What is the recommended treatment for patients with mild Traumatic Brain Injury (mTBI)?

Management of Mild Traumatic Brain Injury (mTBI)

The recommended treatment for mild Traumatic Brain Injury (mTBI) includes a brief period of relative rest (24-48 hours) followed by a gradual return to activities that do not exacerbate symptoms, rather than prolonged complete rest. 1

Initial Management (First 24-48 Hours)

• Observe more restrictive physical and cognitive activity during the first several days after mTBI 2, 1
• Avoid activities that could lead to a second concussion during this vulnerable recovery period 2
• Activities of daily living, including walking and other symptom-limited physical and cognitive activities, are permitted as tolerated 1
• Prolonged complete rest (exceeding 3 days) is not recommended and may be harmful 3

Progressive Return to Activity (After Initial 24-48 Hours)

1. Gradual Activity Resumption:

   • Resume a gradual schedule of activity that does not worsen symptoms 2, 1
   • Monitor symptom expression (number and severity) closely during activity increases 2
   • Implement progressive reintroduction of non-contact aerobic activity that stays below symptom exacerbation threshold 2, 1

2. Cognitive Activities:

   • Gradually increase duration and intensity of cognitive activities as tolerated 1
   • Customize return-to-school or work protocols based on symptom severity 1

3. Full Activity Return:

   • Return to full activity when premorbid performance is achieved and the patient remains symptom-free at rest and with increasing levels of physical exertion 2, 1

Patient Education and Monitoring

Healthcare professionals should provide comprehensive education including:

• Warning signs of more serious injury requiring immediate medical attention
• Description of injury and expected course of symptoms and recovery
• Instructions on monitoring postconcussive symptoms
• Prevention of further injury
• Management of cognitive and physical activity/rest
• Instructions regarding return to play/recreation and work/school
• Clear follow-up instructions 2

Management of Persistent Symptoms (>4 Weeks)

For patients whose symptoms persist beyond 4 weeks:

• Provide or refer for appropriate assessments and interventions 2
• Consider referral to a medically supervised interdisciplinary team that can individually assess exercise tolerance and prescribe appropriate aerobic exercise treatment 1
• Active rehabilitation with progressive reintroduction of non-contact aerobic activity that does not exacerbate symptoms is recommended 2

Assessment Tools for Recovery Monitoring

• Use validated symptom scales to assess recovery 2
• Consider validated cognitive testing (including measures of reaction time) 2
• Balance testing may be useful, particularly for adolescent athletes 2

Special Considerations

• Patients with mTBI who present more than 6 hours after injury with a normal clinical examination and a head CT scan that does not demonstrate acute injury can be safely discharged 2
• Closely monitor patients at high risk for persistent symptoms based on premorbid history, demographics, and/or injury characteristics 2
• Environmental supports and accommodations may be needed during the recovery period, especially for return to school or work 1

Common Pitfalls to Avoid

1. Excessive Rest: Complete rest exceeding 3 days is likely not helpful and may worsen outcomes 3
2. Premature Return to High-Risk Activities: Returning to contact sports or activities with high mTBI exposure risk before full recovery increases reinjury risk
3. Ignoring Persistent Symptoms: Failure to address symptoms that persist beyond 4-6 weeks can lead to prolonged recovery
4. One-Size-Fits-All Approach: Recovery trajectories vary between individuals, requiring personalized management 1
5. Neglecting Psychological Factors: Social support is a key element in recovery from mild TBI 1

The evidence clearly demonstrates that the outdated practice of prolonged complete rest after mTBI has been replaced by a more active approach to recovery that balances appropriate initial rest with gradual, symptom-limited return to activity.