What is the outpatient management for mild traumatic brain injury (mTBI) or concussion?

From the Guidelines

Outpatient management of concussions should focus on a gradual return to activities, with an initial 24-48 hours of rest, followed by a stepwise progression to normal activities, as recommended by the most recent and highest quality study 1. The goal of this approach is to allow the brain to heal while preventing deconditioning from prolonged inactivity. Key components of outpatient management include:

• Initial rest period of 24-48 hours, avoiding physical and cognitive exertion that worsens symptoms
• Gradual return to activities, with a stepwise progression to normal activities, including light aerobic exercise, sport-specific exercise, non-contact training drills, full-contact practice (if applicable), and finally return to competition or full activity
• Each stage should last at least 24 hours, and patients should only progress to the next level if symptoms do not worsen
• Patients should avoid alcohol, sleep medications, and recreational drugs during recovery
• Regular follow-up is important, and patients should be referred to a specialist if symptoms persist beyond 2-4 weeks, as some patients may experience post-concussion syndrome with persistent symptoms 1. It is essential to note that the management of concussions should be individualized, taking into account the patient's specific symptoms, needs, and circumstances. The use of acetaminophen (650mg every 6 hours as needed) is preferred for headache management, while NSAIDs like ibuprofen should be avoided in the first few days due to bleeding risk 1. Overall, the outpatient management of concussions requires a comprehensive and multidisciplinary approach, with a focus on gradual return to activities, symptom management, and regular follow-up to ensure optimal outcomes and prevent further complications.

From the Research

Outpatient Management for Concussions

The outpatient management for concussions typically involves a multidisciplinary approach, with treatment individualized based on predominant signs and symptoms 2, 3. Some key aspects of outpatient management include:

• A structured method for diagnosis, including a history, physical examination, and additional tests as clinically indicated to help identify underlying symptom generators 2
• Treatment options such as:
  • Sub-symptom threshold aerobic exercise 2, 3
  • Cervical physical therapy 2, 3
  • Vestibulo-ocular rehabilitation 2
  • Behavioral and cognitive psychotherapy 2
  • Symptom-specific pharmacological therapies 2, 3, 4
• A brief period of rest, followed by a gradual reintroduction of activities, and a graduated return-to-sport protocol 5
• Exercise, vestibular, and cognitive rehabilitation programs for patients with prolonged recovery from a concussion 5
• Medications to help manage or minimize disruptive symptoms, although these are not routinely used in most concussions that recover within days to weeks 4

Treatment Approaches

Treatment approaches may vary depending on the individual patient's needs and symptoms. For example:

• Patients with persistent post-concussive symptoms (PPCS) may require more involved therapy, including additional education, academic accommodations, physical therapy, cognitive rehabilitation, and medication 6
• Patients with prolonged concussion symptoms or significant deficits in cognitive functioning may benefit from a combination of treatments, including temporary academic adjustments, physical therapy, vestibular and ocular therapy, psychological support, and graded noncontact exercise 4