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Identifying and Treating Concussion/mTBI in Service Members and Veterans
A Course for Civilian Health Care Providers from BrainLineMilitary.org
Regardless of the time elapsed since the concussion/mTBI, you should treat your patient symptomatically. Treatment guidelines follow for the common longer-lasting signs and symptoms of concussion/mTBI:
- Dizziness and balance problems
- Cognitive problems
- Emotional problems
Download the following PDF from the CDC for a quick guide to treating concussion/mTBI.
"Because the effects of mTBI can be so diverse, no standard treatment exists. But physicians can take many actions to improve outcomes for patients with mTBI "
For more detail, download the VA/DOD clinical practice guidelines on concussion/mTBI.
Insomnia is one of the most common symptoms in concussion/mTBI patients. Sleep problems can be caused directly by the brain trauma or indirectly by self-medication, anxiety, and depression. Insomnia is particularly crucial to address because often when it resolves, other symptoms such as headaches, fatigue, and cognitive problems will likely also diminish.
- Urge your patient to avoid any of the following within three hours of bedtime:
- Heavy exercise
- Heavy eating
- Advise your patient to try to go to sleep
- Only when tired
- On a regular schedule
- In a pleasant and suitable room quiet, dark or dimly lit, and at a comfortable temperature
For more information about sleep hygiene consult this printer-friendly online resource from the Defense and Veterans Brain Injury Center.
- If behavioral interventions are not effective, medications can be used to assist with sleep regulation. The VA-DoD guidelines suggest a short trial of non-benzodiazepine hypnotics Proceed with caution and avoid sedatives and sleep aid medications if you suspect sleep apnea.
- Refer your patient to specialty care or to a sleep study if you suspect a more serious sleep disorder.
Read this short piece from the National Sleep Foundation on cognitive behavioral therapy, an innovative way to treat insomnia without the use of pharmaceuticals:
"Cognitive Behavioral Therapy for Insomnia, often called CBT-I, is an approved method for treating insomnia without the use of sleeping pills. Sound impossible? It isn't "
Watch Dr. Alison Cernich acting senior liaison for TBI for the U.S. Department of Veterans Affairs describe the warning signs for sleep disorders:
VIDEO: Getting to the Root of Fatigue Post-TBI
Getting to the Root of Fatigue Post-TBI
Overwhelming fatigue post-injury can be due to disrupted sleep patterns and there are strategies to help.
Watch a brief segment with Adam Anicich, a veteran with concussion/mTBI, talking about his headaches:
VIDEO: Headaches Can Make It Impossible to Focus
Headaches Can Make It Impossible to Focus
Headaches can be so severe they feel like a "pulsating, rumbling fight inside your head."
Watch a brief video with Dr. Alison Cernich on how to treat headache:
VIDEO: Post-Traumatic Headache
"Sometimes simple changes like eating during the day, limiting caffeine, and getting good sleep will improve headaches."
Headache is the most common and complex complaint after a concussion/mTBI. You have multiple treatment options before referring your patient to specialty care.
- Encourage your patient to maintain a headache diary and present it at appointments. The patient should detail:
- The time and duration of headaches
- Intensity (on a 1-10 scale)
- Where in the cranium the pain was experienced
- Other symptoms
- Aggravating and alleviating factors (for example, is the headache better or worse after a meal or a workout?)
- What the patient was doing when the episode occurred (resting, taking medications, turning off the lights, and so on)
With this information you can better characterize the headaches (e.g., tension, cluster, or migraine) and refine your treatment plan. This chart from the Defense Centers of Excellence Case Studies Series can also help. Please note: It includes the two most common types of headaches following concussion/mTBI, but there are other types that occur (cluster, occipital neuralgia, etc.).
- Be aware that excessive use of and withdrawal from caffeine and nicotine can trigger headaches.
- If your patient's headaches are mild, you can advise over-the-counter analgesics that don't contain caffeine.
- You should avoid prescribing narcotics, prescription medications containing caffeine, and benzodiazepines because of the risk of rebound headaches and addiction.
- For acute headache episodes, consider the following: NSAIDs, Triptans, rest, and applications of heat.
- Consider referring your patient to specialists for alternative care such as biofeedback, massage, stress management, and acupuncture.
- For prophylactic measures, refer your patient to specialty care where abortive agents such as tricyclic antidepressants, anticonvulsants, or beta-blockers can be used and monitored. Some of these medications are contraindicated with certain co-morbidities, so the specialist must first review the patient's complete medical history.
|Pain Intensity||Mild-moderate||Often severe/debilitating|
|Pain Character||Dull, aching, or pressure. Can be sharp but that is not predominant||Throbbing/pulsatile, can be sharp/stabbing or electric-like|
|Duration||Usually less than 4 hours||Can be longer than 4 hours|
|Phono- or photo-phobia||One but not both may be present||One or both usually present|
|Able to carry out routine activities/work||Usually||Usually not or decreases ability to participate|
|Location||Bilateral frontal, retro-orbital, temporal, cervical and occipital or holocephalic||Usually unilateral & may vary in location among episodes|
|Nausea/malaise||Not present||Usually present|
|Palpable muscle tenderness/contraction||Pericranial muscles (temporalis, masseter, pterygoid, posterior neck, sternocleidomastoid, splenius, or trapezius||Local muscle tenderness not typical but can be present with long duration headaches|
Read this symptom management sheet from DVBIC, and feel free to share it with your patients:
Headache is one of the most common symptoms after traumatic brain injury. Over 30% of those injured report having headaches which continue long after injury.
Dizziness and Balance Problems
Vestibular dysfunction is one of the top complaints that patients report after a concussion/mTBI. There are several possible causes for dizziness, and it must be assessed appropriately to rule out other organic causes such as anxiety and medication side effects.
Injuries to the cranial nerves (vestibulocochlear, optic, and oculomotor nerves) and cerebellum are possible causes that need further evaluation with a specialist based on a neurological exam and on your patient's report from the Dizziness Handicap Inventory questionnaire.
A referral to vestibular rehabilitation or physical therapy, neuro-optometry, and/or neuro-otology may be warranted, especially if symptoms change or get worse. If a patient presents with neck pain or stiffness along with dizziness, this may indicate a neuromuscular injury and would require an evaluation with physiatry, sports medicine or orthopedics, and/or physical therapy. Once the initial evaluation is complete, a service member or veteran may be able to complete therapy from home, but encourage them to stay within their symptom tolerance.
Read this information sheet from the Defense and Veterans Brain Injury Center:
Dizziness is one of the symptoms that you may experience after a concussion/mild traumatic brain injury. There are several possible causes of your dizziness
Watch this brief video with Dr. Alison Cernich about assessing cognitive problems:
VIDEO: Attention and Memory Issues
Attention and Memory Issues
"It's important to learn what the symptom like attention or memory is and when it happens and what's happening around the person experiencing it."
Treating Cognitive Problems
Among the most typical signs and symptoms after concussion/mTBI are changes in cognition, in particular, problems with attention, memory, speed of processing, and executive function.
These are challenging symptoms to treat, because patients frequently have co-occurring conditions. For example, pain, poor sleep, and depression can each reduce cognitive performance. When trying to treat cognitive problems, be sure to consider not just TBI but other conditions as well.
- Encourage your patient to record important information (such as appointments, errands, and medication schedules).
- Promote better sleep hygiene, diet, and exercise to improve mental well-being.
- If cognitive deficits are not improving, refer your patient to specialty care for complete neuropsychological testing and assessment. Also consider referrals to rehabilitation medicine professionals who work specifically on cognitive challenges following TBI (e.g., neuropsychologists, rehabilitations psychologists, speech-language pathologists, and occupational therapists). If the patient is a veteran and not able to access specialty services for brain injury available to active duty service members, encourage him or her to pursue treatment at Veteran’s Health Administration facilities. Please see www.polytrauma.va.gov for facility locations and services.
- If the service member or veteran has documented cognitive difficulties, cognitive rehabilitation can be effective in helping them to either compensate for or treat their cognitive problems. Evidence varies for the specific cognitive problems that present commonly following concussion/mTBI, but patients often find guidance related to how to compensate for their deficits very helpful, according to a recent Institute of Medicine report.
- If behavioral problems persist, refer your patient to a behavioral health worker.
Watch Adam Anicich, an Iraq veteran with concussion/mTBI, as he describes his cognitive rehabilitation with occupational therapy:
VIDEO: The Benefits of Cognitive Rehabilitation
The Benefits of Cognitive Rehabilitation
Occupational therapy can help a person with TBI with everyday life from learning to make lists and set priorities to improving interpersonal relationships.
Watch Dr. Law describe the reasons for emotional trauma:
VIDEO: The Emotional Trauma Service Members Can Experience
The Emotional Trauma Service Members Can Experience
"There is no single reason for emotional trauma post-TBI, post-combat. It can range from depression to family readjustment."
Watch Dr. Hancock describe his own emotional trauma:
VIDEO: The Emotional Chaos of a Devastating Day
The Emotional Chaos of a Devastating Day
"Being in combat and losing fellow service members can feel like losing brothers emotions run high, nights go sleepless."
Treating Emotional Problems
Inform your patient that changes in emotions are common after a concussion/mTBI and that emotions usually return to normal with time.
- Encourage your patient to discuss his thoughts and feelings.
- Refer your patient to a behavioral health provider for psychotherapy or counseling, and to a psychiatrist if medication may be beneficial.
- Don't overlook the possibility that the patient's caregiver may also need psychological support.
- Concussions are often associated with other psychological health problems, such as anxiety or depression, and the veteran or service member may require specific treatment for those issues. Also, pain disorders or substance use disorders are commonly reported with individuals who have been diagnosed with concussion/mTBI and should be explored to see if they are contributing to the emotional picture.
Addressing Thoughts of Suicide
You should inquire about depression and suicidal ideation with any patient who has been deployed. Suicidal ideation should always be taken seriously. Notify your patient’s behavioral health provider if he/she expresses signs of depression or thoughts of suicide. Or call the VA's suicide hotline:
- Veterans Crisis Line: Dial 1-800-273-8255 and press 1.
Alternatively, report your patient to your emergency department, take your patient to the nearest emergency room, or call 911.
Watch Dr. Wendy Law as she asks a veteran with concussion/mTBI about suicidal thoughts:
VIDEO: Suicidal Ideation
During a case history, it is crucial to listen carefully to service members and vets about possible thoughts of suicide.
With Capt. J.L. Hancock, M.D., U.S. Navy
VIDEO: Final Thoughts
Watch Capt. J.L. Hancock share some final thoughts:
"Most of these patients have an excellent prognosis and don't need a referral to a specialist. What they need is someone like you "
Need More Information?
If you have questions that are not answered by this course, please feel free to contact Sherray L. Holland, PA-C, Neuroscience Clinical Advisor at the Defense and Veterans Brain Injury Center by email: