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Guideline Summary
Guideline Title
VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury.
Bibliographic Source(s)
Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury (mTBI). Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 Apr. 112 p.
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Concussion/mild traumatic brain injury (mTBI)
  • Persistent post-concussive symptoms (PPCS)
Guideline Category
Counseling
Diagnosis
Evaluation
Management
Rehabilitation
Treatment
Clinical Specialty
Emergency Medicine
Family Practice
Internal Medicine
Neurological Surgery
Neurology
Physical Medicine and Rehabilitation
Psychiatry
Psychology
Sleep Medicine
Speech-Language Pathology
Intended Users
Advanced Practice Nurses
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)
  • To reduce practice variation and provide facilities with a structured framework to help improve patient outcomes
  • To provide evidence-based recommendations to assist providers and their patients in the decision-making process related to the patient health care problems
  • To identify outcome measures to support the development of practice-based evidence that can ultimately be used to improve clinical guidelines

Specific Goals of This Guideline

  • To promote evidence-based management of patients diagnosed with mild traumatic brain injury (mTBI)
  • To promote efficient and effective assessment of patient's complaints
  • To identify the critical decision points in management of patients with concussion/mTBI
  • To improve local management of patients with concussion/mTBI and thereby improve patient outcomes
  • To promote evidence-based management of individuals with (post-deployment) health concerns related to head injury, blast, or concussion
  • To accommodate local policies or procedures, such as those regarding referrals to, or consultation with, specialists
  • To motivate administrators at each of the Federal agencies and care access sites to develop innovative plans to break down barriers that may prevent patients from having prompt access to appropriate care
  • To diagnose concussion/mTBI accurately and in a timely manner
  • To appropriately assess and identify those patients who present with symptoms following a concussion/mTBI or other consequences of head injury
  • To identify those patients who may benefit from further assessment, brief intervention and/or ongoing treatment
  • To improve the quality and continuum of care for patients with concussion/mTBI
  • To identify those patients who may benefit from early intervention and treatment to prevent future complications from concussion/mTBI
  • To improve health related outcomes for patients with concussion/mTBI
  • To reduce morbidity and mortality from concussion/mTBI
Target Population

Adult patients (18 years or older) who are diagnosed with concussion/mild traumatic brain injury (mTBI) and complain of symptoms related to the injury and who are treated in Department of Veterans Affairs/Department of Defense (VA/DoD) clinical settings for these symptoms at least 7 days after the initial head injury

Note: This guideline does not address: management of concussion/mTBI in the acute phase (< 7 days post injury), management of moderate or severe TBI, mTBI presented as polytrauma and managed in an inpatient setting, or mTBI in children.

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Identifying patients with emergent conditions
  2. Assessment of symptoms and severity
  3. History and physical examination
  4. Laboratory testing (not indicated routinely)
  5. Neuroimaging as indicated

Management of Concussion/Mild Traumatic Brain Injury (mTBI)

  1. Development of a treatment plan
  2. Early patient and family education about concussion/mTBI symptoms, strategies for prevention of further injuries, techniques to manage stress (sleep education, minimizing consumption of stimulants), and written contact information
  3. Graded return to work/activity
  4. Management of physical, cognitive, and behavioral symptoms
    • Non-narcotic pain relievers, antiemetics, sleep medications, selective serotonin reuptake inhibitors (SSRIs), anti-epileptics
    • Physical therapy
    • Sleep hygiene education
    • Relaxation
    • Reassurance
    • Aerobic exercise
    • Activity restriction adjustment
  5. Physical rehabilitation
  6. Alternative modalities
  7. Follow-up

Assessment and Management of Persistent Post-Concussive Symptoms (PPCS)

  1. Comprehensive psychosocial evaluation including mental health history, co-occurring conditions, substance use disorders, compensation/litigation issues, and unemployment
  2. Assessment of risk factors
  3. Consultation or referral as indicated
  4. Treatment of persistent physical symptoms
  5. Management of persistent behavioral and cognitive symptoms
  6. Case management
  7. Patient and family education
  8. Resumption/modification of functional and vocational activities
  9. Follow-up
Major Outcomes Considered
  • Morbidity and mortality
  • Symptom improvement
  • Effectiveness of treatment

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Formulation of Questions

The Working Group developed researchable questions and associated key terms after orientation to the scope of the guideline and to goals that had been identified by the Working Group. The questions specified:

  • Population – Characteristics of the target patient population
  • Intervention – Exposure, diagnostic, or prognosis
  • Comparison – Intervention, exposure, or control used for comparison
  • Outcome – Outcomes of interest.

These specifications served as the preliminary criteria for selecting studies. Literature searches were conducted on all topics identified in the algorithm or recommendations.

After reviewing the initial search for systematic reviews and meta-analyses, the Working Group decided to focus the search for individual randomized controlled trials (RCT) on specific questions (refer to Appendix A in the original guideline for the list of questions).

Selection of Evidence

The evidence selection was designed to identify the best available evidence to address each key question and ensure maximum coverage of studies at the top of the hierarchy of study types. Published, peer-reviewed RCTs, as well as meta-analyses and systematic reviews that included randomized controlled studies were considered to constitute the strongest level of evidence in support of guideline recommendations. This decision was based on the judgment that RCTs provide the clearest, most scientifically sound basis for judging comparative efficacy. The Working Group made this decision recognizing the limitations of RCTs, particularly considerations of generalizability with respect to patient selection and treatment quality. When available, the search sought out critical appraisals already performed by others that described explicit criteria for deciding what evidence was selected and how it was determined to be valid. The sources that have already undergone rigorous critical appraisal include Cochrane Reviews, Best Evidence, Technology Assessment, and Agency for Healthcare Research and Quality (AHRQ) systematic evidence reports.

In addition to Medline/PubMed, the following databases were searched: Database of Abstracts of Reviews of Effectiveness (DARE) and Cochrane Central Register of Controlled Trials. For Medline/PubMed searches, limits were set for language (English), and type of research (RCT, systematic reviews and meta-analysis).

As a result of the literature reviews, articles were identified for possible inclusion. These articles formed the basis for formulating the guideline recommendations. The following inclusion criteria were used for studies:

  • English language only of studies performed in United States, United Kingdom, Europe, Australia, Japan, New Zealand
  • Full articles only
  • Study populations age limited to adults greater than 18 years; all races, ethnicities, cultural groups
  • Randomized controlled trials or prospective studies
  • Published from 2001 to 2008.

Admissible evidence (study design and other criteria):

  • Original research studies that provide sufficient detail regarding methods and results to enable use and adjustment of the data and results.
  • Randomized controlled trials; systematic reviews and meta-analyses.
  • Relevant outcomes must be able to be abstracted from data presented in the articles.
  • Sample sizes must be appropriate for the study question addressed in the paper.
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Preparation of Evidence Tables (Reports) and Evidence Rating

The results of the search were organized in evidence summary reports and copies of the original studies were provided to the Working Group for further analysis. Each study was appraised for scientific merit, clinical relevance, and applicability to the populations served by the Department of Veterans Affairs (VA) and Department of Defense (DoD) health care system. The body of evidence was rated for quality and level of evidence.

Recommendation and Overall Quality Rating

Evidence-based practice involves integrating clinical expertise with the best available clinical evidence derived from systematic research. The Working Group received an orientation and tutorial on the evidence rating process, reviewed the evidence and independently formulated the Strength of Recommendation (see the "Rating Scheme for the Strength of the Recommendations" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Guideline Development Process

The development of the Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury (mTBI) followed the steps described in "Guideline for Guidelines," an internal working document of the VA/DoD Evidence Based Practice Working Group, that requires an ongoing review of the work in progress. The Working Group of the VA/DoD was charged to update the evidence-based action recommendations whenever possible.

The Offices of Quality and Performance and Patient Care Services, in collaboration with the network Clinical Managers, the Deputy Assistant Under Secretary for Health, and the U.S. Army Medical Command for the DoD identified clinical leaders to champion the guideline development process. During a preplanning conference call, the clinical leaders defined the scope of the guideline and identified a group of clinical experts from the VA and DoD that formed the Management of Concussion/mTBI Working Group. Working Group members included representatives of the following specialties: primary care, internal medicine, physical medicine and rehabilitation (PM&R), psychiatry, neuropsychology, neurology, neurophysiology, neuroradiology, social work/case management, occupational therapy, physical therapy, speech-language therapy, and vocational therapy.

The Working Group defined a set of clinical questions within the area of the guideline. This ensured that the guideline development work outside the meeting focused on issues that practitioners considered important and produced criteria for the search and the protocol for systematic review and, where appropriate, meta-analysis.

The Working Group participated in an initial face-to-face meeting to reach consensus about the guideline algorithm and recommendations and to prepare a draft update document. The draft continued to be revised by the Working Group at-large through numerous conference calls and individual contributions to the document. Following the initial effort, an editorial panel of the Working Group convened to further edit the draft document. Recommendations for the performance or inclusion of specific procedures or services were derived through a rigorous methodological approach that included the following:

  • Determining appropriate criteria, such as effectiveness, efficacy, population benefit, or patient satisfaction
  • Reviewing literature to determine the strength of the evidence in relation to these criteria
  • Formulating the recommendations and grading the level of evidence supporting the recommendation

This update of the Concussion/mTBI Guideline is the product of many months of diligent effort and consensus building among knowledgeable individuals from the VA, DoD, academia, as well as guideline facilitators from the private sector. An experienced moderator facilitated the multidisciplinary Working Group.

Lack of Evidence – Consensus of Experts

Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the Working Group.

Rating Scheme for the Strength of the Recommendations
A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Experts from the Department of Veterans Affairs (VA) and Department of Defense (DoD) reviewed the final draft, and their feedback was integrated into the final draft document.

Recommendations

Major Recommendations

The recommendations for the management of concussion/mild traumatic brain injury (mTBI) are presented in the form of algorithms and annotations. Annotations and recommendations in the text match the box numbers and letters in the respective algorithms. The strength of recommendation (SR) (A-D, I) is provided for specific statements and is defined at the end of the "Major Recommendations" field.

Algorithm A: Initial Presentation

Annotation A-1. Person Injured with Head Trauma Resulting in Possible Alteration or Loss of Consciousness

  1. Definitions/Classifications

    Definition of Traumatic Brain Injury

    A traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event:

    • Any period of loss of or a decreased level of consciousness (LOC)
    • Any loss of memory for events immediately before or after the injury (post-traumatic amnesia [PTA])
    • Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.) (Alteration of consciousness/mental state [AOC])
    • Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient
    • Intracranial lesion

    Severity of Brain Injury Stratification

    Traumatic brain injury (TBI) is further categorized as to severity into mild, moderate, or severe based on the length of LOC, AOC, or PTA (see Table A-1 in the original guideline).

Annotation A-2. Urgent/Emergent Conditions Identified?

Recommendations

The following physical findings, signs and symptoms ("Red Flags") may indicate an acute neurologic condition that requires urgent specialty consultation (neurology, neuro-surgical):

  • Altered consciousness
  • Progressively declining neurological examination
  • Pupillary asymmetry
  • Seizures
  • Repeated vomiting
  • Double vision
  • Worsening headache
  • Cannot recognize people or is disoriented to place
  • Behaves unusually or seems confused and irritable
  • Slurred speech
  • Unsteady on feet
  • Weakness or numbness in arms/legs

Annotation A-3. Evaluate for Diagnosis of Concussion/mTBI, Based on History

Diagnostic Criteria for mTBI

Recommendations

  1. A diagnosis of mild traumatic brain injury (mTBI) should be made when there is an injury to the head as a result of blunt trauma, acceleration or deceleration forces or exposure to blast that result in one or more of the following conditions:
    • Any period of observed or self-reported:
      • Transient confusion, disorientation, or impaired consciousness
      • Dysfunction of memory immediately before or after the time of injury
      • Loss of consciousness lasting less than 30 minutes
    • Observed signs of neurological or neuropsychological dysfunction, such as:
      • Headache, dizziness, irritability, fatigue or poor concentration, when identified soon after injury, can be used to support the diagnosis of mild TBI, but cannot be used to make the diagnosis in the absence of loss of consciousness or altered consciousness.
  2. The severity of TBI must be defined by the acute injury characteristics and not by the severity of symptoms at random points after trauma.

Annotation A-5. Is Person Currently Deployed on Combat or Ongoing Military Operation?

Recommendations

  1. Management of service members presenting for care immediately after a head injury (within 7 days) during military combat or ongoing operation should follow guidelines for acute management published by DoD. (See: Recommendations for acute management of concussion/mTBI in the deployed setting, Defense and Veterans Brain Injury Center Consensus August, 2008) (This guidance is not included in this evidence-based guideline.)

Annotation A-6. Is Person Presenting Immediately (Within 7 Days) After Injury? (Non-Military/Civilian Setting)

Recommendations

  1. Management of non-deployed service members, veterans, or civilian patients presenting for care immediately after a head injury (within 7 days) should follow guidelines for acute management. (These protocols and guidance are not included in this evidence-based guideline.)

Post Deployment Delayed Awareness and Delayed Reporting of Symptoms

Recommendations

  1. Service members or veterans identified by post deployment screening or who present with symptoms should be assessed and diagnosed according to Algorithm A – Initial Presentation. The initial evaluation and management will then follow the recommendations in Algorithm B – Management of Symptoms.
  2. Patients who continue to complain of concussion/mTBI-related symptoms beyond 4 to 6 weeks after treatment has been initiated, should have the assessment for these chronic symptoms repeated and should be managed using Algorithm C – Follow-up Persistent Symptoms.
  3. Patients who continue to have persistent symptoms despite treatment for persistent symptoms (Algorithm C) beyond 2 years post-injury do not require repeated assessment for these chronic symptoms and should be conservatively managed using a simple symptom-based approach.
  4. Patients with symptoms that develop more than 30 days after a concussion should have a focused diagnostic work-up specific to those symptoms only. These symptoms are highly unlikely to be the result of the concussion and therefore the work-up and management should not focus on the initial concussion.

Annotation A-7. Is Person Currently On Treatment for mTBI Symptoms?

Persistent Symptoms after Concussion/mTBI

Recommendations

  1. Persons who complain about somatic, cognitive or behavioral difficulties after concussion/mTBI should be assessed and treated symptomatically regardless of the elapsed time from injury.
  2. The assessment of an individual with persistent concussion /mTBI related symptoms should be directed to the specific nature of the symptoms regardless of their etiology.
  3. The management of an individual who has sustained a documented concussion/mTBI and has persistent physical, cognitive and behavioral symptoms after one month should not differ based on the specific underlying etiology of their symptoms (i.e., concussion vs. pain, concussion vs. stress disorder).
  4. In communication with patients and the public, this guideline recommends using the term concussion or history of mild-TBI and to refrain from using the term 'brain damage'.

Annotation A-8. Provide Education and Access Information; Follow-Up as Indicated

Follow-Up and Monitoring

Recommendations

  1. Individuals who sustain a concussion/mTBI and are asymptomatic should be reassured about recovery and advised about precautionary measures to prevent future head injury.
  2. Patients should be provided with written contact information and be advised to contact their healthcare provider for follow-up if their condition deteriorates or they develop symptoms.
  3. Individuals who sustain a concussion/mTBI and are asymptomatic should be screened for comorbid mental health disorders (major depressive disorder [MDD], post-traumatic stress disorder [PTSD], and substance use disorder [SUD]) and dangerousness.

Algorithm B: Management of Concussion/mTBI Symptoms

Annotation B-2. Complete a History, Physical Examination; Minimal Mental Examination and Psychosocial Evaluation

  1. Assessment of Symptoms and Severity

    History, Physical Examination, Laboratory Tests, Imaging

    Recommendations

    1. Individuals who are presumed to have symptoms related to concussion/mTBI or who are identified as positive for mTBI on the initial screening should receive specific assessment of their symptoms.
    2. Medical history should include the following:
      • Obtaining detailed information on the patient's symptoms and health concerns
      • Obtaining detailed information of the injury event including mechanism of injury, duration and severity of alteration of consciousness, immediate symptoms, symptom course and prior treatment
      • Screening for pre-morbid conditions, potential co-occurring conditions or other psychosocial risk factors, such as substance use disorders that may exacerbate or maintain current symptom presentation (using standardized screening tools such as, Patient Health Questionnaire [PHQ-2], Alcohol Use Disorders Identification Test Consumption Questions [AUDIT-C], PTSD screen)
      • Evaluating signs and symptoms indicating potential for neurosurgical emergencies that require immediate referrals
      • Assessing of danger to self or others
    3. Patient's experiences should be validated by allowing adequate time for building a provider-patient alliance and applying a risk communication approach.
    4. The physical examination of the person sustaining a concussion/mTBI should focus on the following:
      • A focused neurologic examination, including a Mental Status Examination (MSE), cranial nerve testing, extremity tone testing, deep tendon reflexes, strength, sensation, and postural stability (Romberg's Test, dynamic standing)
      • A focused vision examination including gross acuity, eye movement, binocular function and visual fields/attention testing
      • A focused musculoskeletal examination of the head and neck, including range of motion of the neck and jaw, and focal tenderness and referred pain.
    5. The following physical findings, signs and symptoms ("Red Flags") may indicate an acute neurologic condition that requires urgent specialty consultation (neurology, neuro-surgical):
      • Altered consciousness
      • Progressively declining neurological examination
      • Pupillary asymmetry
      • Seizures
      • Repeated vomiting
      • Double vision
      • Worsening headache
      • Cannot recognize people or is disoriented to place
      • Behaves unusually or seems confused and irritable
      • Slurred speech
      • Unsteady on feet
      • Weakness or numbness in arms/legs
    6. Laboratory testing is not necessary to confirm or manage symptoms associated with concussion/mTBI.
    7. Laboratory testing may be considered for evaluating other non-TBI causes of the symptoms presented.
    8. There is insufficient evidence to support the use of serum biomarkers for concussion/mTBI in clinical practice. [SR = I]
    9. A patient who presents with any signs or symptoms that may indicate an acute neurologic condition that requires urgent intervention should be referred for evaluation that may include neuroimaging studies.
    10. Neuroimaging is not recommended in patients who sustained a concussion/mTBI beyond the emergency phase (72 hours post-injury) except if the condition deteriorates or red flags are noted.

    Multiple Concussions

    Recommendations

    1. The management of a patient who has sustained multiple concussions should be similar to the management for a single concussion/mTBI. [SR = I]
    2. The patient with multiple concussions and his/her family should be educated to create a positive expectation of recovery. [SR = I]

Annotation B-3. Clarify the Symptoms

Assessment of Symptoms

Recommendations

  1. Self-reported symptomatology is an appropriate assessment of the patient’s condition in concussion/mTBI when the history is consistent with having sustained an injury event and having a subsequent alteration in consciousness. [SR = C]
  2. Assessment of the patient with concussion/mTBI should include detailed questioning about the frequency, intensity and nature of symptoms the patient experiences, and their impact on the patient's social and occupational functioning.
  3. Assessment should include a review of all prescribed medications and over-the-counter supplements for possible causative or exacerbating influences. These should include caffeine, tobacco and other stimulants, such as energy drinks.
  4. The patient who sustained a concussion/mTBI should be assessed for sleep patterns and sleep hygiene.
  5. If the patient's symptoms significantly impact daily activities (such as child care, safe driving), a referral to rehabilitation specialists for a functional evaluation and treatment should be considered.

Annotation B-5. Determine Treatment Plan

  1. Treatment

    Treatment Plan

    Recommendations

    1. Develop and document a summary of the patient's problems.
    2. Develop a potential treatment plan that includes severity and urgency for treatment interventions
    3. Discuss with the patient the general concept of concussion sequelae, treatment options and associated risk/benefits and prognosis of illness to determine the patient's preferences
    4. Emphasizing good prognosis and empowering the patient for self-management
    5. Implement the treatment plan and follow up
    6. Referral to specialty care is not required in the majority of patients with concussion/mTBI, if their symptoms resolve in the early post acute recovery period as expected.
    7. Treatment should be coordinated and may include consultation with rehabilitation therapists, pharmacy, collaborative mental health, and social support.

Annotation B-6. Educate Patient/Family on Symptoms and Expected Recovery of Concussion/mTBI

Early Education

Recommendations

  1. Patients who sustain a concussion/mTBI should be provided with information and education about concussion/mTBI symptoms and recovery patterns as soon as possible after the injury. Education should be provided in printed material combined with verbal review and consist of:
    • Symptoms and expected outcome [SR = A]
    • Normalizing symptoms (education that current symptoms are expected and common after injury event) [SR = A]
    • Reassurance about expected positive recovery [SR = A]
    • Techniques to manage stress (e.g., sleep education, relaxation techniques; minimize consumption of alcohol, caffeine and other stimulants) [SR = B]
  2. Information and education should also be offered to the patient's family, friends, employers, and/or significant others.
  3. Symptomatic management should include tailored education about the specific signs and symptoms that the patient presents and the recommended treatment.
  4. Patients should be provided with written contact information and be advised to contact their healthcare provider for follow-up if their condition deteriorates or if symptoms persist for more than 4-6 weeks. [SR = B]

Annotation B-7. Provide Early Interventions

Provide Early Intervention

Recommendations

  1. Provide early intervention maximizing the use of non-pharmacological therapies:
    • Review sleep patterns and hygiene and provide sleep education including education about excess use of caffeine/tobacco/alcohol and other stimulants
    • Recommend graded aerobic exercise with close monitoring

Return to Activity (Duty/Work/School/Leisure)

Recommendations

  1. Immediately following any concussion/mTBI, individuals who present with post-injury symptoms should have a period of rest to avoid sustaining another concussion and to facilitate a prompt recovery.
  2. Individuals with concussion/mTBI should be encouraged to expediently return to normal activity (work, school, duty, leisure) at their maximal capacity.
  3. In individuals who report symptoms of fatigue, consideration should be given to a graded return to work/activity.
  4. In instances where there is high risk for injury and/or the possibility of duty-specific tasks that cannot be safely or competently completed, an assessment of the symptoms and necessary needs for accommodations should be conducted through a focused interview and examination of the patient.
  5. If a person's normal activity involves significant physical activity, exertional testing can be conducted that includes stressing the body.
  6. If exertional testing results in a return of symptoms, a monitored progressive return to normal activity as tolerated should be recommended.
  7. Individually based work duty restriction should apply if:
    • There is a duty specific task that cannot be safely or competently completed based on symptoms
    • The work/duty environment cannot be adapted to the patient's symptom-based limitation
    • The deficits cannot be accommodated
    • Symptoms reoccur

Annotation B-8. Initiate Symptom-Based Treatment Modalities

  1. Symptom Management

    Physical Symptoms

    Recommendations

    1. Initial treatment of physical complaints of a patient with concussion/mTBI should be based upon a thorough evaluation, individual factors and symptom presentation.
    2. The evaluation should include:
      • Establishing a thorough medical history, completing a physical examination, and review of the medical record (for specific components for each symptoms see Table B-2 "Physical Symptoms-Assessment", in the original guideline)
      • Minimizing low yield diagnostic testing
      • Identifying treatable causes (conditions) for patient's symptoms
      • Referring for further evaluation as appropriate
    3. The treatment should include:
      • Non-pharmacological interventions such as sleep hygiene education, physical therapy, relaxation and modification of the environment (for specific components for each symptoms see Table B-3 "Physical Symptoms-Treatment", in the original guideline)
      • Use of medications to relieve pain, enable sleep, relaxation and stress reduction
    4. A consultation or referral to specialists for further assessment should occur when:
      • Symptoms cannot be linked to a concussion event (suspicion of another diagnosis)
      • An atypical symptom pattern or course is present
      • Findings indicate an acute neurologic condition that requires urgent neurologic/neuro-surgical intervention (see Section 3– Physical Examination above)
      • There are other major co-morbid conditions requiring special evaluation

    Cognitive Symptoms

    Recommendations

    1. All individuals who sustain a concussion/mTBI should be provided with information and education about concussion/mTBI symptoms and recovery patterns as soon as possible after the injury [SR = A] (See Early Education, Section 4 above)
    2. A patient sustaining a concussion/mTBI should be evaluated for cognitive difficulties using a focused clinical interview. [SR = C]
    3. Comprehensive neuropsychological/cognitive testing is not recommended during the first 30 days post injury. [SR = D]
    4. If a pre-injury neurocognitive baseline was established in an individual case, then a post injury comparison may be completed by a psychologist but should be determined using reliable tools and test-retest stability should be ensured. [SR = B]

    Behavioral Symptoms

    Recommendations

    1. Patients with concussion/mTBI should be screened for psychiatric symptoms and co-morbid psychiatric disorders (Depression, Post Traumatic Stress, and Substance Use).
    2. Treatment of psychiatric/behavioral symptoms following concussion/mTBI should be based upon individual factors and nature and severity of symptom presentation, and include both psychotherapeutic [SR = A] and pharmacological [SR = I] treatment modalities.
    3. Individuals who sustain a concussion/mTBI and present with anxiety symptoms and/or irritability should be provided reassurance regarding recovery and offered a several week trial of pharmacologic agents (see Appendix E in the original guideline). [SR = I]

    Pharmacotherapy

    Recommendations

    1. Medication for ameliorating the neurocognitive effects attributed to concussion/mTBI is not recommended.
    2. Treatment of concussion/mTBI should be symptom-specific.
    3. Medications may be considered for headaches, musculoskeletal pain, depression/anxiety, sleep disturbances, chronic fatigue or poor emotional control or lability.
    4. Appropriate and aggressive pain management strategies should be employed.
    5. When prescribing any medication for patients who have sustained a concussion/mTBI, the following should be considered:
      • Review and minimize all medication and over-the-counter supplements that may exacerbate or maintain symptoms
      • Use caution when initiating new pharmacologic interventions to avoid the sedating properties that may have an impact upon a person's attention, cognition, and motor performance.
      • Recognize the risk of overdose with therapy of many medication classes (e.g., tricyclics). Initial quantities dispensed should reflect this concern.
      • Initiate therapy with the lowest effective dose, allow adequate time for any drug trials, and titrate dosage slowly based on tolerability and clinical response.
      • Document and inform all those who are treating the person of current medications and any medication changes.

    Physical Rehabilitation

    Recommendations

    1. There is no contraindication for return to aerobic, fitness and therapeutic activities after concussion/mTBI. Non-contact, aerobic and recreational activities should be encouraged within the limits of the patient's symptoms to improve physical, cognitive and behavioral complaints and symptoms after concussion/mTBI. [SR = B]
    2. Specific vestibular, visual, and proprioceptive therapeutic exercise is recommended for dizziness, disequilibrium, and spatial disorientation impairments after concussion/mTBI. (See Appendix D in the original guideline)
    3. Specific therapeutic exercise is recommended for acute focal musculoskeletal impairments after concussion/mTBI.

    Alternative Modalities

    Recommendations

    1. Complementary-alternative medicine treatments may be considered as adjunctive treatments or when requested by individuals with concussion/mTBI. [SR = I]

Annotation B-9. Follow-Up and Assess in 4-6 Weeks

  1. Follow-up

    Recommendations

    1. All patients should be followed up in 4 to 6 weeks to confirm resolution of symptoms and address any concerns the patient may have.
    2. Follow-up after the initial interventions is recommended in all patients to determine patient status. The assessment will determine the following course of treatment:
      • Patient recovers from acute symptoms – provide contact information with instructions for available follow-up if needed.
      • Patient demonstrates partial improvement (e.g., less frequent headaches, resolution of physical symptoms, but no improvement in sleep) – consider augmentation or adjustment of the current intervention and follow-up within 4-6 weeks.
      • Patient does not improve or status worsens – focus should be given to other factors including psychiatric, psychosocial support, and compensatory/litigation. Referral to a specialty provider should be considered.

Algorithm C: Follow-Up Management of Persistent Concussion/mTBI Symptoms

Annotation C-2. Reassess Symptom Severity and Functional Status, Complete Psychosocial Evaluation

  1. Assessment of Persistent Symptoms

    Recommendations

    1. Follow-up after the initial interventions is recommended in all patients with concussion/mTBI to determine patient status and the course of treatment.
    2. Evaluation of patients with persistent symptoms following concussion/mTBI should include assessment for dangerousness to self or others.
    3. In assessment of patients with persistent symptoms, focus should be given to other factors including psychiatric, psychosocial support, and compensation/litigation issues and a comprehensive psychosocial evaluation should be obtained, to include:
      • Support systems (e.g., family, vocational)
      • Mental health history for pre-morbid conditions which may impact current care
      • Co-occurring conditions (e.g., chronic pain, mood disorders, stress disorder, personality disorder)
      • Substance use disorder (e.g., alcohol, prescription misuse, illicit drugs, caffeine)
      • Secondary gain issues (e.g., compensation, litigation)
      • Unemployment or/change in job status
      • Other issues (e.g., financial/housing/legal)

Annotation C-3. Assess for Possible Alternative Causes for Persistent Symptoms

Risk Factors for Persistent Post-Concussion Symptoms

Recommendations

  1. Assessment of the patient with concussion/mTBI should include a detailed history regarding potential pre-injury, peri-injury, or post-injury risk factors for poorer outcomes. These risk factors include:
    • Pre-injury: older age, female gender, low socio-economic status, low education or lower levels of intellectual functioning, poorer coping abilities or less resiliency, pre-existing mental health conditions (e.g., depression, anxiety, PTSD, substance use disorders).
    • Peri-injury: lower levels of or less available social support
    • Post-injury: injury-related litigation or compensation, comorbid mental health conditions or chronic pain, lower levels of or less available social support
  2. Any substance abuse and/or intoxication at the time of injury should be documented.
  3. Establish and document if the patient with concussion/mTBI experienced headaches, dizziness, or nausea in the hours immediately following the injury.

Compensation Seeking/Non-Validated Symptoms

Recommendations

  1. Symptom exaggeration or compensation seeking should not influence the clinical care rendered, and doing so can be counter-therapeutic and negatively impact the quality of care.
  2. Focus of the provider-patient interaction should be on the development of a therapeutic alliance [SR = C].

Persistent Post-Concussive Symptoms (PPCS)

Recommendations

  1. For clinical treatment purposes the use of post-concussion syndrome, post-concussive syndrome (PCS) or post-concussion disorder (PCD) as a diagnosis is not recommended. The unique individual pattern of symptoms should be documented and be the focus of treatment.

For the purpose of this clinical practice guideline (CPG), the term persistent post-concussive symptoms will be used.

Annotation C-4. Any Behavioral Health Diagnosis Established?

Persistent Behavioral Symptoms

Recommendations

  1. Patients with persistent symptoms following concussion/mTBI should be re-evaluated for psychiatric symptoms and co-morbid psychiatric disorders.
  2. Treatment of psychiatric symptoms following concussion/mTBI beyond the acute phase should still be based on individual factors and nature and severity of symptom presentation, including psychotherapeutic [SR = A] and pharmacologic [SR = I] treatment modalities.
  3. In patients with persistent post-concussive symptoms, which have been refractory to treatment, consideration should be given to other factors including psychiatric disorders, lack of psychosocial support, and compensation/litigation.

Annotation C-5. Consider Referral to Specialty Care

  1. Consultation and Referral

    Recommendations

    1. A consultation or referral to specialists should occur in a patient with concussion/mTBI who complains of persistent or chronic symptoms when:
      • An atypical pattern or course (worsening or variable symptom presentation) is demonstrated
      • The patient is experiencing difficulties in return to pre-injury activity (work/duty/school)
      • Problems emerge in the role of the patient in family or social life
    2. Patients with multiple problems may benefit from an inter-disciplinary approach to include occupational therapy; recreation therapy; social work; psychology and/or psychiatry; neurology; ears, nose, throat (ENT); ophthalmology or audiology based on individual symptoms. The patient's provider should remain involved in the patient's care.
    3. Referral to mental health specialty of patients with persistent behavioral symptoms should be considered.

    See Table C-4 "Indications for Referral to Mental Health", in the original guideline.

Annotation C-6. Any Persistent Symptoms (Physical, Cognitive or Emotional)?

Persistent Physical Symptoms

Recommendations

  1. Patients who are refractory to treatment of physical symptoms in the initial care setting should be referred to specialty care for further evaluation and management (See Appendix D – "Treatment of Physical Symptoms" in the original guideline).

See also Table C-5 Physical Symptoms – TREATMENT in the original guideline.

Persistent Cognitive Difficulties

Recommendations

  1. Patients who have cognitive symptoms that do not resolve or have been refractory to treatment should be considered for referral for neuropsychological assessment. The evaluation may assist in clarifying appropriate treatment options based on individual patient characteristics and conditions. [SR = B]
  2. Neuropsychological testing should only be conducted with reliable and standardized tools by trained evaluators, under controlled conditions, and findings interpreted by trained clinicians. [SR = C]
  3. Individuals who present with memory, attention, and/or executive function problems which did not respond to initial treatment (e.g., reassurance, sleep education, or pain management) may be considered for referral to cognitive rehabilitation therapists with expertise in TBI rehabilitation (e.g., speech and language pathology, neuropsychology, or occupational therapy) for compensatory training [SR = C]; and/or instruction and practice on use of external memory aids such as a personal digital assistant (PDA) [SR = C]

Annotation C-7. Consider Referral to Occupational or Vocational Therapy and Community Integration Programs (Continue Case Management)

  1. Rehabilitation of Patients with Persistent Post-Concussion Symptoms

    Case Management in the Care of Patients with mTBI

    Recommendations

    1. Patients with persistent symptoms following concussion/mTBI may be considered for case management.
    2. Case managers should complete a comprehensive psychosocial assessment of the patient and the patient's family. It may be necessary or beneficial to meet with other members of the patient's support system (family, care giver) and/or invite the patient to ask them to come to an appointment together with the patient.
    3. Case managers should collaborate with the treatment team, the patient, and the patient's family in developing a treatment plan that emphasizes the psychosocial needs of the patient.
    4. Case managers (in collaboration with the treatment team) should prepare and document a detailed treatment plan in the medical record describing follow-up care and services required.
    5. Case managers who provide care in the clinical setting should communicate and coordinate with other potential care coordinators that provide care for the patient (such as a Veterans Health Administration [VHA] social worker liaison or military social worker at the referring Military Treatment Facility, Patient Treatment Advocate [PTA]).
    6. Case managers may provide assistance to the patient and family who are transferred to another facility (e.g., a polytrauma rehabilitation center).
    7. Case management may serve as the main point of contact for the patient and family. This may include the following:
      • Provide the patient with contact information including after hours calls
      • Maintain frequent contact by phone to remind about or facilitate an appointment
      • Facilitate access to supportive services to the patient and family
      • Serve as a liaison for the patient's family and as an advocate for the patient and the patient's family
      • Provide easy-to-understand information in writing for the patient and the patient's family

    Patient and Family Education

    Recommendations

    1. All members of the treatment team should be involved in patient education as part of their interaction with the patient experiencing persistent symptoms.
    2. Educational interventions should generally include information and a description of the specific procedures and events the patient will experience at the various phases of treatment and continue throughout the continuum of care.
    3. General supportive counseling (e.g., eliciting and validating the patient's anxieties, fears, and concerns) may also be helpful. Open-ended questioning, active listening techniques, eliciting anticipation of future stressors, encouraging the patient to ask questions, and eliciting and encouraging utilization of the patient's social support resources are important strategies regardless of whether information-giving or coping skills training interventions are being used.
    4. Educational interventions may also include coping techniques for symptom management, such as patient education handouts and helpful tips.

    See Appendix B: "Health Risk Communication", in the original guideline.

    Functional and Vocational Activities

    Recommendations

    Family Support

    1. As with other chronic conditions, the focus of the management of patients with persistent symptoms following concussion/mTBI should shift to the psychological and social impacts on the patient.
    2. The clinician should consider having the spouse or partner accompany the patient with concussion/mTBI to a consultation, to help them better understand the condition and provide an opportunity to discuss any coping difficulties.
    3. Family members should be encouraged to consider joining a support group to provide education, advice and opportunities to exchange coping strategies for dealing with the day-to-day difficulties of living with an individual with persistent symptoms following concussion/mTBI.

    Vocational Rehabilitation

    1. Vocational interventions for the patient with persistent symptoms following concussion/mTBI may include modifications such as:
      • Modification of the length of the work day
      • Gradual work re-entry (e.g., starting at 2 days/week and expanding to 3 days/week)
      • Additional time for task completion
      • Change of job
      • Environmental modifications (e.g., quieter work environment; enhanced level of supervision)
    2. Patients who have not successfully resumed pre-injury work duties following injury should be referred for a vocational evaluation by clinical specialists with expertise in assessing and treating concussion/mTBI.
    3. For patients with persistent symptoms following concussion/mTBI, return to full work/duty in the jobs they have previously performed may not be possible. Patients may need to proceed through medical or disability evaluation processes. This process should follow national and local regulations and is beyond the scope of the guideline.

    Community Participation

    1. A referral to a structured program that promotes community integration may be considered for individuals with residual persistent post-concussive symptoms that impede return to pre-injury participation in customary roles.

Annotation C-8. Follow-Up and Reassess in 3-4 Months

  1. Follow-up

    Recommendations

    1. Scheduled follow-up visits are recommended. The amount of time between visits will vary depending on a number of factors, including the following:
      • Quality of the provider/patient relationship
        • Distress of the patient
        • Need for refinement of the treatment plan or additional support
        • Presence or absence of psychosocial stressors
      • Severity of the symptoms
        • Initially, a follow-up at two to three weeks would be appropriate
        • As soon as the patient is doing well, then follow-up every 3 to 4 months would be recommended
        • Telephone follow-up may be sufficient to evaluate resolution of symptoms and reinforce education
      • For concussion/mTBI patients with complicated histories, comorbidities, and lack of social support consider case management.
    2. Continually re-evaluate the patient for worsening of chronic symptoms or presence of new symptoms suggestive of other diagnoses.

Definitions:

Evidence Rating System

A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

  • A: Initial presentation
  • B: Management of symptoms
  • C: Follow-up of persistent symptoms

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

Recommendations were based on evidence published in the medical literature. Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the Working Group.

The quality of the evidence supporting individual recommendations is given for selected recommendations (see "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved management of concussion/mild traumatic brain injury (mTBI) resulting in improved health-related outcomes and reduced morbidity and mortality

Potential Harms

Side effects of pharmacotherapy (Refer to Appendix E: "Pharmacotherapy", in the original guideline for information on potential side effects of medications used in concussion/mild traumatic brain injury)

Contraindications

Contraindications

Refer to Appendix E: "Pharmacotherapy", in the original guideline for information on contraindications of agents used in concussion/mild traumatic brain injury.

Qualifying Statements

Qualifying Statements
  • The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision-making. They are not intended to define a standard of care and should not be construed as one. In addition, they should not be interpreted as prescribing an exclusive course of management.
  • Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.

Implementation of the Guideline

Description of Implementation Strategy
  • The guideline and algorithms are designed to be adapted to individual facility needs and resources. The algorithms serve as a guide that providers can use to determine best interventions and timing of services for their patients to optimize quality of care and clinical outcomes. This should not prevent providers from using their own clinical expertise in the care of an individual patient. Guideline recommendations are intended to support clinical decision-making but should never replace sound clinical judgment.
  • Although this guideline represents the state of the art practice at the time of its publication, medical practice is evolving and this evolution will require continuous updating of published information. New technologies and increased ongoing research will improve patient care in the future. This clinical practice guideline can assist in identifying priority areas for research and optimal allocation of resources as regards to traumatic brain injury (TBI) in general and mild TBI (mTBI) in particular. Future studies examining the results of clinical practice guidelines such as these may lead to the development of new practice-based evidence and treatment modalities.
  • A recently developed program that has been created for post-deployment personnel and veterans experiencing head injury deserves mention here. The program for post-deployment care which features an interdisciplinary team of a primary care staff, mental health clinician, and clinical social worker assist in implementation of post-deployment care models across the Department of Veterans Affairs (VA). The providers in these settings have received specialty training in this condition and treatment approaches. Assessment and treatment is organized in a collaborative team model. All referred patients are screened for the need for case management services and all severely ill or injured Operations Iraqi Freedom (OIF) and Operations Enduring Freedom (OEF) patients are case managed.
Implementation Tools
Clinical Algorithm
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury (mTBI). Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 Apr. 112 p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Apr
Guideline Developer(s)
Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

The Concussion/Mild Traumatic Brain Injury (mTBI) Guideline Working Group

Composition of Group That Authored the Guideline

Working Group Members (VA): David Cifu, MD*; Robin Hurley, MD*; Michelle Peterson, DPT, NCS*; Micaela Cornis-Pop, PhD, SLP*; Robert L. Ruff, MD, PhD*; Patricia A. Rikli, PhD, MSN; Steven G. Scott, DO; Kristin A. Silva, RNC, MN, NP; Barbara J. Sigford, MD, PhD*; Aaron Schneiderman, PhD, MPH, RN; Gretchen C. Stephens, MPA, OTR/L; Kathryn Tortorice, Pharm D, BCPS*; Rodney D. Vanderploeg, PhD, ABPP-CN*; Warren Withlock, MD

Working Group Members (DoD): Amy Bowles, MD*; Douglas Cooper, PhD*; Angela Drake, PhD*; Charles Engel, MD, MPH, COL, USA, MC; Lori Simmers Geckle; Kathy Helmick, MS, CNRN, CRNP*; Charles Hoge, MD, COL, USA, MC; Michael Jaffee, MD, COL, FS, USAF; Robert Labutta, MD, COL, USA, MC*; Geoffrey Ling, MD, PhD, COL, USA, MC*; Lynne Lowe, PT, DPT, OCS, LTC; Sheryl Mims, RN; Lisa Newman, ScD; David T. Orman, MD, DAC COL*; Benjamin E. Solomon, MD LTC, USA, MC; Jay M. Stone, PhD Lt Col, USAF; Heidi P. Terrio, MD, MPH COL, USA MC*; Kimialeesha Thomas, RN, MSN; Mary Tolbert, PA-C; Christopher S. Williams, MD, COL, USAF

Facilitator: Oded Susskind, MPH*

Private Sector: Jeffrey Barth PhD, ABPP-CN; Kathleen R. Bell, MD

Office of Quality and Performance: Carla Cassidy, RN, MSN, NP

Quality Management Division US Army Medical Command: Ernest Degenhardt, RN, MSN, ANP-FNP, COL, AN; Angela Klar, RN, MSN, ANP-CS; Mary Ramos, RN, PhD

Research: Jessica Cohen, MS, MPH.; Jennifer J. Kasten, PhD; Sue Radcliff; William E. Schlenger, PhD

Healthcare Quality Informatics, Inc.: Martha D'Erasmo, MPH; Rosalie Fishman, RN, MSN, CPHQ; Joanne Marko, MS, SLP

*Members of the CORE Editorial Panel

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Department of Veterans Affairs Web site External Web Site Policy.

Print copies: Available from the Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

Availability of Companion Documents

The following is available:

  • VA/DoD clinical practice guideline for the management of concussion/mild traumatic brain injury (mTBI). Guideline summary. Washington (DC): Department of Veterans Affairs (U.S.); 2009. 69 p. Electronic copies: Available from the Department of Veterans Affairs Web site External Web Site Policy.

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

Patient Resources

None available

NGC Status

This summary was completed by ECRI Institute on June 24, 2010.

Copyright Statement

No copyright restrictions apply.

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