Management of traumatic brain injury (TBI) is often focused on reducing the injury related to identifiable abnormalities seen on brain imaging studies. However, increasing awareness of the microscopic damage incurred in mild TBI has brought new and evolving treatment protocols to this condition, which had been largely ignored until relatively recently. 

Clinical evaluation of mild traumatic brain injury

A careful history of neuropsychiatric symptoms combined with a neurological examination and an evaluation of cognitive function is a large part of the diagnosis of mild TBI. Subtle neuropsychiatric sequelae of mild TBI include difficulty concentrating, depression, agitation, anxiety, irritability, and trouble sleeping. Persistent head or neck pain without supportive imaging pathology is common among individuals who have suffered from TBI. Focal deficits on neurological examination may be present with TBI, but are not characteristics of mild TBI.

Treatment of mild traumatic brain injury 

Currently there is no pharmacologic or surgical treatment for mild TBI. Symptomatic treatment of pain or sleeping problems is typically reduced over time as patients recover. The prognosis of mild TBI is good, with resolution over 6-12 months for most individuals who are otherwise healthy. 

Controversies in the management of mild traumatic brain injury  

The approach to medical management of mild TBI has largely involved conservative observation paired with avoiding activities that are likely to lead to repeated head injury. 

Physical and cognitive rest is often recommended after mild TBI. While prevention of further head trauma and brain injury is undoubtedly beneficial, it is unclear whether physical or cognitive inactivity is inherently beneficial. A standard approach to the management of mild TBI, rest, has not been proven to be beneficial, and some articles in the medical literature suggest that it may, in fact, be counterproductive for recovering patients. Overall, in healthy individuals of all ages, the practice of using cognitive skills to solve tasks of progressively increasing difficulty is known to sharpen thinking ability. The question of whether cognitive rest could result in the weakening of cognitive skills has not been a studied in the management of mild TBI. Currently, there are not uniform guidelines for duration or extent of cognitive rest after mild TBI. While there is scant data on the impact of physical and cognitive rest, there is no evidence to support the suggestion that cognitive rest is detrimental or helpful in the recovery of mild TBI either.

How important do you consider cognitive rest in the management of your patients with TBI? How long do you recommend cognitive rest in patients who have mild TBI?

References:

Johnson RS, et al. The effect of cognitive rest as part of post-concussion management for adolescent athletes: a critically appraised topic. J Sports Rehab. 2016 Feb 26.

Agrawal S, Branco RG. Neuroprotective measures in children with traumatic brain injury. World J Crit Care Med. 2016 Feb 4.