TBI Awareness Month: Observations from a Concussion Clinic Chief

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Munson Army Health Center Public Affairs

Written by Dr. Patrick Armistead-Jehle, Chief, Concussion Clinic, Munson Army Health Center

FORT LEAVENWORTH, Kansas — Traumatic brain injuries (TBIs) have garnered a notable amount of media attention, particularly over about the last decade. I have been engaged in the care and research of this injury for the better part of my 20 plus years of doctoring. As March is TBI awareness month, I wanted to pass along several observations.

Not all brain injuries are created equal

At the most elementary level, TBIs are divided into severity based on how long one is knocked out or how long one has a lack of memory after the injury event — a state called post traumatic amnesia. The least severe level is termed a mild TBI, which is also known as a concussion. The projected outcome following a TBI is heavily influenced by the initial severity of injury. For prognostic and treatment purposes, it is important to consider the severity of TBI.

TBIs are fairly common injuries, within and outside of the military

Since 2000 there have been nearly 500,000 reported TBIs among military personnel. The vast majority of these (82%) are categorized as mild TBIs (a.k.a. concussions). Among civilians the Brain Injury Association of American estimates that there are nearly 3 million TBIs a year in the U.S, with the majority of these again being considered mild in severity.

One does not need to be knocked out to have had a concussion

The diagnosis of and the recognition that one has experienced a concussion is certainly made easier if the recipient loses consciousness. However, an alteration of consciousness after an external blow to the head, blast exposure, or rapid acceleration and deceleration of the head (such as a whiplash injury) qualifies for a concussive injury. Phrases such as “seeing stars,” “feeling dazed and confused,” or “clearing out the cobwebs” are all euphemisms that described this experience.

Symptoms can be wide ranging and can vary from person to person.

I like to think of concussive symptoms as falling into three general categories: (1) Physical (e.g., headaches, dizziness, vertigo, insomnia, visual tracking problems); (2) cognition (e.g., poor memory, inattention, slowed processing speed); and (3) emotional (e.g., anxiety, irritability, depression). The mix of symptoms can be different from person to person and even within the same person with different injuries. However, these generally develop quickly after the injury.

The vast majority will experience a full recovery

The exact time frame for recovery depends on a number of factors, but most people with this severity of injury get better within a few days to at most a few months. Of note, recovery following a moderate to severe brain injury (which is not considered a concussion) can last longer and the probability of long-standing residual symptoms is higher.

Appropriate management of the concussive injury is essential to optimized outcomes

While most of those who experience a concussion will recover, management of this injury via a medical professional is incredibly important. The primary mechanism of this management is a graded return to physical and cognitive activities. In the past, many health care providers (and well-meaning care takers) would recommend “cocooning therapy”, which essentially equated to the patient being told to stay alone in a dark room with minimal stimulation until the concussive symptoms had abated. This has proven to be a rather ineffective treatment strategy. Current treatment starts with something akin to this, but within a day or two increasing activity levels are prescribed. Outcomes are optimized with such a protocol and within military medicine we call this the Progressive Return to Activities (PRA). This is often done with adjunctive symptom management, but the PRA is the core of a concussion treatment plan.

For those in the military, it is medically mandated to present for evaluation following a suspected concussion

Frequently, the military mind set to ‘drive on’ prevents a service member from seeing a health care provider after a possible concussive injury. However, current policy dictates such evaluation, which should be initiated by the individual service member or leadership. Primary among the reasons for such an evaluation is to prevent a repeat injury while one is still in recovery from the initial concussion. Such an event will almost certainly result in a protracted period of recovery.

When it comes to the long-term outcomes of repeated concussions (to include sub-concussive exposures), the media is way in front of the science.

One can scarcely turn on the news these days without seeing a reference to the purported dire long term neurologic consequences of repeated brain injuries. Simply stated, at present, there is more we don’t know than we do about this topic. Personally, I agree it is a bad idea to keep having brain injuries and if this situation can be prevented, one should. However, the notion that everyone who has had a history of concussions is destined to develop a crippling neurodegenerative disease is not supported by the current research. At present, the best advice I can give to those who have a history of repeat concussion and are concerned about such an outcome is to visit their primary care provider. Frequently, comorbid medical conditions can be addressed in primary care (or with a referral to a brain health specialist) that can improve the chances of optimizing current functioning and cerebral heath with age.