What is the evaluation and treatment for a patient with a concussion or Mild Traumatic Brain Injury (mTBI)?

Evaluation and Treatment for Concussion or Mild Traumatic Brain Injury (mTBI)

The evaluation and treatment for concussion or mild traumatic brain injury should include an initial 24-48 hours of moderate rest followed by a gradual, structured return to activity with specialized rehabilitation for persistent symptoms. 1, 2

Initial Evaluation

• Assess for warning signs requiring immediate medical attention: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, or visual changes 1, 3
• Evaluate Glasgow Coma Scale (GCS) score - mTBI is typically defined by a GCS score between 13-15 at 30 minutes post-injury 4
• Document presence of symptoms including confusion, disorientation, amnesia, headache, dizziness, and balance problems 1
• Consider neuroimaging (CT or MRI) for patients with concerning symptoms, though standard structural neuroimaging is typically normal in uncomplicated concussion 5
• If focal lesions are found on imaging, the term "complicated mild TBI" may be used 4

Acute Management (First 24-48 Hours)

• Implement moderate physical and cognitive rest for the first 24-48 hours to allow for initial recovery during the acute neurometabolic cascade 1, 2
• Avoid strict prolonged rest (exceeding 3 days) as this can worsen outcomes and delay return to productivity 1, 6
• Remove from play/activity immediately if a concussion is suspected - "When in doubt, sit them out!" 1
• For pain management, acetaminophen may be used as recommended by a physician 1, 2
• Avoid NSAIDs and aspirin immediately after suspected head injury due to theoretical risk of intracranial bleeding 2

Gradual Return to Activity Phase (After Initial 24-48 Hours)

• Begin gradual reintroduction of activities that do not worsen symptoms after the initial rest period 1, 2
• Implement a progressive schedule with close monitoring of symptom expression (number and severity) 1
• Exercise should be performed below symptom exacerbation threshold 2, 3
• Supervised, non-contact aerobic exercise is particularly beneficial for adolescents with acute concussion 5, 2
• Each step in the return-to-activity protocol should take a minimum of 24 hours 1, 2
• If symptoms recur during the protocol, return to the previous asymptomatic level and try to progress again after 24 hours 1

Return to School/Cognitive Activities

• Gradually increase duration and intensity of academic activities as tolerated 1, 3
• Implement appropriate educational accommodations if symptoms interfere with academic performance 1
• Temporary accommodations may include shortened school days, reduced workloads, extended time for assignments and tests, and postponement of standardized testing 2, 3
• Avoid activities requiring concentration that may exacerbate symptoms, such as video games, computer use, television viewing, and exposure to loud music 2

Return to Play/Sports Protocol

• Follow a stepwise return to play protocol that typically includes: 1, 2
  1. Light aerobic exercise (walking, swimming, stationary cycling)
  2. Sport-specific exercise (skating drills in hockey, running drills in soccer)
  3. Non-contact training drills (passing drills, resistance training)
  4. Full-contact practice (following medical clearance)
  5. Return to competition
• Allow return to full activity only when the individual has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 1, 2
• Do not return to play while taking any medications for concussion symptoms 1, 2
• Athletes who experienced loss of consciousness or amnesia should be disqualified from further participation on the day of the injury 2

Management of Persistent Symptoms (Beyond 3 Weeks)

• Implement multidisciplinary management for symptoms persisting beyond 3 weeks 1, 2
• Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome 1
• Consider formal neuropsychological assessment for patients with persistent cognitive symptoms 1
• A multidisciplinary approach may include: 1, 3
  • Graded physical exercise (performed at least once weekly for a minimum of 4 weeks)
  • Vestibular rehabilitation (including otolith manipulating procedures, habituation exercises)
  • Manual therapy for the neck and spine when neck pain is present
  • Psychological treatment
  • Oculomotor vision treatment

Special Considerations

• Recovery may take longer in younger athletes compared to older ones; manage more conservatively with stricter return-to-play guidelines 1, 2
• Older patients often experience concussions from low-velocity mechanisms such as falls from standing height 1
• Avoid high-intensity physical activity during recovery as this can be detrimental 5, 1, 2
• Be more conservative in treating athletes with a history of previous concussions 2

Common Pitfalls to Avoid

• Returning to activity too soon before symptoms have resolved, which can worsen outcomes 1, 3
• Advising prolonged rest (>2 days) which is associated with delayed return to productivity 6
• Inadequate rest during the acute phase (first 24-48 hours) 1
• Relying solely on patient-reported symptoms without objective assessment 1, 3
• Inconsistent online resources that may provide conflicting information about concussion management 1