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Three Part Question

For [adults or children presenting to the emergency department following a mild traumatic brain injury] is [there evidence for any interventions] to reduce [the incidence, severity and/or duration of post-concussion syndrome or symptoms?]

Clinical Scenario

A patient has attended the Emergency Department following a head injury. They have had a normal CT head scan and are going to be discharged, however they still have a headache. You are concerned they are at risk for post concussion syndrome and wish to know if there are any interventions that may benefit them?

Search Strategy

Prior systematic review search updated based on Eliyahu L, et al The Effectiveness of Early Educational Interventions in the Emergency Department to Reduce Incidence or Severity of Postconcussion Syndrome Following a Concussion: A Systematic Review. Acad Emerg Med. 2016;23(5):531-542.
(concuss* or brain injur* or commotio cerebri or head injur* or brain trauma* or head trauma* or postconcuss* or craniocerebral trauma or craniocerebral injur*) AND (er or emergency or emergency medical services or emergency medicine or emergency nursing or emergency department or ED) AND (patient or patients or discharge or exit or self care or consumer participation or self manag*) AND (educat* or teach* or instruct* or advice or advise or pamphlet* or brochure* or kiosk* or intervention*) AND (followup or follow up or re-check or outcomes)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mittenberg W 1996 USA	Cognitive-behavioural prevention of postconcussion syndrome. Intervention Arm 1 – routine discharge instructions Arm 2 – printed manual and meeting with therapist prior to discharge to explain PCS	RCT (single blind)	Follow-up at 6 months Symptom number Symptom duration	Patients in arm 2 reported significantly fewer symptoms and duration when follow-up at 6 months.	Small number (n = 29 each arm). Old study (1996) and so the information given is out of date with current understanding. Single center
Ponsford J 2002 Australia	>15 years Consecutive presentations to an ED with mild TBI. None of the patients required or underwent CT scanning.	RCT N= 262 Arm 1 – contacted with 48 hours and seen at 5 to 7 days after injury. Given information about PCS. Arm 2 – no information booklet, standard treatment	Assessment at 3 months. symptom checklist-90-revised (SCL-90-R) Holmes Rahe survey of recent experiences. post-concussion syndrome checklist.	Patients in the intervention group reported significantly fewer symptoms and were significantly less stressed at 3 months after injury.	Large loss to follow-up (62% returned) Old study (2002) and so the information given is out of date with current understanding. Two centers
Bell KR et al 2008 USA	>15 years Presented to an ED within 48 hours of injury GCS 13 to 15	RCT Arm 1 (n=195) – usual care Arm 2 (n = 171) Telephone counselling (5 calls) Arm 3 – pamphlet was combined with arm 1 midway	Followed-up at 6 months	Posttraumatic symptom composite: significant improrvement. General health composite: No difference Significantly improved in these symptoms: Fatigue Trouble sleeping Sexual difficulties Function at work Function in recreation Memory and concentration Financial independence	Groups were not balanced on some key characteristics Eg intervention group more patients with GCS 15 Single center Trial changed midway from 3 to 2 groups due to enrolment problems
de Kruijk JR et al. 2002 Netherlands	>15 years Presentation to ED within 6 hours mTBI GCS 14 to 15 Absence of extracranial injury	RCT Arm 1 (n = 54). No rest Arm 2 (n = 53). Advised to rest for 6 days	Followed up at 2 weeks, 3 months and 6 months Severity of postconsussion symptoms and Quality of life measures	6 full days of bed rest had no “beneficial effect on the severity of posttraumatic complaints or on general health status (SF-36) at 6 mo after mTBI.	Contamination in arms (ie many of those in arm 1 rested and vice versa) Biased selection of patients (convenience sample) Differing follow-up rates (87% full bed rest) and 61% in no bed rest
Matuseviciene G et al. 2013 Sweden	16 to 70 years Presentation to ED within 24 hours GCS 14 to 15	RCT Arm 1 (n = 48) Seen in person. Arm 2 (n = 49) Routine Rx including written information Randomized 10 days after injury	Rivermead Post-concussion symptom questionnaire	No differences found	Biased population recruited (younger patients and men tended to decline participation)

Comment(s)

This is a large population of patients with a significant burden of injury for which the ED visit is often the only health care received. Gaining more evidence about how to manage patients in the acute phase to prevent long-term sequelae could have a significant benefit for patients after mild TBI.

Clinical Bottom Line

There is limited evidence concerning interventions to aid recovery following mild traumatic brain injury, benefit has been shown to psychological follow up of patients following injury .

References

1. Mittenberg W Cognitive-behavioral prevention of postconcussion syndrome. Archives of clinical neuropsychology 1996;11(2):139-45.
2. Ponsford J Impact of early intervention on outcome following mild head injury in adults. Journal of Neurology Neurosurgery and Psychiatry. 2002;73(3):330-332.
3. Bell KR et al The effect of telephone counselling on reducing posttraumatic symptoms after mild traumatic brain injury: a randomised trial Journal of Neurology Neurosurgery and Psychiatry. 2008;79:1275–81.
4. de Kruijk JR et al Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest Journal of Neurology Neurosurgery and Psychiatry. 2002;73:167–72.
5. Matuseviciene G Early intervention for patients at risk for persisting disability after mild traumatic brain injury: a randomized, controlled study Brain Injury 2013;27:318–24.