Concussion-mild Traumatic Brain Injury
Publication Date: January 1, 2016
Last Updated: January 19, 2024
Recommendations
Diagnosis and Assessment
We suggest using the terms “history of mild traumatic brain injury (mTBI)” or “concussion” and to refrain from using the terms “brain damage” or “patients with mTBI” in communication with patients and the public. (Weak for)
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We recommend evaluating individuals who present with symptoms or complaints potentially related to brain injury at initial presentation. (Strong for)
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Excluding patients with indicators for immediate referral, for patients identified by post-deployment screening or who present to care with symptoms or complaints potentially related to brain injury, we suggest against using the following tests to establish the diagnosis of mTBI or direct the care of patients with a history of mTBI:
a. Neuroimaging
b. Serum biomarkers, including S100 calcium-binding protein B (S100-B), glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCH-L1), neuron specific enolase (NSE), and α-amino-3-hydroxy-5- methyl-4-isoxazolepropionic acid receptor (AMPAR) peptide
b. Serum biomarkers, including S100 calcium-binding protein B (S100-B), glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCH-L1), neuron specific enolase (NSE), and α-amino-3-hydroxy-5- methyl-4-isoxazolepropionic acid receptor (AMPAR) peptide
c. Electroencephalogram (EEG)
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We recommend against performing comprehensive neuropsychological/ cognitive testing during the first 30 days following mTBI. For patients with symptoms persisting after 30 days. (Strong against)
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For patients identified by post-deployment screening or who present to care with symptoms or complaints potentially related to brain injury, we recommend against using the following tests in routine diagnosis and care of patients with symptoms attributed to mTBI:
a. Comprehensive and focused neuropsychological testing, including Automated Neuropsychological Assessment Metrics (ANAM), NeuroCognitive Assessment Tool (NCAT), or Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).
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For patients with new symptoms that develop more than 30 days after mTBI, we suggest a focused diagnostic work-up specific to those symptoms only. (Weak for)
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Co-occurring Conditions
We recommend assessing patients with symptoms attributed to mTBI for psychiatric symptoms and comorbid psychiatric disorders including major depressive disorder (MDD), posttraumatic stress disorder (PTSD), substance use disorders (SUD) and suicidality. Consult appropriate VA/DoD clinical practice guidelines. (Strong for)
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Treatment
We suggest considering, and offering as appropriate, a primary care, symptom-driven approach in the evaluation and management of patients with a history of mTBI and persistent symptoms. (Weak for)
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Effect of mTBI Etiology on Treatment Options and Outcomes
We recommend not adjusting treatment strategy based on mechanism of injury. (Strong against)
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We recommend not adjusting outcome prognosis based on mechanism of injury. (Strong against)
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Headache
We suggest that the treatment of headaches should be individualized and tailored to the clinical features and patient preferences. The treatment may include:
a. Headache education including topics such as stimulus control, use of caffeine/tobacco/alcohol and other stimulants
b. Non-pharmacologic interventions such as sleep hygiene education, dietary modification, physical therapy (PT), relaxation and modification of the environment (for specific components for each symptom)
c. Pharmacologic interventions as appropriate both for acute pain and prevention of headache attacks
(Weak for)b. Non-pharmacologic interventions such as sleep hygiene education, dietary modification, physical therapy (PT), relaxation and modification of the environment (for specific components for each symptom)
c. Pharmacologic interventions as appropriate both for acute pain and prevention of headache attacks
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Dizziness and Disequilibrium
In individuals with a history of mTBI who present with functional impairments due to dizziness, disequilibrium, and spatial disorientation symptoms, we suggest that clinicians offer a short-term trial of specific vestibular, visual, and proprioceptive therapeutic exercise to assess the individual’s responsiveness to treatment. Refer to occupational therapy (OT), physical therapy (PT) or other vestibular trained care provider as appropriate. A prolonged course of therapy in the absence of patient improvement is strongly discouraged. (Weak for)
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Tinnitus
There is no evidence to suggest for or against the use of any particular modality for the treatment of tinnitus after mTBI. ()
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Visual Symptoms
There is no evidence to suggest for or against the use of any particular modality for the treatment of visual symptoms such as diplopia, accommodation or convergence disorder, visual tracking deficits and/or photophobia after mTBI. ()
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Sleep Disturbance
We suggest that treatment of sleep disturbance be individualized and tailored to the clinical features and patient preferences, including the assessment of sleep patterns, sleep hygiene, diet, physical activities and sleep environment. The treatment may include, in order of preference:
a. Sleep education including education about sleep hygiene, stimulus control, use of caffeine/tobacco/alcohol and other stimulants
b. Non-pharmacologic interventions such as cognitive behavioral therapy specific for insomnia (CBTi), dietary modification, physical activity, relaxation and modification of the sleep environment (for specific components for each symptoms see Appendix B: Clinical Symptom Management)
c. Pharmacologic interventions as appropriate to aid in sleep initiation and sleep maintenance
(Weak for)b. Non-pharmacologic interventions such as cognitive behavioral therapy specific for insomnia (CBTi), dietary modification, physical activity, relaxation and modification of the sleep environment (for specific components for each symptoms see Appendix B: Clinical Symptom Management)
c. Pharmacologic interventions as appropriate to aid in sleep initiation and sleep maintenance
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Behavioral Symptoms
We recommend that the presence of psychological or behavioral symptoms following mTBI should be evaluated and managed according to existing evidence-based clinical practice guidelines, and based upon individual factors and the nature and severity of symptoms. (Strong for)
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Cognitive Symptoms
We suggest that patients with a history of mTBI who report cognitive symptoms that do not resolve within 30-90 days and have been refractory to treatment for associated symptoms (e.g., sleep disturbance, headache) be referred as appropriate for a structured cognitive assessment or neuropsychological assessment to determine functional limitations and guide treatment. (Weak for)
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We suggest that individuals with a history of mTBI who present with symptoms related to memory, attention or executive function problems that do not resolve within 30-90 days and have been refractory to treatment for associated symptoms should be referred as appropriate to cognitive rehabilitation therapists with expertise in TBI rehabilitation. We suggest considering a short-term trial of cognitive rehabilitation treatment to assess the individual patient responsiveness to strategy training, including instruction and practice on use of memory aids, such as cognitive assistive technologies (AT). A prolonged course of therapy in the absence of patient improvement is strongly discouraged. (Weak for)
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We suggest against offering medications, supplements, nutraceuticals or herbal medicines for ameliorating the neurocognitive effects attributed to mTBI. (Weak against)
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Setting of Care
We suggest against routine referral to specialty care in the majority of patients with a history of mTBI. (Weak against)
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If the patient’s symptoms do not resolve within 30-90 days and are refractory to initial treatment in primary care and significantly impact activities of daily living (ADLs), we suggest consultation and collaboration with a locally designated TBI or other applicable specialist. (Weak for)
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For patients with persistent symptoms that have been refractory to initial psychoeducation and treatment, we suggest referral to case managers within the primary care setting to provide additional psychoeducation, case coordination and support. (Weak for)
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There is insufficient evidence to recommend for or against the use of interdisciplinary/multidisciplinary teams in the management of patients with chronic symptoms attributed to mTBI. ()
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Recommendation Grading
Overview
Title
Management of Concussion-Mild Traumatic Brain Injury
Authoring Organization
Veterans Health Administration / Department of Defense
Endorsing Organization
Centers for Disease Control and Prevention
Publication Month/Year
January 1, 2016
Last Updated Month/Year
January 11, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital
Intended Users
Social worker, mri technologist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D001924 - Brain Concussion
Keywords
concussion, mild-traumatic brain injury, posttraumatic amnesia, Neurological deficits
Methodology
Number of Source Documents
136
Literature Search Start Date
March 1, 2008
Literature Search End Date
March 1, 2015