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Corresponding author Noah D. Silverberg, PhD, Division of Physical Medicine & Rehabilitation, University of British Columbia, 4255 Laurel St, Vancouver, British Columbia, Canada V5Z2G9.
Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, British Columbia, CanadaRehabilitation Research Program, GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada
Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MassachusettsDepartment of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MassachusettsHarvard Medical School, Boston, Massachusetts
BC Mental Health and Addictions Research Institute, Vancouver, British Columbia, CanadaBritish Columbia Provincial Neuropsychiatry Program, Vancouver, British Columbia, CanadaDepartment of Psychiatry, University of British Columbia, Canada
Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MassachusettsMassGeneral Hospital for Children Sport Concussion Program, Boston, MassachusettsHome Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts
Division of Physical Therapy, Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, CanadaDepartment of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
At least 3 million Americans sustain a mild traumatic brain injury (mTBI) each year, and 1 in 5 have symptoms that persist beyond 1 month. Standards of mTBI care have evolved rapidly, with numerous expert consensus statements and clinical practice guidelines published in the last 5 years. This Special Communication synthesizes recent expert consensus statements and evidenced-based clinical practice guidelines for civilians, athletes, military, and pediatric populations for clinicians practicing outside of specialty mTBI clinics, including primary care providers. The article offers guidance on key clinical decisions in mTBI care and highlights priority interventions that can be initiated in primary care to prevent chronicity.
Centers for Disease Control and Prevention. Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths—United States, 2014.
Centers for Disease Control and Prevention, U.S. Department of Health and Human Services,
Atlanta, GA2019
are classified as “mild” (mTBI), meaning that they involve no or only a brief (<30min) loss of consciousness and period of posttraumatic amnesia (<24h).
Management of mTBI largely occurs outside of the hospital. Although the emergency department is the typical point of entry into the health care system, increasingly, patients with mTBI are first seeking medical attention from a community-based primary care provider.
Primary care providers and specialists (eg, neurologists, physiatrists, etc) unattached to a TBI-specific clinic are often relied on to provide and/or arrange early follow-up care.
Statements of agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.
Statements of agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.
Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.
Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.
Statements of agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.
Scandinavian guidelines for the acute management of adult patients with minimal, mild, or moderate head injuries: an evidence and consensus-based update.
The present review aims to synthesize this rapidly advancing knowledge for the clinician whose primary practice is not mTBI. We provide evidence-based recommendations to guide key clinical decisions and highlight priority interventions that can be initiated by nonexpert clinicians to potentially prevent chronicity.
The recommendations in this article will generally apply across age (school-aged children through adulthood) and injury setting (trauma, sport, military), although tailoring care to each is advisable. Note that some consensus statement and guideline documents synthesized here were intended to apply only to patients with “uncomplicated” mTBI (also known as “concussion” and characterized by an absence of trauma-related intracranial abnormalities on conventional structural neuroimaging),
The recommendations outlined below can be used for patients with uncomplicated and complicated mTBI, at the clinician’s discretion.
Methods
An interdisciplinary group of content experts (American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group Mild TBI Task Force) extracted evidence-based recommendations from the latest versions of expert consensus statements and clinical practice guidelines for school-aged children,
Scandinavian guidelines for the acute management of adult patients with minimal, mild, or moderate head injuries: an evidence and consensus-based update.
Statements of agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.
Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.
Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.
with mTBI. To incorporate the most up-to-date evidence, a supplementary MEDLINE search was performed on December 14, 2018, to identify recent systematic reviews by combining mTBI-related terms with a validated search filter for systematic reviews
A narrative synthesis of the consensus statements, clinical practice guidelines, and updated evidence follows. To supplement the narrative, we identified management recommendations that were consistent across the most recent and widely cited statement or guideline for each of the following areas: adults,
To be included, a management recommendation had to (1) be explicit in at least 3 of the 4 core statements or guidelines and (2) be implied by, or at least consistent with any core statement or guideline that did not recommend the strategy explicitly. Eligible management recommendations, their associated strength (using guideline-specific grading systems), and their location within the source document were extracted by 2 authors independently (N.S. and K.M.), with discrepancies resolved by a third (W.P.), and are presented in table 1.
Table 1Recommendation number/location and strength
Detailed recommendations for clinicians regarding rest and return to activity in an active duty military setting are covered in the Defense and Veterans Brain Injury Center’s (2014) Progressive Return to Activity Following Acute Concussion/Mild TBI (accessed May 2, 2019: https://dvbic.dcoe.mil/material/progressive-return-activity-following-acute-concussionmild-tbi-clinical-suite).
Pg. 5
Guidance on gradual stepwise return to preinjury activities
Detailed recommendations for clinicians regarding rest and return to activity in an active duty military setting are covered in the Defense and Veterans Brain Injury Center’s (2014) Progressive Return to Activity Following Acute Concussion/Mild TBI (accessed May 2, 2019: https://dvbic.dcoe.mil/material/progressive-return-activity-following-acute-concussionmild-tbi-clinical-suite).
Pg. 5, 7
Early education for patient/family
2.3 (A), 2.6 (A)
7A/7B (B), 12 (A)
11, 15, 22 (Weak)
C
Use validated symptom scales for initial assessment and to track recovery
4.1 (C)
5A, 10B (B)
C
Pg. 3, 4, 7
Neuropsychological assessment to investigate persistent (>30d) cognitive symptoms
9.4 (A)
19C (C)
17 (Weak)
C
Referral to specialist or higher level of care for slow to recover patients (>10-14d for adult athletes, >30d for others)
2.4 (C)
11B/15F (B)
21 (Weak)
Pg. 5
NOTE. C, consistent with but not explicitly recommended in guideline/statement.
CDC, Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (2019). Strength of recommendations: A, almost always should be followed; B, usually should be followed; C, may sometimes be followed; R, intervention generally should not be done outside of a research setting; U, insufficient evidence.
CISG, Consensus Statement on Concussion in Sport–the 5th International Conference on Concussion in Sport (2016). Strength of recommendations: Not applicable.
ONF, Ontario Neurotrauma Foundation Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms (3rd edition; 2018). Levels of evidence: A, ≥1 randomized controlled trial, meta-analysis, or systematic review; B, ≥1 cohort comparison, case study, or other type of experimental study; C, expert opinion, experience, or consensus panel.
VA/DoD, Department of Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Concussion-Mild Traumatic Brain Injury (2016). Strength of recommendations: Strong For, Weak For, Strong Against, Weak Against.
Some patients with mTBI (12%-20%) will have macrostructural intracranial injury visible on computed tomography (CT); most common are cerebral contusions (disproportionately frontal-temporal), subdural hematomas, and subarachnoid hemorrhages.
Magnetic resonance imaging studies using modern techniques such as diffusion tensor imaging suggest that microstructural pathology (eg, weakened integrity of long white matter tracts) can also be a feature of mTBI,
mTBI can be challenging to diagnose in any setting because the acute signs and symptoms of altered mental status (AMS) are often subtle and transient, and available diagnostic tests (eg, CT) are not sensitive. These issues may be compounded in primary care, where patients are often first evaluated days or even weeks after an injury event and factors that mimic mTBI-like symptoms (fig 1) may have emerged. Many novel biomarkers for mTBI are under development, but none have yet been validated for diagnostic purposes.
A clinical interview based on patient self-report (and corroborated with medical records, when available) with physical examination remains the criterion standard for diagnosing mTBI in primary care.
Fig 1Conditions that can mimic or exacerbate “postconcussion” symptoms.
Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: a retrospective analysis.
Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members.
The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury.
is reasonable. The critical first step should be to establish a plausible injury mechanism. The mechanism of injury must transmit sufficient biomechanical energy to disrupt brain function, recognizing there are between-person variability thresholds.
may cause an mTBI in the absence of contact between the head and another surface.
Second, the clinician should query for signs and symptoms of AMS that presented immediately following the impact. The most compelling evidence of AMS is loss of consciousness (observed period of unresponsiveness), posttraumatic amnesia (gap in memory following the impact), or confusion (eg, inability to follow commands or disorientation to time or place). By some definitions, subtler symptoms such as slowed thinking
Other potential confounds include acute psychological stress, severe musculoskeletal pain, pulmonary or circulatory disruption, and syncope or hypoglycemia prior to a fall. People who are exposed to a psychologically traumatic event that does not involve mTBI (eg, witnessing violence) and react with panic (eg, fear of death, tachycardia, hyperventilation) can have difficulty recalling part or all of the event.
Example questions for the diagnostic interview are provided in fig 2. The final step in the diagnostic process is to incorporate all available information into a probabilistic determination.
Equivocal evidence of AMS may warrant an mTBI diagnosis if it occurred in the context of a high-energy impact and the absence of confounding factors. The decision to rule in mTBI must be weighed against the potentially iatrogenic consequences of a false positive mTBI diagnosis, such as misdirecting treatment so that a clinically important underlying condition (eg, posttraumatic stress) is not addressed.
Postconcussion symptoms such as headache, dizziness, fatigue, irritability, and forgetfulness can support a diagnosis or trigger a diagnostic evaluation (and precautionary measures such as removal from sport)
Centers for Disease Control and Prevention Report to Congress on Mild Traumatic Brain Injury in the United States: steps to prevent a serious public health problem; 2003. Available at: https://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf. Accessed June 11, 2018.
The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury.
Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.
; the poor specificity of these symptoms weakens their diagnostic utility. Nevertheless, if a patient experiences new or worsened physical, cognitive, or emotional symptoms after a plausible mechanism of mTBI in the absence of AMS and confounding factors that might account for those symptoms (see fig 1), it would be prudent to proceed with clinical management under the assumption that the individual may have sustained an mTBI,
for example, by temporarily restricting the patient from safety-sensitive activities until their symptoms resolve and/or an alternative etiology is identified and addressed.
Prognosis
Recent inception cohort studies suggest that at least 1 in 5 patients with mTBI will experience symptoms that persist for longer than 1 month
have been inconsistent predictors of clinical outcome. The more symptoms a patient has soon after mTBI, the more symptoms they tend to have weeks and months later
In adults, preinjury mental health problems and postinjury psychological distress (symptoms of depression and anxiety) are robust predictors of prolonged recovery.
Early clinical management. Ruling out medical emergencies
When a primary care provider sees a patient with suspected mTBI within the first 48 hours of injury and is the first medical professional to evaluate the patient, the top priority is to rule out a neurosurgical emergency (eg, expanding intracerebral hemorrhage). The potential for cervical spine injury should be investigated by assessing neck motion or tenderness to palpation of the boney vertebral elements, airway trauma, and sensory-motor deficits. Positive examination findings warrant immediate cervical spine stabilization and trauma evaluation.
Acute neuroimaging of the brain should not be performed routinely following mild head trauma in previously healthy children and adults younger than 65 years old.
for children were developed to guide physicians in determining the need for urgent neuroimaging after mTBI. When the clinical indication for head CT is ambiguous, it is reasonable to counsel patients and their families on the benefits and risks (eg, radiation exposure).
Scandinavian guidelines for the acute management of adult patients with minimal, mild, or moderate head injuries: an evidence and consensus-based update.
Patients with skull fracture or trauma-related intracranial abnormalities on CT have nontrivial rates of clinical deterioration (11.7%), emergency neurosurgical intervention (3.5%), and death (1.5%), especially older adults and anticoagulated patients.
The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by computed tomography imaging: a systematic review and meta-analysis.
Signs of clinical deterioration such as reduced responsiveness, somnolence, severe and worsening headache, repeated vomiting, and emergence of focal neurologic signs warrant urgent evaluation at an emergency department.
Fig 3Indications for urgent noncontrast computed tomography of the head after suspected mild traumatic brain injury. Abbreviation: MOI, mechanism of injury.
Scandinavian guidelines for the acute management of adult patients with minimal, mild, or moderate head injuries: an evidence and consensus-based update.
recommend that S100B values of <0.10 μg/L, if sampled within 6 hours of injury, can help rule out the need for CT in patients younger than 65 years with a Glasgow Coma Scale score of 14 or a Glasgow Coma Scale score of 15 with loss of consciousness or repeated vomiting. This approach has been empirically cross-validated.
Utility and effectiveness of the Scandinavian guidelines to exclude computerized tomography scanning in mild traumatic brain injury - a prospective cohort study.
In early 2018, the United States Food and Drug Administration approved the Banyan Brain Trauma Indicator for adults with suspected mTBI, based on evidence that low values of C-terminal hydrolase-L1 (<327pg/mL) and glial fibrillary acidic protein (<22pg/mL) within 12 hours of injury are associated with very high probability (0.996) of negative head CT.
C-terminal hydrolase-L1 and glial fibrillary acidic protein have not yet been incorporated into any published clinical practice guidelines. Their incremental value over clinical decision rules (eg, Canadian CT head rule
The relationship between mTBI and epilepsy varies with injury severity. There may be no significantly increased risk following uncomplicated mTBI (concussion)
Concussive convulsion, in which brief posturing or other seizure-like activity is observed immediately after impact (in 1%-2% of cases), is thought to result from a transient loss of cortical inhibition (ie, have a nonepileptogenic cause) and is not associated with prolonged recovery from mTBI or the development of posttraumatic epilepsy.
Routine seizure prophylaxis is not recommended in any mTBI clinical practice guideline.
Education
After critical medical complications are ruled out, the clinician should provide the patient (and family members and caregivers, if appropriate) with verbal and written education.
Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.
; the goal is to alleviate symptoms and reduce metabolic demands on the brain. Complete rest, such as lying in a dark room and avoiding all sensory stimuli (eg, reading, interacting with family and friends, etc) does not accelerate recovery and is therefore not advisable.
Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members.
After an initial period of relative rest and symptom stabilization, patients should be encouraged to gradually resume normal daily activities (including screen time) as tolerated.
This means that physical and cognitive activities can be progressively resumed at a pace that does not significantly worsen existing symptoms or generate new symptoms.
Environmental conditions with high sensory stimulation can also be gradually reintroduced. Clinicians may provide more detailed, structured guidance for a graduated activity progression with return to school,
Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.
Usual daily activities that do not provoke symptoms
Gradual reintroduction to school and work
2
Light aerobic exercise
Walking or stationary biking at slow to medium pace without resistance.
Increase heart rate
3
Sport-specific exercise
Aerobic exercises such as running, sprinting, skating. Sport-specific warm-up and light drills. No head impact activities
Increase motion
4
Noncontact training drills
More intense training drills. May start progressive resistance training and weight lifting
Assess coordination, fitness, and concentration
5
Full contact practice
Participate in normal training activities including scrimmaging
Restore confidence and assess functional skills by coaching staff
6
Return to sport
Normal game play
NOTE. There should be at least 24 h (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back to the previous step.
Has trouble focusing during lessons and assignments.
Advise a lighter work load with shorter/modified assignments. Provide written notes of lessons.
Trouble remembering
Struggles holding instructions in mind, retaining information, and accessing new concepts. Trouble with reading comprehension and math calculations.
Provide written instructions, shorter reading assignments, and offer smaller amounts of new material to learn.
Decreased processing speed
Struggles to keep up with work demands and processes information at a slower rate.
Provide increased time for tests and/or assignments.
Cognitive fatigue
Decreased arousal.
Provide breaks throughout day as needed.
Emotional symptoms (eg, anxiety or depression)
Increased social isolation or lack of interest in participating in usual activities (eg, sports, clubs).
Provide encouragement to engage in social activities at school and outside of school. Suggest an appointment with a school counselor.
Headaches
Interferes with ability to concentrate and perform school work.
Breaks as needed in a quiet environment.
Light or noise sensitivity
Symptoms may worsen with screen time or in loud environments.
Offer written assignments vs computer-based assignments. Avoid loud settings, such as cafeteria or assemblies.
Symptom sensitivity
Symptoms worsen with cognitive and/or physical exertion.
Reduce cognitive or physical demands by providing rest breaks and completing work in small sections (ie, working to a point that does not elicit symptoms).
To mitigate the risk of repeated mTBI, patients should be counseled to not return to activities that involve a relatively high risk head impact exposure (eg, collision sports) until they are clinically recovered.
Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.
Clinical recovery from mTBI is determined by symptom resolution, normalization of physical examination findings, and tolerance for usual daily activities (including vigorous exercise for athletes).
The balance and cognitive tests within the SCAT5 are most sensitive during the first 24 hours following injury but rapidly lose sensitivity to more subtle lingering deficits thereafter. Their utility for tracking recovery beyond 3-5 days after mTBI has not been established.
What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? A systematic review.
Follow-up care for patients with persistent symptoms
Patients who experience moderate-severe symptoms or are unable to promptly resume their usual activities (within 1-2 weeks for adults or 2-4 weeks for children and adolescents) require more active management.
This section outlines strategies for more detailed assessment and treatment initiation for nonexpert clinicians to consider for the second clinic visit and beyond. Appropriate early intervention can mitigate symptom chronicity.
Investigations
Most practice guidelines discourage postacute neuroimaging in a typically recovering patient.
However, it is reasonable to obtain an imaging study if symptoms are prolonged and are not improving over the course of weeks/months to rule out other contributors to the clinical presentation (eg, chronic subdural hematoma in an older adult).
Clinicians should check for treatable causes of persistent dizziness, vision problems, sleep disturbance, and fatigue. For example, patients with persistent dizziness can be assessed for benign paroxysmal positional vertigo with the Dix-Hallpike maneuver or supine roll test.
If fatigue does not improve with treatment of other symptoms, consideration should be given to alternative causes of fatigue (eg, adverse medication effects, sleep apnea, anemia, hypothyroidism), with limited investigations (eg, bloodwork for metabolic and electrolyte abnormalities) as needed.
may be more appropriate for children. There is substantial overlap between mental health and post-mTBI symptoms. A positive screening test result should trigger a detailed psychiatric history and review of symptoms.
Persistent subjective cognitive symptoms are often not associated with objective cognitive impairments. They can occur in the context of preexisting neurodevelopmental problems (eg, attention-deficit/hyperactivity disorder or learning disability) or present health conditions (eg, depression, pain, substance misuse) that carry substantial cognitive burden.
Health care utilization of workers’ compensation claimants associated with mild traumatic brain injury: a historical population-based cohort study of workers injured in 1997-1998.
Patients who have activity-limiting cognitive symptoms beyond 1 month after mTBI may benefit from neuropsychological assessment to identify treatment recommendations and/or work or school accommodations.
Underlying this approach is an assumption that mTBI symptoms that persist past the acute period (2 weeks for adults and 4 weeks for school-aged children and adolescents) usually do not have a single etiology. Symptoms result from a complex interplay of biopsychosocial factors, many of which are not unique to mTBI. Two key principles guide treatment. First, treatment algorithms that have a substantial evidence base in primary medical or psychiatric disorders generally do not require modification to treat symptoms that occur after an mTBI.
Second, clinicians should prioritize the treatment of symptoms that are most amenable to intervention and most likely to bring about improvement in other symptoms. Priority symptoms in the subacute to chronic stage of mTBI recovery include headaches, insomnia, anxiety, and depression.
Posttraumatic headaches do not have a unique location pattern or character but instead mimic primary headache types such as migraine, tension, cervicogenic, and those with mixed features.
Early management should include avoidance of fasting (skipping meals) and maintaining adequate hydration. During the immediate postinjury period, acetaminophen may be preferred over aspirin and certain other nonsteroidal anti-inflammatory agents that confer a slightly increased risk of hemorrhagic stroke.
Consider prescription medications when headaches are refractory to lifestyle interventions and occasional over-the-counter analgesics. Medication choice should be based on the primary headache type that the posttraumatic headache most closely resembles.
Excessive use of rescue pain medications (generally >10 days a month for opiates and triptans or >15 days a month for simple analgesics) for prolonged periods should be discouraged.
Both hypersomnia and insomnia are common after mTBI. The goal of treatment is to normalize the sleep-wake cycle. Initial management of sleep disturbance should include environmental and behavioral modifications, such as setting a regular nighttime sleep schedule, limiting daytime naps, and avoiding foods or substances that may have a stimulating effect.
Emergent obstructive sleep apnea, catalyzed by inactivity and weight gain after the injury, should be considered before treating insomnia in adults.
Psychological distress
Patients with severe depression or anxiety disorders should be referred to a mental health provider, but mild-moderate symptoms (eg, Generalized Anxiety Disorder–7 and Patient Health Questionnaire–9 screening scores both <15) can generally be managed within primary care.
Alternative medications such as serotonin-norepinephrine reuptake inhibitors, tricyclics, trazodone, or mirtazapine may be appropriate, particularly if treating concurrent symptoms such as sleep disturbance, headache, or bodily pain. Several of these agents have antiheadache properties, extending their usefulness. Benzodiazepines for anxiety should be avoided.
In general, treatment should be initiated as soon as a patient meets diagnostic criteria for a mental health disorder (eg, ≥2 weeks of persistent depressive symptoms for major depressive disorder), and effective pharmacotherapy should be maintained for at least 6 months before considering discontinuation.
Exercise as treatment
Physical activity has pan-domain beneficial effects. Following an initial brief period symptom subsidence, aerobic exercise at insufficient intensity and duration to provoke symptoms appears safe and therapeutic.
The preinjury activity level of the patient should be considered in making exercise recommendations, but the clinician could recommend 20 minutes of aerobic exercise 5-6 times a week, initially at light intensity (no more than [220−age]×0.7 heart beats per minute) and supervised (eg, by a physical therapist) and then at home.
Referral to individual medical specialists or to a specialized multidisciplinary mTBI clinic is appropriate for patients with persistent symptoms (lasting more than 4-6 weeks) that do not respond to treatment in a primary care setting.
Earlier referral may be helpful when (1) patients have a high symptom burden or known risk factors for prolonged recovery, such as a preexisting mental health disorder,
(2) patients are unable to progress with their return to activity or are attempting to return to high-stakes roles soon after injury (eg, competitive sport or university examinations), or (3) access to care is limited (eg, long waitlist times). mTBI clinics should have access to a physician and a multidisciplinary team of licensed health professionals who provide coordinated, evidence-based care.
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.
Statements of agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.
Patients with 1-2 specific symptoms may only require individual disciplines rather than referral to a multidisciplinary clinic. For example, patients with primarily vestibular symptoms should be referred to physical therapy or otolaryngology.
There is expert consensus that management of school-aged children and adolescents with mTBI should consider that (1) recovery time might be slower than adults,
especially in unpredictable environments (eg, schoolyard), and (4) successful return to school (ie, symptom-free during school activities with no accommodations) should precede return to sport.
Narrative reviews have important limitations. The clinical practice guidelines and consensus statements we drew from had already conducted systematic searches and critical appraisals of the available evidence. We therefore considered the risk of including recommendations that were not supported by evidence or expert consensus opinion to be low. However, it is possible that author bias resulted in an incomplete or imbalanced synthesis of management recommendations. The narrower list of recommendations in table 1 represents the clinical actions with the most consistent support across statements or guidelines, as determined by independent extractors.
Conclusions
Clinicians without a specialty practice in mTBI are increasingly involved in providing and coordinating care for patients with mTBI. Careful diagnostic assessment and proactive clinical management is essential to maximizing recovery. Patient education, return to activity guidance, and symptom-targeted treatment are pillars of mTBI management in primary care.
Acknowledgments
Other members of the American Congress of Rehabilitation Medicine Mild TBI Task Force were collaborators on this article: Alison M. Cogan, PhD, OTR/L, Washington DC Veterans Affairs Medical Center; Min Jeong Park Graf, MD, University of Minnesota Medical School & Department of Physical Medicine and Rehabilitation, Hennepin Healthcare; Maria Kajankova, PhD, Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai & Brain Injury Research Center; Gary McKinney, MHSc, CBIS, CPT, Defense and Veterans Brain Injury Center; Christina Weyer Jamora, PhD, RN, Department of Neurological Surgery, University of California San Francisco & Department of Psychiatry, Zuckerberg San Francisco General Hospital, University of California San Francisco.
The authors wish to thank primary care providers Sarah Shaw, MD, CCFP (Toronto, Canada), and Vivienne Lemos, MD, CCFP (Toronto, Canada), for providing helpful feedback from a user perspective on an early manuscript draft.
The American Congress of Rehabilitation Medicine Brain Injury Special Interest Group provided administrative support for the activities of the Task Force and funded the open access fees for this article through a Task Force grant.
Centers for Disease Control and Prevention. Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths—United States, 2014.
Centers for Disease Control and Prevention, U.S. Department of Health and Human Services,
Atlanta, GA2019
Statements of agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.
Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.
Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.
Scandinavian guidelines for the acute management of adult patients with minimal, mild, or moderate head injuries: an evidence and consensus-based update.
Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: a retrospective analysis.
Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members.
The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury.
Centers for Disease Control and Prevention Report to Congress on Mild Traumatic Brain Injury in the United States: steps to prevent a serious public health problem; 2003. Available at: https://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf. Accessed June 11, 2018.
Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.
The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by computed tomography imaging: a systematic review and meta-analysis.
Utility and effectiveness of the Scandinavian guidelines to exclude computerized tomography scanning in mild traumatic brain injury - a prospective cohort study.
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