Review ArticlePractice

Clinical practice guidelines for mild traumatic brain injury and persistent symptoms

Shawn Marshall, Mark Bayley, Scott McCullagh, Diana Velikonja and Lindsay Berrigan
Canadian Family Physician March 2012; 58 (3) 257-267;

Abstract

Objective To outline new guidelines for the management of mild traumatic brain injury (MTBI) and persistent postconcussive symptoms (PPCS) in order to provide information and direction to physicians managing patients’ recovery from MTBI.

Quality of evidence A search for existing clinical practice guidelines addressing MTBI and a systematic review of the literature evaluating treatment of PPCS were conducted. Because little guidance on the management of PPCS was found within the traumatic brain injury field, a second search was completed for clinical practice guidelines and systematic reviews that addressed management of these common symptoms in the general population. Health care professionals representing a range of disciplines from across Canada and abroad were brought together at an expert consensus conference to review the existing guidelines and evidence and to attempt to develop a comprehensive guideline for the management of MTBI and PPCS.

Main message A modified Delphi process was used to create 71 recommendations that address the diagnosis and management of MTBI and PPCS. In addition, numerous resources and tools were included in the guideline to aid in the implementation of the recommendations.

Conclusion A clinical practice guideline was developed to aid health care professionals in implementing evidence-based, best-practice care for the challenging population of individuals who experience PPCS following MTBI.

New Canadian guidelines have been developed to aid health care professionals in implementing evidence-based, best-practice care for the challenging population of individuals who experience persistent postconcussive symptoms (PPCS) following mild traumatic brain injury (MTBI). The diagnostic criteria for MTBI are outlined in Box 1.1 Mild traumatic brain injury, also commonly referred to as mild head injury or concussion, is one of the most common neurologic disorders occurring today and is gaining increasing public awareness particularly through concussion-in-sport prevention initiatives2 as well as media attention on military blast injuries.3 Recently, a study examining both hospital-treated cases of MTBI and those presenting to family physicians calculated the incidence of MTBI in Ontario to be between 493 and 653 per 100 000 people.4 While it is expected that in most cases patients who experience MTBI will fully recover within days or months, the Centers for Disease Control and Prevention note that “up to 15% of patients diagnosed with MTBI may have experienced persistent disabling problems.”5 Although these cases represent a minority of patients, given the high incidence of MTBI, this potentially translates to a substantial number of individuals.

Physical, emotional, behavioural, and cognitive symptoms such as headache, sleep disturbance, disorders of balance, fatigue, irritability, and memory and concentration problems all commonly occur after MTBI. Box 2 outlines some of the common symptoms.6 Although the International Classification of Diseases diagnosis of postconcussion syndrome (Box 3)7 and the Diagnostic and Statistical Manual of Mental Disorders diagnosis of postconcussional disorder (Box 4)8 are controversial,9 what cannot be debated is that persistent symptoms following MTBI can result in substantial functional disability interfering with patients’ ability to return to work or school and can result in low levels of satisfaction with quality of life.10 An evaluation of the quality of available guidelines for MTBI found that more guidance has become available in the past 2 years, with 4 clinical practice guidelines (CPGs) solely dedicated to the topic having been published in that time.11 However, very little guidance is provided for the assessment and management of persistent symptoms that extended beyond the typical acute recovery period. The exceptions to this finding were guidelines developed by military groups. The study concluded that a clear need existed for systematically developed practice recommendations to guide health care professionals in the identification and management of patients who experience persistent symptoms following MTBI.

Box 1. Diagnostic criteria for mild traumatic brain injury from the American Congress of Rehabilitation Medicine

A patient with mild traumatic brain injury has had a traumatically induced physiologic disruption of brain function, as manifested by 1 or more of

  • any loss of consciousness up to 30 min,

  • any loss of memory for events immediately before or after the accident for as much as 24 h,

  • any alteration of mental state at the time of the accident (eg, feeling dazed, disoriented, or confused), or

  • focal neurologic deficits that might or might not be transient, but where the severity of the injury does not exceed

  • loss of consciousness exceeding 30 min,

  • posttraumatic amnesia longer than 24 h, or

  • a Glasgow Coma Scale score falling below 13 after 30 min.

  • Adapted from the Mild Traumatic Brain Injury Committee of the American Congress of Rehabilitation Medicine.1

    • Box 2. Common symptoms of mild traumatic brain injury

    Physical

    • Headache

    • Nausea

    • Vomiting

    • Blurred or double vision

    • Seeing stars or lights

    • Balance problems

    • Dizziness

    • Sensitivity to light or noise

    • Tinnitus

    Behavioural or emotional

    • Drowsiness

    • Fatigue or lethargy

    • Irritability

    • Depression

    • Anxiety

    • Sleeping more than usual

    • Difficulty falling asleep

    Cognitive

    • Feeling “slowed down”

    • Feeling “in a fog” or “dazed”

    • Difficulty concentrating

    • Difficulty remembering

  • Adapted from Willer and Leddy.6

    • Box 3. International Classification of Diseases7 (ICD-10) diagnostic criteria for postconcussion syndrome

    1. History of head trauma with loss of consciousness preceding symptom onset by a maximum of 4 wk.

    2. Symptoms in 3 or more of the following symptom categories:

      • headache, dizziness, malaise, fatigue, noise intolerance;

      • irritability, depression, anxiety, emotional lability;

      • subjective concentration, memory, or intellectual difficulties without neuropsychological evidence of marked impairment;

      • insomnia;

      • reduced alcohol tolerance; and

      • preoccupation with above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role.

    Box 4. Diagnostic and Statistical Manual of Mental Disorders, 4th edition,8 diagnostic criteria for postconcussional disorder

    1. A history of head trauma that has caused considerable cerebral concussion.*

    2. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning or recall of information).

    3. Three (or more) of the following occur shortly after the trauma and last at least 3 mo:

      • becoming fatigued easily;

      • disordered sleep;

      • headache;

      • vertigo or dizziness;

      • irritability or aggression on little or no provocation;

      • anxiety, depression, or affective instability;

      • changes in personality (eg, social or sexual inappropriateness); or

      • apathy or lack of spontaneity.

    4. The symptoms in criteria B and C have their onset following head trauma or else represent a substantial worsening of pre-existing symptoms.

    5. The disturbance causes considerable impairment in social or occupational functioning and represents a considerable decline from a previous level of functioning. In school-aged children, the impairment might manifest as a substantial worsening in school or academic performance dating from the trauma.

    6. The symptoms do not meet criteria for dementia due to head trauma and are not better accounted for by another mental disorder (eg, amnestic disorder due to head trauma, personality change due to head trauma).

  • ↵* The manifestations of concussion include loss of consciousness, posttraumatic amnesia, and, less commonly, posttraumatic onset of seizures. The specific method of defining this criterion needs to be established by further research.

    • Scope

    The present guidelines are intended to assist health care professionals with the assessment and management of PPCS following MTBI. The guidelines are appropriate for use with adults (≥ 18 years) who have experienced MTBI of various causes. The scope of the guidelines does not include penetrating brain injuries, birth injuries, brain damage from stroke or other cerebrovascular accidents, shaken baby syndrome, or moderate to severe brain injuries. Early, acute management of MTBI is addressed to a lesser extent in these guidelines, as their focus is the assessment and management of PPCS. Nonetheless, the most critical issues for early management have been incorporated because early management can influence the development and maintenance of persistent symptoms. The guidelines will be helpful to various health care professionals, including family physicians, neurologists, physiatrists, psychiatrists, psychologists, counselors, physiotherapists, occupational therapists, and nurses.

    Development

    Leadership

    Development of the guidelines was led by a team composed of clinicians with substantial experience in treating MTBI as well as past experience in developing CPGs. The project team convened an MTBI Expert Consensus Group. The members of the consensus group were recruited so as to ensure adequate representation of the various health care professions serving the MTBI patient population, domain of expertise, and geographic location. With respect to health care professions, a range of disciplines including emergency medicine, neurology, physical medicine and rehabilitation, radiology, psychiatry, psychology, physical therapy, and occupational therapy were represented. In addition, relevant stake-holder organization representatives were included from the Ontario Neurotrauma Foundation, the Ontario Brain Injury Association, and the International Brain Injury Association, as well as an individual who experienced PPCS following MTBI. Individuals with expertise in physical, cognitive, and affective symptoms as well as in diagnosis, quality-of-life assessment, outcomes measurement, and knowledge translation all took part. Similarly the panel represented the various causes of MTBI with expertise from the sport, motor vehicle accident, and military fields. The members of the expert consensus group were recruited from across Canada and abroad.

    Literature review

    The Practice Guidelines Evaluation and Adaptation Cycle12 was used as the model for development, and the first step taken was to search for and review existing guidelines addressing MTBI in order to identify high-quality recommendations that could be adapted to minimize repetition of previously completed work. A comprehensive search for existing CPGs published in English or French within the past 10 years (1998 to 2008) that were relevant to traumatic brain injury and that included recommendations for the care of individuals with mild injuries was undertaken. This was conducted using bibliographic databases (eg, Cochrane Library, National Guidelines Clearing House), MEDLINE, PsycINFO, and a general Web search, as well as searches of websites of relevant organizations (eg, Canadian Medical Association, National Institute for Health and Clinical Excellence). Twenty-three guidelines were identified. These were screened, and guidelines found to be more than 10 years old, those that did not address MTBI, those that were reviews only and that did not include practice recommendations, those that only addressed prehospital or acute care, and those that only addressed pediatric care were excluded from further review. Seven guidelines met the inclusion criteria (Table 113–19), and recommendations relevant to MTBI were extracted.

    View this table:
    Table 1

    Existing traumatic brain injury guidelines evaluated in the process of developing the current guideline

    The next step was to conduct a systematic literature search in order to capture all published research evaluating the effectiveness of treatments or interventions intended to prevent or manage persistent symptoms following MTBI. A comprehensive systematic review conducted by Borg and colleagues20 was relied upon for literature published up to 2001, therefore requiring an updated search of the MEDLINE and PsycINFO databases for the period extending from 2001 to 2008. There were 9435 results obtained from MEDLINE and 8432 results obtained from PsycINFO. These were reviewed by 2 independent reviewers, and 36 met the criteria for inclusion.

    Because very few guidelines on the management of symptoms following MTBI were found, a second search was completed for CPGs and systematic reviews that addressed the management of common symptoms (eg, insomnia) in the general population. Although these guidelines do not include recommendations specific to managing symptoms within an MTBI population, they do provide some general direction on how to best treat symptoms that commonly persist following MTBI. The procedures used to identify these CPGs and reviews were similar to those described above. The categories of symptoms for which CPGs were developed outside of the traumatic brain injury field, and from which recommendations were extracted, included cognitive dysfunction (n = 1), fatigue (n = 1), mood disorders (n = 4), and sleep disorders (n = 4).

    Practice recommendations

    The expert consensus group convened at a conference where they attended presentations on the methodologic factors critical to the development of evidence-based, best-practice care and were presented with the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument rating scores for existing traumatic brain injury guidelines, the results of the systematic reviews of the literature, and the summary of recommendations and levels of evidence extracted from existing guidelines. In addition, the topics of definition, prognosis, and risk factors were also discussed. Attendees then worked in groups to adapt high-quality recommendations extracted from existing guidelines and to generate new recommendations based on current research and clinical expertise.

    The group drafted 152 initial guideline recommendations. Final recommendations were produced using a modified Delphi process.21 A vote was taken at the conference after all initial recommendations had been presented. Following the conference, the draft recommendations and vote results were circulated to the consensus panel to ensure agreement with each recommendation. A recommendation was retained for inclusion if it met at least 1 of the following criteria: it was based on grade A evidence, it received either a minimum of 10 votes or 75% endorsement by the expert consensus group, or it represented an important care issue (ie, addressed a topic relevant to a large proportion of the MTBI population and clearly represented a current gap in treatment guidance). After applying these criteria, 71 recommendations remained and these comprise the current guideline.

    The following system was used for grading levels of evidence and was applied to the guideline recommendations: grade A evidence included at least 1 randomized controlled trial, meta-analysis, or systematic review; grade B evidence included at least 1 cohort comparison, case study, or other type of experimental study; grade C evidence included expert opinion or the experience of a consensus panel.

    A draft of the guideline was circulated to recognized experts in the field who did not participate in the development process. The external reviewers were asked to provide input about the validity and relevance of the guideline. This feedback was incorporated into the final draft.

    Highlights

    The 71 recommendations of the guideline are presented in Table 2.13–19,22–30 The complete guideline document22 can be obtained from the Ontario Neurotrauma Foundation’s website (www.onf.org), and detailed information about the source of individual recommendations is provided in Appendix D of the complete document. In the complete document, background information pertaining to each topic precedes the specific recommendations to be implemented. Each section also includes relevant resources (eg, criteria for diagnosis of MTBI and postconcussion disorder), and various tools that can aid in assessment and management of symptoms (eg, patient advice sheet, standardized questionnaires, therapeutic options tables) are provided in appendices. There is evidence supporting the validity of several of the objective symptom monitoring tools included in the guideline for use with MTBI patients (Rivermead Post-Concussion Symptoms Questionnaire,31,32 Abbreviated Westmead Post-Traumatic Amnesia Scale, 33,34 Fatigue Severity Scale,35,36 and the Patient Health Questionnaire–937,38). In contrast, such evidence was not identified for the PTSD CheckList–Civilian Version39 or the Sport Concussion Assessment Tool 240 with this population. However, these tools are in use in clinical settings and the development group thought it was worthwhile to recommend their use so that practitioners would have some types of objective measures to use rather than no objective measures at all. In addition, a modified scoring procedure for the Rivermead Post-Concussion Symptoms Questionnaire exists (RPQ-13) that has been reported to possess improved psycho-metric characteristics according to one study.41

    View this table:
    Table 2

    Guideline recommendations: Appendices, tables, and figures referred to in the following table are located in the full Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms.22

    Implementation and update plans

    The Ontario Neurotrauma Foundation is developing an MTBI strategy to improve care across the population, with one subcommittee focused on the evaluation and implementation of these guidelines. Particular barriers to implementation include the multiple clinical settings in which individuals present after MTBI. For example, given the symptom spectrum, patients might be seen in the emergency setting, a family physician’s office, or a specialist setting, including neurology, physiatry, psychiatry, or otolaryngology. The evaluation process will include a pilot test of the guideline recommendations. Feedback from front-line clinicians and their patients during the pilot implementation phase, as well as findings from an ongoing literature review, will inform the update of these recommendations scheduled for 2012.

    Comparison with other guidelines

    As mentioned previously, other CPGs address the care of individuals who have experienced MTBI. There are guidelines that focus on traumatic brain injury in general, but which provide some recommendations addressing mild injuries.15,16,18 Also, recent guidelines have been developed that focus specifically on MTBI.13,14,17,19,40,42 When work began on our guidelines, only the earlier version of the Concussion in Sport Group guidelines19 and the guidelines from New South Wales,13 the Defense and Veterans Brain Injury Centre,14 and the Ontario Workplace Safety and Insurance Board17 had been published. However, aside from the clinical guidance document from the Defense and Veterans Brain Injury Centre (which is not a formal guideline), the other pre-existing guidelines offered little to no guidance on the care of persistent symptoms. The Veterans Affairs–Department of Defense guideline42 was published in 2009, when development of our guidelines was well under way, and has independently taken a similar approach to creating guidelines addressing persistent symptoms following MTBI in order to fill the current lack of direction for clinicians in managing this challenging patient population. But, as noted, the Veterans Affairs–Department of Defense guideline was developed for use with military personnel with a focus on blast injury and management within the military medical infrastructure.

    Limitations

    Our guidelines are constrained by the paucity of supporting evidence in most of the topic areas for which recommendations for practice were considered necessary and relevant. This constraint necessitated a heavy reliance on practice recommendations and clinician resources developed for other clinical populations (eg, headache, sleep disorder), as opposed to MTBI patients specifically. Because very few randomized controlled trials were found in the review of the literature, many of the guideline recommendations are based on the opinions and expertise of the consensus group members (grade C).

    A further limitation or challenge is the ongoing controversy and debate surrounding the pathogenesis of postconcussional disorder or postconcussion syndrome. Despite evident dysfunction and disability occurring frequently after injury, health care providers and funders have emphasized the issue of validation of the diagnosis and issues of potential secondary gain,7,43,44 as MTBI has generally been perceived as a self-limiting and nondisabling condition. The expert consensus group agreed it would be most beneficial for clinicians to focus on the development of guidance for management of PPCS following MTBI, emphasizing a symptom-based approach as opposed to deliberating diagnostic criteria.

    Gaps in MTBI knowledge

    Most of the guideline recommendations are based on expert consensus opinion, thereby highlighting the notable gaps in MTBI knowledge that should be addressed by research, including the following.

    Consensus definition

    A consensus definition for patients with persistent symptoms following MTBI is needed. The consensus group could not formally endorse either the Diagnostic and Statistical Manual of Mental Disorders diagnosis of postconcussional disorder or the International Classification of Diseases diagnosis of postconcussion syndrome.

    Timing of intervention

    The ideal timing for delivery of interventions, follow-up assessment, and referral for specialist care is not known.

    Effectiveness of intervention

    The effectiveness of treatment intervention for specific symptoms following MTBI is not known.

    Effects of coexisting injuries on MTBI outcomes

    There are a variety of causes of MTBI, such as sports-related injury, motor vehicle accidents, blast injury, work-related injury, and falls. Evidence suggests sport-related MTBI has a lower incidence of persistent symptoms compared with other traumatic causes; however, the reason for this is unknown. In contrast, other causes, such as falls and motor vehicle collisions, are more likely to result in multiple trauma including fractures and internal organ injury or substantial emotional reactions to unanticipated injury, which might predispose patients to acute and posttraumatic stress disorders. The effect of factors related to more complex presentations remains a knowledge gap.

    Implementation and dissemination of guidelines

    The ideal method for implementation and dissemination of guidelines across multiple health care specialties, health care professionals, and different settings remains unknown.

    Conclusion

    The current guidelines are intended to fill a gap in delivery of care and to serve as a resource for clinicians who encounter patients with MTBI with the intent of either preventing symptoms from becoming chronic or minimizing the effects of PPCS. Further research is required both to improve the evidence for provision of care for MTBI and PPCS and to identify the best methods for uptake and implementation of guidelines that span multiple types of health care professionals and health care settings.

    Acknowledgments

    We thank the MTBI Expert Consensus Group (Markus Bessemann, MD, FRCPC, DipSportMed, LCol; Angela Colantonio, PhD; Paul Comper, PhD, CPsych; Nora Cullen, MD, MSc, FRCPC; Anne Forrest, PhD; Jane Gillett, MD, FRCPC; John Gladstone, MD, FRCPC; Wayne Gordon, MD, PhD, ABPP/CN, FACRM; Elizabeth Inness, MSc; Grant Iverson, PhD, Rpsych; Corinne Kagan; Vicki Kristman, PhD; John Kumpf; Andrea LaBorde, MD; Shayne Ladak, MD, CSCS NASM-CPT; Sue Lukersmith, OT; Willie Miller, MD, FRCPC; Alain Ptito, PhD, OPQ; Laura Rees, PhD, CPsych; Jim Thompson, MD, CCFP(EM), FCFP; and Rob van Reekum, MD, FRCPC) and the external reviewers (Erin Bigler, PhD; Anthony Feinstein, MB BCh, MPhil, PhD, FRCPC, MRCPsych; Paul Mendella, PhD, CPsych; Jennie Ponsford, PhD; Mark Rapoport, MD, FRCPC; and Andree Tellier, PhD, CPsych). We also thank John Gladstone for authoring the guidance on assessment and management of posttraumatic headache. The Ontario Neurotrauma Foundation initiated and funded the development of the guidelines.

    Notes

    KEY POINTS

    Mild traumatic brain injury (MTBI) is one of the most common neurologic disorders occurring today. Persistent symptoms following MTBI might occur in 10% to 15% of patients and can include posttraumatic headache, sleep disturbance, disorders of balance, cognitive impairments, fatigue, and mood disorders. Persistent postconcussive symptoms can result in functional disability, stress, and time away from work or school. These guidelines address the fact that to date, other than for sport concussion, little information and direction has been available to physicians to manage recovery from MTBI.

    Footnotes

    • This article has been peer reviewed.

    • This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.

    • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2012 à la page e128.

    • Contributors

      All authors contributed to the guideline development process and to preparing the manuscript for submission.

    • Competing interests

      None declared

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