With the increased awareness of mild traumatic brain injury (mTBI) or concussion, many military health care providers find themselves without the necessary tools to treat chronic and co-occurring symptoms. Although the majority of patients with a concussion recover quickly and with minimal intervention, some develop lingering symptoms that interfere with social and occupational functioning.
(U.S. Air Force Photo by Senior Airman Corey Hook/Released)The overarching goal of assessment is to identify those patients who have suffered a concussion, treat their symptoms and identify any co-occurring conditions that may delay their return to duty. For a variety of reasons, patients with a concussion may not have sought treatment immediately after an injury. Therefore, the purpose of your assessment may vary slightly based on the timing of their presentation.
Imaging studies are not necessary for the majority of concussion patients. Imaging is typically negative in this population but should be preformed whenever more severe pathology is suspected.
Pharmacologic therapy of concussion is often necessary for the treatment of symptoms such as headache, nausea and insomnia. It is also critical to identify co-occurring conditions such as depression, anxiety and PTSD. Key points to consider when prescribing medications are:
- “Start low and go slow” (low dose with slow titration).
- Try to avoid narcotics.
- If possible, keep the number of medications prescribed to a minimum avoiding polypharmacy.
Some medications treat multiple symptoms. Refer to resources such as the Co-Occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health (see Related Content).
Interdisciplinary teams are common and sometimes necessary for the management of concussion. Referrals for physical therapy, occupational therapy, speech and language pathology, pharmacy, audiology/vestibular, optometry, primary care or other specialties may be appropriate in some cases. If cognitive rehabilitation is indicated, it should not be initiated until other medical issues, such as sleep and pain, are adequately managed.
Follow-up for the patient with a concussion is based on an individual plan of care. After the initial evaluation, the asymptomatic patient can be discharged from care. Continued care of the symptomatic patient should be determined by the provider and based on the particular needs of that individual. At times, service members may transfer to new duty stations while still undergoing treatment for concussion. In these situations, the profile/limited duty and transfer of care note should clearly specify the follow-up needs of the patient. Case managers and DVBIC regional care coordinators (RCC) are available to assist with the arrangement of services the patient may need for continuity of care. Contact DVBIC at info@DVBIC.org for a referral to the RCC for your region.
Duty restrictions should be based on the individual needs of the patient and their provider’s judgment. In the acute phase (first seven days), symptomatic patients should be considered for limited duty hours to facilitate brain recovery. Slowly increasing the patient’s physical activity should be encouraged and monitored. The patient may exercise as long as they do not precipitate symptoms. Restricting the patient’s work environment and activities (i.e., driving, airborne operations, weapons, working at heights, and combatives) further protects the service member from risk of secondary injury or delayed recovery. Whenever possible, include the chain of command in the process to increase the chance of compliance.
Exertion testing should be performed when a patient with a concussion has recovered to a point where return to duty is considered. This helps ensure that symptoms do not recur with physical stress. (At the present time there is no clinical practice guideline for return to duty decisions).
- New Clinical Recommendation for the Assessment and Management of Dizziness Associated With Mild TBI: This clinical recommendation, released in September 2012, provides the primary care provider an approach to evaluating dizziness following mTBI and guidance regarding referral for further vestibular evaluation and care. Includes training slides and reference card.
- Co-Occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health [app]
- Co-Occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health [pdf]
- VA/DoD Clinical Practice Guidelines
- Signs and Symptoms [pdf]
- National Intrepid Center of Excellence: The center works to advance mTBI and psychological health treatment, research and education.