individualized, highlighting the specific issues most relevant to the patient.
Informing the public regarding mTBI risk factors and ways to prevent injuries can help decrease the number of preventable cases.
At time of injury, patients and families need education regarding potential symptoms and how to manage them. They also need to know when to seek additional care if they either experience unexpected symptoms or are not recovering as expected. They need appropriate information regarding recommendations for returning to activity.
During recovery, patients should understand the rationale for medication and therapies. They should know the best team member to contact with questions or concerns. Patients need to be reminded that full recovery is expected.
Return to activity may be smoother if reliable and consistent information is appropriately shared with other involved people, such as coaches, teachers, and supervisors at work.
Nutrition: There is some evidence that some vitamins and nutrients can assist with brain recovery. Omega-3 fatty acids, which are postulated to have benefits including modulating neuro-inflammation and oxidation, could potentially mitigate some of the effects of mTBI. Vitamin E and A may also be beneficial. Additional evidence is needed. At this point, clinicians should recommend a balanced diet during recovery from mTBI.24
Transcranial magnetic stimulation (TMS): TMS, which is already FDA-approved for treatment of some sub-types of depression, may also have potential to help treat symptoms following mild TBI. TMS, a type of neuromodulation that is delivered non-invasively, may help improve depression and headaches. Studies are underway.25
Measurement of patient outcomes
Brain injuries and the individuals who sustain them are heterogeneous. Across the board, though, the goal of treatment is to address symptoms. This could be measured by patient reports of symptoms on measures like the Neurobehavioral Symptom Inventory. Perhaps an even more important outcome would be the degree to which the individual returns to prior social, vocational, and overall functional status. Health related quality of life can also correlate with effective treatment of mTBI.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Overlap with mental health: In at least some people with mTBI, there is a complex interplay between symptoms of mental health conditions and mTBI during the course of recovery. The symptoms of these two domains can overlap and make each one more intense. Alternately, mTBI can be mistaken for mental health conditions, or vice versa, based on presenting symptoms. Further, the presence of either mTBI or mental health conditions can cause clinicians to mistakenly miss the presence of the other one. The resultant clinical conundrum is best addressed by an interdisciplinary team. Mental health providers, including psychologists who can help patients focus on the goal of recovery and optimizing function, play crucial roles. Psychiatrists can also help with management of medications, balancing benefits with side effects for the healing brain. The entire rehabilitation team needs to communicate effectively regarding goals and planned interventions. Perhaps most importantly, the patient and family need to receive consistent and ongoing information about these complex issues and plans for addressing them.
Therapeutic exercise: The benefits of exercise for overall health, cardiovascular fitness, and even brain function, have been well-described. There is also a growing body of literature demonstrating that exercise after brain injury can be beneficial. After mTBI, as soon as initial symptoms subside, aerobic exercise can be started. The intensity and duration of aerobic exercise should be limited to avoid symptoms, and if symptoms do recur, subsequent sessions should be decreased. Recommendations would of course be individualized and would take the patient’s prior activity level and other health issues into account. General recommendations could include 20 minutes of aerobic activity 5-6 times per week, at light intensity, and then increasing gradually as tolerated. It makes sense to start with a physical therapist and then transition to a home program.4
Cutting Edge/ Emerging and Unique Concepts and Practice
Telehealth: Using modern phone and computer technology, clinicians can provide care from sites that are distant from the patient’s location. Telehealth can be particularly useful for patients who require evaluation for mTBI. Positive aspects of using telehealth include convenience, high patient satisfaction, and more efficient use of resources. Telehealth visits requiring a physical exam can include a practitioner in the patient’s local clinic. If no exam is required, visits can be done at the patient’s home, workplace, or other convenient yet private spot. Barriers to using telehealth effectively in mTBI include issues with technology and scheduling. There may also be logistics issues regarding licensure and insurance. It is important to have a plan for follow-up, which might include a local team member coordinating therapies and prescriptions. In addition, a plan for handling potential emergencies which may become apparent during the telehealth visit needs to be in place.26,27
Postural Orthostasis and Tachycardia Syndrome (POTS): Individuals who have persisting fatigue, dizziness, cognitive and exercise intolerance symptoms may be experiencing POTS. This syndrome is related to autonomic dysfunction. Emerging research demonstrates at least some association between mild TBI and POTS. It is possible that a rehabilitation program specifically geared toward these symptoms can be beneficial.28
Gaps in the Evidence-Based Knowledge
Difference between athletes, non-athlete civilians, and post-combat Service Members and Veterans: Members of these disparate groups receive different amounts and intensities of treatment and activity following mild TBI. Their baseline physical and functional status and the typical etiology of their injuries are also very different. It seems to make sense that they would also be likely to have different recovery trajectories. It also seems plausible that some aspects of the evaluation and treatment approaches that help members of one group could also be applied to members of other groups. For example, the early supervised exercise programs that likely contribute to better outcomes in athletes could be made available for non-athlete civilians as well. More research into these issues is needed.
Injury prevention through safer equipment: Research into methods of mitigating force that is applied to the head can help minimize mTBI effects. For example, different helmets provide varying levels of protection. However, at least at the moment, recommendations regarding helmets and other equipment remain non-standardized. Additional research will inform these recommendations and help clinicians provide evidence-based advice about safety equipment.Long term cumulative effects of mTBI: Multiple large, prospective studies are underway. The goal is to discern and describe the potential risk of long-term sequelae from mTBI, particularly in individuals who have sustained mTBI repeatedly. The Long-Term Impact of Military Brain Injury Consortium, for example, is looking at these timely issues. Details about the project, and helpful resources for concerned patients and families, can be found at www.limibic-cenc.org.7,29
- Department of Veterans Affairs and Department of Defense. Clinical Practice Guideline for the Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury. Version 3.0. 2021: Washington DC. Website: https://www/healthquality.va.gov/index.asp. Accessed 3/27/23.
- Centers for Disease Control and Prevention. Traumatic brain injury: Heads up. 2019: Atlanta GA. Website:Https://www.cdc.gov/headsup. Accessed 3/19/23.
- Department of Defense Traumatic Brain Injury Center of Excellence. TBI worldwide numbers. 2023: Washington DC. Website: TBICoE. DOD TBI Worldwide Numbers | Health.mil. Accessed 03/12/2023.
- Silverberg ND, Iaccarino MA, Panenka WJ, et al. Management of concussion and mild traumatic brain injury: A synthesis of practice guidelines. Arch Phys Med Rehabil. 2020; 101(2): 382-393.
- McAllister T, McCrea M. Long-term cognitive and neuropsychiatric consequences of repetitive concussion and impact exposure. J. Athl Train. 2017; 52(3):309-317.
- Stovitz SD, Wesenman JD, Hooks MC et al. What definition is used to describe second impact syndrome in sports? A systematic and critical review. Curr Sports Med Rep. 16(1): 50-55.
- Cifu DX. Clinical research findings from the long-term impact of military-relevant brain injury consortium-Chronic effects of neurotrauma consortium (LIMBIC-CENCI) 2013-2021. Brain Inj. 2022; 36(5): 587-597.
- Marion DW, Lattimore TB, Helmick KM. Military Acute Concussion Evaluation screen in a civilian population. J Trauma Acute Care Surg. 2016; 80(2):351-352.
- Yorke AM, Smith M, Babcock M et al. Validity and reliability of the vestibular/ ocular motor screening and associations with common concussion screening tools. Sports Health. 2017; 9(2):174-180.
- Wickwire EM, Schnyer DM, Germain A et al. Sleep, sleep disorders, and circadian health following mild traumatic brain injury in adults: Review and research agenda. J Neurotrauma 2018. 35 (22): 2615-263.
- Helmrich IR, Czeiter E, Amrein K et al. Incremental prognostic value of acute serum biomarkers for functional outcome after traumatic brain injury (CENTER-TBI): An observational cohort study. Lancet Neurol 2022; 21: 792-802.
- Papa L, Ladde JG, O’Brien JF et al. Evaluation of glial and neuronal blood biomarkers compared with clinical decision rules in assessing the need for computed tomography in patients with mild traumatic brain injury. JAMA Netw Open. 2022; 5 (3): e221302.
- Wang KK, Yang Zhu T, et al. An update on diagnostic and prognostic biomarkers for traumatic brain injury. Expert Rev Mol Diagn. 2018; 18(2):165-180.
- Douglas DB, Muldermans JL, Wintermark M. Neuroimaging of brain trauma. Curr Opin Neurol. 2018; 31(4):362-370.
- Silva, MA. Review of the neurobehavioral symptom inventory. Rehabil Psychol. 2021; 66(2); 170-182.
- Vos L, Whiteneck GG, Ngan E et al. Comparison of the Neurobehavioral Symptom Inventory and the Rivermead Postconcussion Symptoms Questionnaire. Brain Inj. 2019; 33(9): 1165-1172.
- Larson EC, Belanger HG. Cognition in mild traumatic brain injury: Neuropsychological assessment. In Zollman FS. Manual of Traumatic Brain Injury (3rd Ed.). 2022. Springer/ Demos: New York.
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Original Version of the Topic
Charles E. Levy, MD, Neha Dixit, PhD and David Fitzgerald, MD. Mild TBI. 10/08/2015
Previous Revision(s) of the Topic
Diane Schretzman Mortimer, MD, Matthew Puderbaugh, DO. Mild TBI. 7/27/2020
Diane Schretzman Mortimer, MD
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Matthew Puderbaugh, DO
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Ameya Joshi, MD
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