Strategies for Symptom Management
With the increased awareness of mild traumatic brain injury (mTBI) or concussion, many military healthcare providers find themselves treating patients without formal training in neurotrauma. Although the majority of patients with mTBI/concussion recover quickly with minimal intervention, there is a subset that develops lingering symptoms that interfere with social and occupational functioning.
ASSESSMENT
The overarching goal of assessment is to identify those patients who may be at risk for traumatic brain injury (TBI), minimize the impact of secondary effects, improve treatment outcome, optimize mTBI/concussion care, and to ultimately reduce disability. Since patients with mTBI/concussion may not come to clinical attention for a variety of reasons, the purpose of assessment may vary slightly based on the timing of presentation following injury.
Imaging studies are not necessary for all mTBI/concussion patients. The absence of pathologic signs on computed tomography (CT) does not preclude the presence of mTBI/concussion. Indications for CT scanning in the acute phase include drug or alcohol intoxication, physical evidence of trauma above the clavicles, age > 60 years, seizure, headache, vomiting, and coagulopathy (Haydel, 2000). Structural magnetic resonance imaging (MRI) has a low incidence of positive findings in mTBI/concussion (Lewine, 2007). It is contra-indicated in patients with shrapnel and is of limited use with acute mTBI/concussion. MRI, single photon emission computed tomography (SPECT) and functional MRI (fMRI) may be more useful for patients who manifest symptoms of cognitive dysfunction after the acute phase has passed. It is recommended that advanced imaging techniques including but not limited to SPECT and fMRI be used only after consultation with a radiologist and a TBI specialist.
MEDICATION THERAPY
There is little level 1 evidence to guide pharmacologic treatment in the mTBI/concussion patient. Therefore, these recommendations are made based on available evidence and expert opinion. Key points to consider when prescribing medications are:
- Recognition of important premorbid/comorbid conditions or “red flags”
- “Start low and go slow” (low dose with slow titration)
- Initiate medications one at a time, allow an appropriate interval for effect, and titrate to effect
- There is a complex relationship between mTBI/concussion symptoms (sleep, headache, cognition, mood) and it is clinically reasonable that alleviating/improving one symptom may lead to improvement in other symptom clusters.
INTERDISCIPLINARY THERAPY
It is strongly recommended that mTBI/concussion treatment should involve an interdisciplinary team and should be guided by a comprehensive brain injury and mental health assessment. Referrals for physical therapy, occupational therapy, speech & language pathology, pharmacy, audiology/vestibular and optometry can be made at anytime. If cognitive rehabilitation is indicated, it should not be initiated until other medical issues are stabilized and pain is adequately managed. Symptom-specific interventions may need to be modified to accommodate cognitive, sensory, or mechanical limitations of the patient. Further investigation regarding the timing and components of cognitive rehabilitation are warranted.
FOLLOW-UP
Follow-up for the patient with mTBI/concussion is based on the individual plan of care. After initial evaluation, the asymptomatic patient should have follow-up within three to six months. This may be done by telephone. The frequency of follow-up is clinically determined to meet the individual plan of care. Symptomatic patients should be followed every two to four weeks from the time of initial contact. Symptomatic patients may be seen more frequently than two to four weeks while those who are stable may be seen less frequently. It is recognized that patients may transfer duty stations while still undergoing treatment for TBI. In such situations, the profile/limited duty or transfer of care note should clearly specify follow-up needs. Case managers need to arrange the services the patient will need for continuity of care in the community/command in which the patient will reside.
DUTY RESTRICTIONS
Currently, there is variability among the Service branches in recording duty restrictions for Service members with TBI. Duty restrictions should be informed by the patient’s symptoms and progressively task the individual toward return to full duty. In the sub-acute phase (>seven days), symptomatic patients should be considered for limited duty 
hours to facilitate brain recovery. Progressive physical activity should be encouraged and monitored to the maximum tolerance of the patient without precipitating symptoms. Restricting the work environment and activities (i.e. driving, airborne operations, weapons, working at heights, combatives) further protects the Service member from risk of secondary injury or re-exposure and helps ensure the safety and welfare of others. The stress of complex leadership positions may also complicate or exacerbate functional deficits, and may also be considered for limitation. This facilitates TBI recovery and may promote unit cohesion.
Exertion testing should be performed when a patient with TBI with previously functionally limiting symptoms, has recovered to a point where return to duty is considered. This ensures that symptoms do not recur with physical stress. When considering return to duty, it is recommended that the following criteria be met:
- Pass a physical fitness test (PFT)
- Pass “warrior training” if needed for duty
- Have anger, depression, PTSD and other psychological health issues controlled and monitored by the primary care clinician
- Have neuropsychological testing within functional limits as determined by a neuropsychological evaluation (including attention, memory, processing speed, executive function domains and others as previous deficits warrant) if cognitive impairment was noted during the assessment and treatment of mTBI /concussion
ADDITIONAL RESOURCES