Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8(3), 86-87.

A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following:

1. any period of loss of consciousness;
2. any loss of memory for events immediately before or after the accident;
3. any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused);
   focal neurological deficit(s) that may or may not be transient but where the severity of the injury does not exceed the following:
   a. loss of consciousness of approximately 30 minutes or less;
   b. after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and
   c. posttraumatic amnesia (PTA) not greater than 24 hours.

• Determine whether or not consciousness was lost

• Determine the duration (or estimate) of loss of consciousness

• Determine whether there was an alteration of consciousness (dazed, stunned, confused)

• Determine duration of altered consciousness

• Characterize, in detail, the specifics of how the injury occurred

• Document key information pertaining to the biomechanics of the injury (amount of force, rotatory forces present, accompanied by fall, size and speed of vehicles or objects struck by or against, damage to vehicles or objects struck by or against, detail all other bodily injuries sustained)

• Determine the history of previous head injury or concussion by interview with the patient and family

• Determine previous alcohol use

• Determine previous substance use

• Determine previous vocational pursuits, positions, and durations

• Determine previous leisure pursuits, to include hobbies, athletics, and other recreational pursuits

• Determine and, if possible, obtain academic record and rule out pre-existence of attention deficit disorder or learning disabilities

• Determine social/legal history

• The term "concussion" should be avoided and replaced with the term "mild traumatic brain injury" (MTBI) (American Congress of Rehabilitation Medicine, 1992[3])

• Determine current sleep patterns time to bed, time to sleep, times awake, activities during wakefulness, rise time, and restedness upon awakening
• Determine dietary habits
• Determine exercise routine
• Determine caffeine and nicotine usage and chronicle any changes since injury
• Determine past medical history
• Determine family medical history
• Determine past medications
• Determine current medications; chronicle changes in medications
• Check neuroendocrine function: FSH, LH, IGF-1, T3, T4, TSH, free testoserone, total testoserone, estradiol, progesterone, cortisol
• Check for hypercholsteremia, weight gain and exercise intolerance
• Correlate symptomatology with medications. Review possible side effects. Determine use of over-the-counter medications/vitamins/supplements
• Review EEG's
• Review CT and MRI scans of the head. Note MRI strength. Review sinuses
• Review skull x-rays
• Review cervical x-rays, CT's, and MRI's
• Review headache history. Characterize headaches to differentiate for sinusitis, tension, TMJ dysfunction, medication/substance withdrawal, migraine. Headaches should be fully characterized and described
• Characterize and describe all visual complaints. Differentiate blurred vision from diplopia. Evaluate visual fields and ocular motor skills. Determine presence of photophobia, image suppression, image persistence
• Characterize and describe all pain complaints as well as past/current treatments for same
• Characterize complaints of dizziness, imbalance, and dyscoordination
• Evaluate balance by protected single-foot standing, Romberg, star-march
• Evaluate history of balance in low-light conditions
• Evaluate for perilymphatic fistula, cupulolithiasis, and cervical dizziness
• Evaluate cardiac status and serum glucose levels as possibly contributory to dizziness.
• Review ENG's

Characterize the individual's daily routine.

• Fully describe the individual's vocational history

• Fully describe the individual's current job description. Include whether or not the work is full-time, part-time, seasonal

• Determine the presence or absence of a supplemental disability insurance income

• Determine workers' compensation TD payment level

• Determine presence of salary continuation agreement

• Determine status vs. wage loss compensation

• Evaluate for anxiety, depression, panic attacks, somatization, hypochondriasis, malingering
• Evaluate for issues of secondary gain
• Evaluate for family system adaptation/adjustment
• Differentiate psychiatric symptoms from iatrogenic or seizure-induced symptoms

• Evaluate for overall fitness and conditioning, muscular strength, range of motion, sensation, proprioception
• Characterize pain complaints
• Balance/coordination diagnostics

Tests to be considered: MMPI-II, Beck's Depression Inventory, Taylor-Johnson Temperament Analysis, FIRO-B, Woodcock-Johnson Psychoeducational Battery, Detroit Tests of Learning Aptitudes, Booklet Category Test, Wisconsin Card Sort, Trails-A & B, Neuropsychological Battery, Wide Range Achievement Test, Motor Free Visual Perception Test, Test of Visual Perception Skills, and the Santa Clara Valley Perceptual Motor Evaluation.

• Review pain medications to avoid medications which can cause dependence or rebound headache.

• Avoid over the counter medications that contain caffeine such as Excedrin, Anacin.

• Gradually reduce caffeine intake, in particular, for individuals with irritability or sleep disruption.

• Consider short-term (90-120 days) utilization of stimulant therapy. This is particularly useful in cases where speed of processing is demonstrated to be delayed or slowed. Ritalin can be particularly effective, initiating therapy at 10 mg. at 8:00 a.m. for 3-4 days, progressing to 10 mg. at 8:00 a.m. and 10 mg. at noon, progressing to 20 mg. at 8:00 a.m. and 10 mg. at noon, progressing to 20 mg. at 8:00 a.m. and 20 mg. at noon for a period of approximately 90 days. The medication should be tapered in a schedule similar to initiating therapy.

• Anti-anxietals should be systematically weaned. Anti-depressant therapies can be considered. Preferential response seems related to serotonergic medications. Consider changing dosage to before bed should undue daytime sedation occur with serotonergic medications.

• Pharmacological assistance to re-establish sleep patterns can be used on a short-term basis. Medications such as Restoril and Ambien can be used and should be tapered prior to discontinuation. Total days used should be less than two weeks. A program should be initiated for sleep education and return to normal sleep cycle and pattern. Naps should be tapered when attempting to re-establish a normal sleep cycle. Regular bedtime and rise-time should be utilized. The individual should be counseled to remain in bed with the lights off if they awaken during the night. An individual awakened by dream activity may be advised to utilize a low sodium diet and ample hydration prior to bed time. Individuals whose sleep is disrupted for urination can be counseled to restrict fluids two hours prior to bed time, emptying the bladder prior to retiring. Use an alarm clock to ensure a consistent and routine rise time should be encouraged. Exercise in the early portion of the day should be undertaken to increase physical conditioning. Exercise in the evening hours should be avoided.

• Complaints of parathesias or radiculopathy should be evaluated via sophisticated imaging of the cervical region or appropriate thoracic/lumbar region

• Headache management should be conducted following careful differentiation of potential etiologies with appropriate consults for headaches arising from sinusitis, temporomandibular joint dysfunction, or cervical strain/sprain. Additionally, the contribution of vestibular hypersensitivity to increased tension in the cervical musculature should be considered. Long-standing cervical strain/sprain is often associated with temporomandibular joint dysfunction and headache as a symptom triad. Consideration should be given to augmenting the above treatments with relaxation, visual imagery, or hypnotherapy.

• Medications for dizziness, such as Antivert, should be avoided wherever possible. Instead, physical therapy for treatment of vestibular hypersensitivity should be undertaken with medication provided which is comfort-oriented, such as for nausea. In extreme cases, utilization of medications such as Antivert may be necessary and should be used on a tapering basis in conjunction with treatment for vestibular hypersensitivity.

• Careful neuro-ophthalmologic evaluation should be undertaken for complaints of visual blurring, double vision, difficulty reading, etc. Diplopia should be measured with documentation of the divergence in prism diopters, nystagmus should be characterized, oculomotor pursuits should be characterized, visual fields and visual acuity should be characterized. Referral should be made to occupational therapy or visual therapy for addressing oculomotor deficits which result in deficits in saccades, pursuits, or diplopia. Patching should be avoided. Use of prism lenses, on a graduated basis, can be helpful. Strabismus repair surgeries should be avoided until at least one year post injury and until no further progression is seen in resolution of ocular divergence. Should strabismus repair be undertaken, this is best accomplished with adjustable sutures. The need to undertake these surgeries is rare in post-concussion syndrome.

• Referral should be made to physical therapy to increase flexibility and mobility, improve strength, improve cardiorespiratory endurance, improve muscular endurance, improve range of motion, decrease pain, and treat vestibular hypersensitivity. Physical therapy should carefully evaluate sleep positions in cases involving back pain. A routine exercise program to improve physical conditioning should be undertaken. If sleep problems exist, every effort should be made to undertake the exercise routine at times other than the evening hours.

• Musculo-skeletel pain should be aggressively managed by modalities such as mobilization, heat/cold, ultrasound, regional anethesia, hypnotherapy induced glove anethesia, biofeedback, non-opoid analgesics and muscle relaxants.

• The treating physician's goal should be to gradually progress to no long-term medications, with possible exception of antidepressant or mood-altering medications (Lithium) in individuals with a pre-injury chronic condition or anticonvulsants in individuals with a seizure disorder. This does not preclude long-term use of chronic medications such as antihypertensives, etc., when used for those conditions. Any hypertensive used for behavioral dyscontrol should be weaned. Regional anesthesia combined with physical/occupational therapy is often preferred to avoid iatrogenic complication. Opoid analgesics should only be used as a last result.

• The individual should be referred to treatment designed to improve ability to maintain focus of attention, ability to shift focus of attention, ability to maintain vigilance, perceptual feature identification, categorization, cognitive rigidity, cognitive flexibility, and speed of processing.

• Attempts should be undertaken to understand the relative etiological contribution to decreased cognitive function of neurological damage versus psychological/emotional disturbances such as anxiety and depression.

Education should be provided to the family regarding all deficits and their relationship to the concussive injury. The family should be educated regarding the importance of all interventions and the relationship of the interventions to each other. Family must understand the role of medications and substances, both beneficial and detrimental. Family systems should be evaluated and counseling provided for families as well as injured individuals for purposes of this educational process and adjustment to abrupt changes in routines and lifestyles.

• Psychiatric/psychological diagnoses should be made carefully, ruling out the influence of medications, sleep disturbance, complex partial seizure disorders, and pre-injury personality characteristics. Counseling efforts should be routine for purposes of education and adjustment to changes in routine, lifestyle, vocation, family, etc. Counseling should address issues of sexual performance from an educational perspective. Reduction in male libido is often related to emotional or neuroendocrine issues while difficulties such as inability to maintain erection may be related to attentional deficits and/or depression.

• The therapist should ensure a gradual return to a normal pre-injury lifestyle and routine prior to discontinuation of treatment.

• It may be necessary to undertake hypotherapy, systematic desensitization approaches, relaxation approaches, hypnotherapies, rational emotive therapy, or biofeedback, in isolation or in tandem.

• Education should be given regarding the cumulative nature of mild traumatic brain injury and counsel should be given to avoid engaging in activities which will potentially result in additional injuries.

Return to vocational involvement is most often possible; however, must be undertaken only following resolution of problems in all other areas. Return to work should be graduated from part time to full time and should be supervised by a competent vocational rehabilitation counselor who will observe job performance regularly, meet with the injured worker regularly, and meet with the employer regularly. Utilization of a job coach to assist with initial placement should be considered. The contact should be three times per week, at a minimum. Job modifications and/or work place modifications may be advisable for those individuals having suffered olfactory loss.

Careful comparison to pre-injury academic skill sets should be made and a determination of congruences with vocational accomplishments and aptitudes should be conducted. Attention should be paid to abilities in iconic store, echoic store, visual, attentional vigilance, reading comprehension, reading speed, and mathematical computational abilities.

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