Mild Traumatic Brain Injury Rehabilitation

  • Bruno S. Subbarao
  • Rebecca N. Tapia
  • Blessen C. Eapen


Mild traumatic brain injury (or concussion) is fairly common in both civilian and military populations. Acute assessment for red flag symptoms is essential in the immediate period to determine the need for higher-level care. Although the natural course of concussion tends to resolve in a matter of days to weeks, some individuals will have persistent cognitive, physical, or behavioral symptoms. Symptom management, education, and reassurance are the current mainstay of treatment as the management of this condition continues to evolve rapidly. Return to play/activity guidelines are available to develop a stepwise progression to symptom-free activity.


Concussion Mild traumatic brain injury Rehabilitation Post-concussion syndrome Second impact syndrome Post-traumatic headaches 


  1. 1.
    Management of Concussion/mTBI Working Group. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. J Rehabil Res Dev. 2009;46:CP1–68.CrossRefGoogle Scholar
  2. 2.
    Menon DK, Schwab K, Wright DW, Maas AI. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil. 2010;91:1637–40.CrossRefGoogle Scholar
  3. 3.
    Carroll L, Cassidy JD, Peloso P, Borg J, von Holst H, Holm L, Paniak C, Pépin M. Prognosis for mild traumatic brain injury: results of the who collaborating centre task force on mild traumatic brain injury. J Rehabil Med. 2004;36:84–105.CrossRefGoogle Scholar
  4. 4.
    Cernak I, Noble-Haeusslein LJ. Traumatic brain injury: an overview of pathobiology with emphasis on military populations. J Cereb Blood Flow Metab. 2010;30(2):255–66.CrossRefGoogle Scholar
  5. 5.
    CDC – Traumatic Brain Injury – Injury Center. Accessed 5 Feb 2014.
  6. 6.
    TBI: Get the Facts|Concussion|Traumatic Brain Injury|CDC Injury Center. Accessed 26 Nov 2016.
  7. 7.
    DoD Worldwide Numbers for TBI|DVBIC. Accessed 2 Apr 2013.
  8. 8.
    Helmick KM, Spells CA, Malik SZ, Davies CA, Marion DW, Hinds SR. Traumatic brain injury in the US military: epidemiology and key clinical and research programs. Brain Imaging Behav. 2015;9:358–66.CrossRefGoogle Scholar
  9. 9.
    Su JK, Ramirez JF. Management of the athlete with concussion. Perm J. 2012;16:54–6.CrossRefGoogle Scholar
  10. 10.
    Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Palm M, TC VML, National Athletic Trainer’s Association. National Athletic Trainers’ association position statement: management of sport concussion. J Athl Train. 2014;49:245–65.CrossRefGoogle Scholar
  11. 11.
    Hyden J, Petty B. Sideline management of concussion. Phys Med Rehabil Clin N Am. 2016;27:395–409.CrossRefGoogle Scholar
  12. 12.
    Bainbridge J, Khirwadkar H, Hourihan MD. Vomiting – is this a good indication for CT head scans in patients with minor head injury? Br J Radiol. 2012;85:183–6.CrossRefGoogle Scholar
  13. 13.
    Hoffmann M, Lefering R, Rueger JM, Kolb JP, Izbicki JR, Ruecker AH, Rupprecht M, Lehmann W, Trauma Registry of the German Society for Trauma Surgery. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg. 2012;99(Suppl 1):122–30.CrossRefGoogle Scholar
  14. 14.
    Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, Draviam S, Wells GA. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center. Acad Emerg Med Off J Soc Acad Emerg Med. 2012;19:2–10.CrossRefGoogle Scholar
  15. 15.
    Stiell IG, Clement CM, Grimshaw JM, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ Can Med Assoc J J Assoc Medicale Can. 2010;182:1527–32.CrossRefGoogle Scholar
  16. 16.
    Coldren RL, Kelly MP, Parish RV, Dretsch M, Russell ML. Evaluation of the military acute concussion evaluation for use in combat operations more than 12 hours after injury. Mil Med. 2010;175:477–81.CrossRefGoogle Scholar
  17. 17.
    Stone ME, Safadjou S, Farber B, Velazco N, Man J, Reddy SH, Todor R, Teperman S. Utility of the military acute concussion evaluation as a screening tool for mild traumatic brain injury in a civilian trauma population. J Trauma Acute Care Surg. 2015;79:147–51.CrossRefGoogle Scholar
  18. 18.
    Kelly MP, Coldren RL, Parish RV, Dretsch MN, Russell ML. Assessment of acute concussion in the combat environment. Arch Clin Neuropsychol Off J Natl Acad Neuropsychol. 2012;27:375–88.CrossRefGoogle Scholar
  19. 19.
    Reeves DL, Winter KP, Bleiberg J, Kane RL. ANAM genogram: historical perspectives, description, and current endeavors. Arch Clin Neuropsychol Off J Natl Acad Neuropsychol. 2007;22(Suppl 1):S15–37.CrossRefGoogle Scholar
  20. 20.
    McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport – the 4th international conference on concussion in sport held in Zurich, November 2012. Clin J Sport Med Off J Can Acad Sport Med. 2013;23:89–117.CrossRefGoogle Scholar
  21. 21.
    Okonkwo DO, Tempel ZJ, Maroon J. Sideline assessment tools for the evaluation of concussion in athletes: a review. Neurosurgery. 2014;75(Suppl 4):S82–95.CrossRefGoogle Scholar
  22. 22.
    Yengo-Kahn AM, Hale AT, Zalneraitis BH, Zuckerman SL, Sills AK, Solomon GS. The sport concussion assessment tool: a systematic review. Neurosurg Focus. 2016;40:E6, 1–14.CrossRefGoogle Scholar
  23. 23.
    Bin Zahid A, Hubbard ME, Dammavalam VM, et al. Assessment of acute head injury in an emergency department population using sport concussion assessment tool – 3rd edition. Appl Neuropsychol Adult. 2016;1–10.Google Scholar
  24. 24.
    McCrea M, Guskiewicz K, Randolph C, Barr WB, Hammeke TA, Marshall SW, Powell MR, Woo Ahn K, Wang Y, Kelly JP. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J Int Neuropsychol Soc JINS. 2013;19:22–33.CrossRefGoogle Scholar
  25. 25.
    Cassidy JD, Cancelliere C, Carroll LJ, et al. Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the international collaboration on mild traumatic brain injury prognosis. Arch Phys Med Rehabil. 2014;95:S132–51.CrossRefGoogle Scholar
  26. 26.
    Wäljas M, Iverson GL, Lange RT, Hakulinen U, Dastidar P, Huhtala H, Liimatainen S, Hartikainen K, Öhman J. A prospective biopsychosocial study of the persistent post-concussion symptoms following mild traumatic brain injury. J Neurotrauma. 2015;32:534–47.CrossRefGoogle Scholar
  27. 27.
    Management of Concussion-mild Traumatic Brain Injury (mTBI) (2016) – VA/DoD Clinical Practice Guidelines. Accessed 26 Nov 2016.
  28. 28.
    Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia Int J Headache. 2013;33:629–808.CrossRefGoogle Scholar
  29. 29.
    Theeler B, Lucas S, Riechers RG, Ruff RL. Post-traumatic headaches in civilians and military personnel: a comparative, clinical review. Headache. 2013;53:881–900.CrossRefGoogle Scholar
  30. 30.
    Lucas S. Headache management in concussion and mild traumatic brain injury. PM R. 2011;3(10 Suppl 2):S406–12. CrossRefGoogle Scholar
  31. 31.
    Karr JE, Areshenkoff CN, Garcia-Barrera MA. The neuropsychological outcomes of concussion: a systematic review of meta-analyses on the cognitive sequelae of mild traumatic brain injury. Neuropsychology © 2013 American Psychological Association. 2014;28:(3)321–36.Google Scholar
  32. 32.
    Turner-Stokes L, Pick A, Nair A, Disler PB, Wade DT. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database Syst Rev. 2015;CD004170.Google Scholar
  33. 33.
    Dougall D, Poole N, Agrawal N. Pharmacotherapy for chronic cognitive impairment in traumatic brain injury. Cochrane Database Syst Rev. 2015;CD009221.Google Scholar
  34. 34.
    Flynn FG. Memory impairment after mild traumatic brain injury. Contin Minneap Minn. 2010;16:79–109.Google Scholar
  35. 35.
    Cooper DB, Bowles AO, Kennedy JE, Curtiss G, French LM, Tate DF, Vanderploeg RD. Cognitive rehabilitation for military service members with mild traumatic brain injury: a randomized clinical trial. J Head Trauma Rehabil. 2016.
  36. 36.
    Chamelian L, Feinstein A. Outcome after mild to moderate traumatic brain injury: the role of dizziness. Arch Phys Med Rehabil. 2004;85:1662–6.CrossRefGoogle Scholar
  37. 37.
    Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011;39:2311–8.CrossRefGoogle Scholar
  38. 38.
    Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sports Med. 2015;34:213–31.CrossRefGoogle Scholar
  39. 39.
    Bland DC, Zampieri C, Damiano DL. Effectiveness of physical therapy for improving gait and balance in individuals with traumatic brain injury: a systematic review. Brain Inj. 2011;25:664–79.CrossRefGoogle Scholar
  40. 40.
    Pavlou M, Davies RA, Bronstein AM. The assessment of increased sensitivity to visual stimuli in patients with chronic dizziness. J Vestib Res Equilib Orientat. 2006;16:223–31.Google Scholar
  41. 41.
    Hoffer ME, Gottshall KR, Moore R, Balough BJ, Wester D. Characterizing and treating dizziness after mild head trauma. Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol. 2004;25:135–8.CrossRefGoogle Scholar
  42. 42.
    Ouellet M-C, Savard J, Morin CM. Insomnia following traumatic brain injury: a review. Neurorehabil Neural Repair. 2004;18:187–98.CrossRefGoogle Scholar
  43. 43.
    Castriotta RJ, Wilde MC, Lai JM, Atanasov S, Masel BE, Kuna ST. Prevalence and consequences of sleep disorders in traumatic brain injury. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med. 2007;3:349–56.Google Scholar
  44. 44.
    Babson KA, Blonigen DM, Boden MT, Drescher KD, Bonn-Miller MO. Sleep quality among U.S. military veterans with PTSD: a factor analysis and structural model of symptoms. J Trauma Stress. 2012;25:665–74.CrossRefGoogle Scholar
  45. 45.
    Wilde MC, Castriotta RJ, Lai JM, Atanasov S, Masel BE, Kuna ST. Cognitive impairment in patients with traumatic brain injury and obstructive sleep apnea. Arch Phys Med Rehabil. 2007;88:1284–8.CrossRefGoogle Scholar
  46. 46.
    Mahmood O, Rapport LJ, Hanks RA, Fichtenberg NL. Neuropsychological performance and sleep disturbance following traumatic brain injury. J Head Trauma Rehabil. 2004;19:378–90.CrossRefGoogle Scholar
  47. 47.
    Ponsford JL, Ziino C, Parcell DL, Shekleton JA, Roper M, Redman JR, Phipps-Nelson J, Rajaratnam SMW. Fatigue and sleep disturbance following traumatic brain injury – their nature, causes, and potential treatments. J Head Trauma Rehabil. 2012;27:224–33.CrossRefGoogle Scholar
  48. 48.
    Larson EB, Zollman FS. The effect of sleep medications on cognitive recovery from traumatic brain injury. J Head Trauma Rehabil. 2010;25:61–7.CrossRefGoogle Scholar
  49. 49.
    Bey T, Ostick B. Second impact syndrome. West J Emerg Med. 2009;10:6–10.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Cantu RC. Second-impact syndrome. Clin Sports Med. 1998;17:37–44.CrossRefGoogle Scholar
  51. 51.
    McCrory P. Does second impact syndrome exist? Clin J Sport Med Off J Can Acad Sport Med. 2001;11:144–9.CrossRefGoogle Scholar
  52. 52.
    McCulloch KL, Goldman S, Lowe L, Radomski MV, Reynolds J, Shapiro R, West TA. Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers. J Head Trauma Rehabil. 2015;30:56–67.CrossRefGoogle Scholar
  53. 53.
    Conaton E. DoD policy guidance for management of mild traumatic brain injury/concussion in the deployed setting. Wash. DC Dep. Def. 2012.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Bruno S. Subbarao
    • 1
  • Rebecca N. Tapia
    • 2
    • 3
  • Blessen C. Eapen
    • 3
    • 4
  1. 1.Polytrauma / Transition and Care Management ProgramsPhoenix VA Health Care SystemPhoenixUSA
  2. 2.Polytrauma Network Site, South Texas Veterans Health Care SystemSan AntonioUSA
  3. 3.Department of Rehabilitation MedicineUniversity of Texas Health Science Center San AntonioSan AntonioUSA
  4. 4.Polytrauma Rehabilitation Center, South Texas Veterans Health Care SystemSan AntonioUSA

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