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Part 2: Treating What Can't Be Seen: Neurological, Psychological, and Physical Symptom Management in Mild TBI Patients

Mild traumatic brain injuries (TBIs) are among the most frustrating from a treatment perspective, for both patients and health care professionals. Simply put, there is a single physiological therapy recommended (past the immediate interventions associated with a head injury concurrent with TBI): rest1.

That term can be a loaded one for patients dealing with persistent post-concussive symptoms (also known by various terms including, for example, as post-concussion syndrome) because it entails avoiding an entire host of activities known to trigger TBI symptoms for a period of time that is unique to each individual's recovery from these symptoms (often within the 48-hour to three-month range2, although in some cases longer than six months3). While bed rest is a primary component of this treatment, those in recovery are also cautioned to avoid bright lights, loud sounds, crowd situations, and physical activity which can raise the heart rate or run the risk of exposure to a second head impact4. By extension, this often restricts the driving or cycling privileges of patients, reducing their mobility.

While being confined to a dark, quiet room for an indeterminate length of time can be trying for anyone, the fact that this avoidance of external stimuli and activity must also be paired with cognitive rest is another factor to consider when putting together a treatment program for patients dealing with a mild traumatic brain injury. This can mean not overdoing reading, television, computer and smart phone screens, video games, and music5 and leaving the door open to start to slowly reintegrate these activities. There are currently no neurological drug therapies available to assist with either of these forms of rest in dispelling concussion symptoms3.

After an initial period of 48 hours, patients can be encouraged to gradually ease back into cognitive engagement and physical activity, with the caveat that the return of post-concussion symptoms may require additional support1. A re-evaluation by a medical professional of any remaining symptoms should be performed every two to four weeks until recovery is completed, or a long-term symptom management plan has been put into place.

Patients forced to endure this type of forced physical and cognitive rest can begin to exhibit psychological symptoms associated with depression and anxiety. These can also arise from the uncertain duration of the recovery period, the frequent setbacks that can be experienced after a symptom-free period is tested with physical activity, and even the relationships between family and friends who, in the absence of any overt symptoms can be less than understanding concerning the need for rest and the abstention from normal activity. Educating the patients and their friends and family about their symptoms, expectations surrounding recovery times, and the potential long-term effects of the injury are key to reducing this type of anxiety and depression3.

Given that mild traumatic brain injury itself can also trigger depression, as well as a number of other behavioural issues, it's also important for patients to receive psychological evaluations and counselling during the course of their recovery, and for the establishment of individualized recovery goals3. This is especially true for individuals facing long-term symptoms that may never completely clear, and who must avoid certain activities in the future as a result of their injury. It's also crucial for those medical professionals providing this type of care to separate new symptoms from previous neurological or physical conditions to ensure the most effective treatment3.

  1. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51:930-934.
  2. Marshall S, Bayley M, McCullagh S, et al. Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Can Fam Physician. March 2012;58(3):257-267.
  3. Arciniegas D, Anderson C A, Topkoff J, et al. Mild traumatic brain injury: a neuropsychiatric approach to diagnosis, evaluation, and treatment. Neuropsychiatr Dis Treat. December 2005;1(4):311-327.
  4. Cleveland Clinic. Concussions: Management and Treatment. https://my.clevelandclinic.org/health/diseases/15038-concussions/management-and-treatment (accessed May 8, 2018).
  5. Halstead ME, Walter KD. American Academy of Pediatrics Clinical report - sport-related concussion in children and adolescents. Pediatrics. September 2010. 126(3):597-615.
  6. Defense and Veterans Brain Injury Center . Updated mTBI clinical guidance. www.dvbic.org/pdfs/mTBI_recs_for_CONUS.pdf. (Accessed May 7, 2018).