Clinical practice guideline: Management of Concussion/Mild Traumatic Brain Injury

Cifu, David X.; Hurley, Robin A.; Peterson, Michelle; Cornis-Pop, Micaela; Rikli, Patricia A.; Ruff, Robert L.; Scott, Steven; Sigford, Barbara; Silva, Kristin A.; Tortorice, Kathryn L.; Vanderploeg, Rodney D.; Withlock, Warren; Bowles, Amy O.; Cooper, Douglas; Drake, Angela; Engel, Charles C.

doi:10.1682/jrrd.2009.06.0076

Cited by 113 publications

(33 citation statements)

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“…The WHO task force team added the exclusion criteria that these abnormalities should not be due to alcohol or other recreational drugs, medications, systemic diseases, or extracranial injuries [12]. According to the US Department of Veterans Affairs (DVA) and the Department of Defense (DoD) guidelines, lesions identified by using structural imaging modalities such as magnetic resonance imaging (MRI) or CT suggest that the condition is more severe than mild [13].…”

Section: Biomarker In Mild Traumatic Brain Injurymentioning

confidence: 99%

Current State and Prospects of Development of Blood-based Biomarkers for Mild Traumatic Brain Injury

Lee

Seo

et al. 2017

Brain Neurorehabil

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Highlights• There are many unresolved clinical problems about mild traumatic brain injury (mTBI) such as a low sensitivity of standard neuroimaging studies, and absence of reliable predicting models.• It is very difficult to diagnose mTBI in symptomatic patients in the absence of witnesses, clear signs of head trauma, and abnormalities on neuroimaging.• Blood proteins have great potential as diagnostic and prognostic biomarkers of mTBI.• Technological advances in the targeted proteomics are expected to realize the clinical potential of blood-based protein biomarkers. ABSTRACTThe current understanding of the pathophysiology of mild traumatic brain injury (mTBI) is, without doubt, incomplete. Nevertheless, we tried to summarize the state-of-the-art explanation of how the brain is continuously injured even after a single impact. We also reviewed the real struggle of diagnosing mTBI, which culminated in showing the potential of blood-based biomarkers as an alternative or complementary way to overcome this difficulty. Pathophysiology of mTBI is subdivided into primary and secondary injuries. Primary injury is caused by a direct impact on the head and brain. Secondary injury refers to the changes in energy metabolism and protein synthesis/degradation resulting from the biochemical cascades as follows; calcium influx, mitochondrial dysfunction, fractured microtubules, and Wallerian degeneration, neuroinflammation, and toxic proteinopathy. Since the diagnosis of mTBI is made through the initial clinical information, it is difficult and inaccurate to diagnose mTBI without the absence of a witness or sign of head trauma. Blood-based biomarkers are expected to play an important role in diagnosing mTBI and predicting functional outcomes, due to their feasibility and the recent progress of targeted proteomics techniques (i.e., liquid chromatography tandem mass spectrometry [LC-MS/MS]).

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Section: Biomarker In Mild Traumatic Brain Injurymentioning

confidence: 99%

Current State and Prospects of Development of Blood-based Biomarkers for Mild Traumatic Brain Injury

Lee

Seo

et al. 2017

Brain Neurorehabil

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“…Reasons for the growing numbers of combat-related TBI are multifactorial, including increasingly large numbers of blast attacks, which are the most common etiology of TBI in the current war zones; improved body armor, resulting in improved survival rates; and better medical recognition of TBI [3]. Although TBI has been designated the "signature wound" of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) [1], wound characteristics are quite diverse and classified according to (1) whether or not the skull has been breached (penetrating vs nonpenetrating) and (2) the severity of the initial impairment (mild, moderate, or severe) [4][5][6][7][8]. Severity is typically determined by the presenting Glasgow Coma Scale (GCS), the duration of loss and alteration of consciousness, and posttraumatic amnesia (PTA), as well as the presence or absence of structural imaging findings (Table 1) [4,6,[8][9][10].…”

Section: Introductionmentioning

confidence: 99%

“…Although TBI has been designated the "signature wound" of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) [1], wound characteristics are quite diverse and classified according to (1) whether or not the skull has been breached (penetrating vs nonpenetrating) and (2) the severity of the initial impairment (mild, moderate, or severe) [4][5][6][7][8]. Severity is typically determined by the presenting Glasgow Coma Scale (GCS), the duration of loss and alteration of consciousness, and posttraumatic amnesia (PTA), as well as the presence or absence of structural imaging findings (Table 1) [4,6,[8][9][10]. Although mild TBI accounts for the majority of cases [4,11], its criteria are an active area of debate [12], which has diagnostic, treatment, and prognostic implications.…”

Section: Introductionmentioning

confidence: 99%

“…Severity is typically determined by the presenting Glasgow Coma Scale (GCS), the duration of loss and alteration of consciousness, and posttraumatic amnesia (PTA), as well as the presence or absence of structural imaging findings (Table 1) [4,6,[8][9][10]. Although mild TBI accounts for the majority of cases [4,11], its criteria are an active area of debate [12], which has diagnostic, treatment, and prognostic implications.…”

Section: Introductionmentioning

confidence: 99%

“…As such, we hypothesized that CLOX1 would correlate significantly with functional performance and that subjects with better functional status scores would have higher mean clock drawing performance. Considering the typically brief natural recovery time (e.g., hours to days) following mild TBI [4,12], as well as evidence that injury and/or subject characteristics such as comorbid psychological sequelae (e.g., PTSD anxiety and/or depression) can contribute to worsened neuropsychological [24] and/or functional status [1], we also examined our data for significant correlations between these characteristics and psychometric performance and functional status in an effort to mitigate potential confounding of results.…”

Section: Introductionmentioning

confidence: 99%

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Executive clock drawing correlates with performance-based functional status in people with combat-related mild traumatic brain injury and comorbid posttraumatic stress disorder

Writer

Schillerstrom

Regwan

et al. 2010

JRRD

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Abstract-Executive Clock Drawing Tasks (CLOX parts 1 and 2) can predict functional impairment. This study determined the correlation between CLOX and other psychometric screening instruments with the Structured Assessment of Independent Living Skills (SAILS)-defined performance-based functional status in people with combat-related mild traumatic brain injury (TBI) and comorbid posttraumatic stress disorder (PTSD). We hypothesized that CLOX would correlate significantly with functional performance. This prospective, crosssectional study design determined the correlation between a structured neuropsychological battery and functional status assessment. We calculated Pearson correlation coefficients between neuropsychological instruments and functional status scores. We entered neuropsychological measures correlating p < 0.1 with functional status into a linear regression model to determine independent contributions. Fifteen Operation Iraqi Freedom veterans participated. Only CLOX1 correlated significantly with functional competency and efficiency. Only mean CLOX1 scores were significantly lower in those scoring below the median for SAILS competency and in those scoring above the median for SAILS efficiency. CLOX1 contributed significant variance to functional status independent of mood or anxiety symptoms and was not affected by age or time since injury. Executive dysfunction per the brief, easily administered CLOX1 is sensitive to functional status following combatrelated mild TBI, independent of PTSD anxiety with or without depression.

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The Ritual of Hyperbaric Oxygen and Lessons for the Treatment of Persistent Postconcussion Symptoms in Military Personnel

Hoge

Jonas

2015

JAMA Intern Med

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During the past decade, unprecedented clinical and research resources have been directed toward addressing 2 conditions considered "silent" and "signature injuries" of the Iraq and Afghanistan wars, namely, posttraumatic stress disorder (PTSD) and concussion ( m i l d t r a u m a t i c b r a i n injury). This investment is increasingly paying dividends in knowledge and interventions that are changing the standards of clinical practice. Notable examples include emerging trauma-focused psychotherapies and the antihypertensive prazosin hydrochloride for PTSD. 1 However, along with these successes have also come seemingly promising interventions that in due course are shown to lack efficacy when tested in clinical trials such as the multicenter trial of risperidone augmentation for PTSD. 1 This issue of JAMA Internal Medicine publishes results of a clinical trial that illuminates the challenges in designing effective interventions for silent war-related injuries. 2 While the sample size was modest, this unique well-designed 3-arm double-blind study of hyperbaric oxygen (HBO) treatment provides compelling results with broad implications. Seventytwo service members who experienced concussions (including at least 1 concussion during war-zone deployment) and were having persistent postconcussion symptoms (≥4 months' duration) were randomized to receive 40 HBO treatments (100% oxygen at 1.5 atmospheres absolute for 60 minutes 5 days per week), a sham procedure (40 equivalent sessions involving slightly pressurized room air, sufficient to induce a feeling of inner ear pressure), or routine postconcussion care. Results showed that both the HBO and sham procedures were associated with significant improvements in postconcussion symptoms and secondary outcomes, including PTSD (which most participants had), depression, sleep quality, satisfaction with life, and physical, cognitive, and mental health functioning. However, there were no significant differences between HBO and the sham procedure, and change scores for all secondary outcomes favored sham.Although this trial was technically a pilot investigation designed to produce data necessary for a pivotal study and will not likely end debate on this topic (given tenacious advocacy by HBO proponents 3 ), these results are consistent with 2 other sham-controlled clinical trials among service members and veterans involving a range of HBO doses. 2 Given the outstanding methods, consistency in results, and lack of dose response across these studies, it is increasingly hard to argue that a phase 3 trial of HBO for the treatment of postconcussion symptoms (or PTSD) is warranted.

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Clinical practice guideline: Management of Concussion/Mild Traumatic Brain Injury

Cited by 113 publications

References 0 publications

Current State and Prospects of Development of Blood-based Biomarkers for Mild Traumatic Brain Injury

Current State and Prospects of Development of Blood-based Biomarkers for Mild Traumatic Brain Injury

Executive clock drawing correlates with performance-based functional status in people with combat-related mild traumatic brain injury and comorbid posttraumatic stress disorder

The Ritual of Hyperbaric Oxygen and Lessons for the Treatment of Persistent Postconcussion Symptoms in Military Personnel

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