Treatment Guidelines for Mild Traumatic Injuries

  • 1. Diagnosis or assessment of Mild Traumatic Brain Injury: Many patients who attend at the emergency department or their health care provider’s office following trauma are often unaware that they have sustained a mild traumatic brain injury. For this reason formal evaluation with a standardized tool is essential in diagnosing mTBI. The main goal of early diagnosis is to rule out acute, life threatening complications such as intracranial hemorrhage. However early diagnosis is also useful prepare the patient and his or her family members for future complications. Although most patients will not experience acute complications, many patients will be symptomatic immediately post injury, and provision of information regarding mild traumatic brain injury symptoms, and instructions for follow up have been shown to be one of the more effective strategies in addressing persistent symptoms.

 

  • 2. Management of Mild Traumatic Brain Injury: A management plan must  be initiated for patients suffering mTBI.  The plan must include information regarding monitoring for potential acute complications requiring reassessment, information regarding expected symptoms of mTBI, the expected course of recovery, reassurance that the symptoms are temporary, and recommendations for health care follow up. The plan should also consider pre-injury or current psychiatric difficulties (for example depression or anxiety) as these conditions may place the patient at increased risk for persistence of symptoms.

 

  • 3. Sport Related Mild Traumatic Brain Injury:  It is estimated that contact sport results in 300,000 mild traumatic brain injuries per year in the United States.[1] Guideline 3 sets out a list of indicators of sport-related mTBI. If any signs or symptoms (see Table 8) of possible sport related mTBI are observed following a blow to, or jarring of the head, the guidelines recommend that the player should not be allowed to return or play in the current game or practice while symptomatic (“If in doubt, sit them out”), he or she should be regularly monitored for changes in condition, and eventual return to play after mTBI should follow an incremental process, proceeding to the next level only when the patient is asymptomatic both at rest and with exertion.

 

  • 4. General Recommendations Regarding Diagnosis/Assessment of Persistent Symptoms Following a Mild Traumatic Brain Injury: Full recovery from an mTBI is generally expected within 3 months; however there are a number of factors that influence the rate of recovery. Individuals with persistent symptoms should be assessed and monitored using a standardized scale such as the Rivermead Post Concussion Symptoms Questionnaire. Because mTBI symptoms can overlap with other diagnoses including depression, anxiety, or PTSD, differential diagnoses should be considered in order to identify and manage symptoms.  Regardless of their formal diagnosis symptoms following mTBI need to be addressed to prevent potential delay in recovery.

 

  • 5. General Recommendations Regarding Management of Persistent Symptoms Following a Mild Traumatic Brain Injury: The use of early education regarding mTBI has been shown to be effective method to decrease the likelihood of persistent symptoms. Patients should be advised that they are likely to experience one or more persistent symptoms as a consequence of the mTBI for a short period, but that a full recovery of symptoms is expected. Where there are prolonged and significant complaints, care providers should rule out other contributing or confounding factors. Individuals who suffer mTBI who have pre-injury mental conditions or other risk factors should be considered for early referral to a multidisciplinary treatment clinic as these factors are associated with poorer outcomes.

 

  • 6. Post Traumatic Headache: Between 30 – 90 % of mTBI patients suffer from headaches[2]  The guidelines recommend  practitioners take a headache history to identify the characteristics of the patient’s headache and tailoring management strategies accordingly.

 

  • 7. Persistent Sleep Disturbances: Although sleep disturbance is one of the most common symptoms following TBI, it is the least studied of all sequelae. Guideline 7 recommends providing mTBI patients with advice on sleep hygiene, underlining the importance of continuous and restorative sleep, and recommending pharmacotherapy at the lowest effective dose as short term treatment lasting less than 7 days.

 

  • 8. Persistent Mental Health Disorders: A significant number of patients develop persistent mental health disorders, most commonly major depression and anxiety. Guideline 8 recommends screening all mTBI patients with persistent symptoms for mental health symptoms and disorders, as well as the management of persistent mental health disorders through referral to a psychiatrist/mental health team, medication, regular follow up, and cognitive behaviour therapy.

 

  • 9. Persistent Cognitive Difficulties: Many mTBI patients experience issues with concentration, memory, executive functioning and slowed processing. Any co-morbid diagnoses that could potentially influence cognition such as depression, PTSD, or pain should be considered. If cognitive symptoms persist for 3 months, or if screening shows cognitive dysfunction is likely attributable to the mTBI itself, the patient should be referred for formal assessment. If a patient exhibits persistent cognitive impairments on formal evaluation, or the cognitive impairments interfere with the patients work or safety, guideline 9 recommends provision of cognitive rehabilitation including compensatory strategies and restorative approaches such as using electronic external memory devices, or portable voice organizers to improve the patient’s everyday activities.

 

  • 10. Persistent Balance Disorders: Impairment of the vestibular system is common post mild TBI, and complaints ranger from vertigo to problems with dizziness, balance, vision or mobility. Guideline 10 recommends screening for balance deficits, or positional vertigo. If these deficits are present, the guidelines recommend consideration of further balance assessments, and treatment by physiotherapy or vestibular rehabilitation therapy.

 

  • 11. Persistent Vision Disorders:  Individuals with an mTBI may experience diplopia, inability to fixate, scanning deficits, poor visual acuity, photosensitivity and other vision disorders. The guidelines recommend practitioners take a history of visual symptoms and perform examinations to detect potentially unrecognized visual deficits. If abnormalities are observed upon examination, guideline 11 recommends referral to an ophthalmologist, preferably one who specialized in brain injury.

 

  • 12. Persistent Fatigue: Fatigue is one of the most pervasive symptoms following mTBI, and has been found to significantly impact well-being and quality of life. Guideline 12 recommends that all patients be assessed for fatigue through a personal history and review of the Rivermead Post Concussion Symptoms Questionnaire or a specific measure of fatigue, such as the Fatigue Severity Scale. Because certain medications can cause fatigue, health care providers should also review a patient’s medication use. In addition patients should be provided with advice on how to cope with fatigue. In the event that fatigue persists, the practitioner should consider referral to a brain injury specialist.

 

  • 13. Return to Work/School Considerations: An estimated 73 to 88 per cent of mTBI patients are able to return to their job within a year of injury. Even when individuals return to work or school they may still experience symptoms. Guideline 13 recommends considerations of patient-related and contextual variables including: physical limitations, psychosocial issues, cognitive impairment, and cultural or work related contextual factors. For individuals who experience persistent deficits following mTBI or who experience difficulty when back at work, a carefully designed return to work program should be implemented. Referral to an occupational therapist to review the return to work program is recommended.

 


[1] (Canadian Academy of Sport Medicine Concussion Committee, 2000)

[2] (Bazarian, Wong & Harris, 1999)

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