Medical Treatment of Traumatic Brain Injury
Our traumatic brain injury lawyers have represented thousands of people with TBIs over the past 25 years. One unique part of representing people with traumatic brain injuries is that every person's TBI will present differently in terms of the person's symptoms. This requires a variety of treating doctors and expert witnesses to help our clients based on their specific needs. Our expertise in traumatic brain injury symptoms and treatments help us guide our clients through the recovery process with the hope of achieving a complete recovery. A common question from our TBI clients and their families is "what types of treatments will best help a person with a TBI?"
Traditional western medicine has provided very few answers historically in traumatic brain injury cases designated as "mild TBI" or "moderate TBI" that don't involve a frank brain bleed or "severe TBI" requiring emergency medical services. Mainly a "wait and see" approach has been used that results in little or no viable treatment methods and has left TBI survivors with little improvement. By contrast, we've found that a wide variety of alternative or complimentary treatments can help people with a TBI to improve. This is dependent upon the patient's symptoms, examination findings, and seeking out treatments from professionals with expertise and experience in traumatic brain injuries.
Yet, the medical profession is changing its approach in light of a wealth of research into TBI. An article titled "Action Collaborative on Traumatic Brain Injury Care — Adapted Clinical Practice Guideline" Annals of Family Medicine (2025) addresses changes to conventional medical approaches to brain injury treatment.
What Is Traumatic Brain Injury?
A traumatic brain injury (TBI) occurs when an external force — such as a fall, motor vehicle crash, assault, or sports collision — disrupts normal brain function. TBI can range from mild concussion to severe injury, and even injuries not requiring hospitalization can produce long-lasting cognitive, emotional, and physical symptoms. At least 50 million people worldwide sustain a traumatic brain injury each year, costing the global economy an estimated $400 billion annually.
Our part as brain injury lawyers is to help our clients get fair compensation when they sustain financial and personal losses caused by someone else.
Why This TBI Medical Treatment Guideline Was Needed
Despite the massive global burden of traumatic brain injury, medical outpatient care has historically been fragmented, inconsistent and largely ineffective. Fewer than half of all TBI patients see a physician after leaving the emergency department, and those who do encounter widely varying care pathways. The National Academies of Sciences, Engineering, and Medicine (NASEM) identified this critical gap in their 2022 Traumatic Brain Injury: A Roadmap for Accelerating Progress report, calling for standardized outpatient guidance.
Medical TBI Treatment Guideline
The Action Collaborative on TBI Care — a working group convened under NASEM — used a systematic methodology for adapting existing clinical practice guidelines to a new clinical context. Key methodological steps included:
- Systematic review identifying 18 eligible evidence-based clinical practice guidelines (CPGs) from the US, Canada, UK, France, Denmark, Scotland, and internationally
- Quality rating using the AGREE II tool (Appraisal of Guidelines for Research & Evaluation); sources included top-rated guidelines from the American Physical Therapy Association, American College of Emergency Physicians, and VA/DoD
- Priority setting surveys with 112 TBI survivors and caregivers and 99 community clinicians to ensure patient-centered relevance
- Consensus voting with ≥10 Working Group members required for final approval of each recommendation
- External review by 20 health professional and brain injury organizations, yielding mean confidence scores of 7.1/10 for agreement that clinicians should use the guideline
Evidence strength was rated using the GRADE system (adapted by the American Academy of Family Physicians) with three levels: Strong, Weak, and Good practice.
The 11 Core Recommendations for Medical Traumatic Brain Injury Care
1. Confirm the TBI Diagnosis
Clinicians should confirm or rule out TBI using the 2023 American Congress of Rehabilitation Medicine (ACRM) mild TBI criteria, which are based on mechanism of injury plausibility, acute signs/symptoms, and physical examination. The new guideline recommends abandoning the traditional "mild / moderate / severe" classification — the word "mild" was found to trivialize patients' experiences, and misrepresents a patient's symptoms and permanency. This carries a Strong recommendation.
2. Determine Emergency Department Need
Patients must be urgently redirected to an ED if they display:
- Declining or fluctuating consciousness
- New focal neurologic abnormalities, pupil asymmetry, or seizures
- Severe or worsening headache
- Signs of skull fracture (e.g., Battle's sign, raccoon eyes)
- Imminent suicidality
This is a Strong recommendation, though less than 0.1% of discharged TBI patients will actually require readmission for neurosurgery.
3. Neuroimaging and Neuropsychological Testing
Clinicians should not order brain MRI or CT for every TBI patient, reserving imaging for atypical presentations such as progressively worsening symptoms or focal neurological abnormalities. This is also because CT is negative in nearly 95% of all TBI cases and MRI is negative in over 80%. Formal neuropsychological assessment may be offered for patients with persisting (>1 month) cognitive symptoms that are disabling or not improving.
4. Screen for Social Determinants of Health
This is one of the guideline's most novel contributions — it explicitly calls on clinicians to assess food, housing, and transportation insecurity, financial difficulties, immigration status, and interpersonal safety. Social determinants of health (SDoH) contribute to inequities in TBI incidence, care access, and outcomes, and must be addressed in individualized treatment planning. Clinicians should also screen for possible domestic violence or neglect as a cause of TBI.
5. Return to Usual Activities
The medical profession's historical treatment "do nothing" is changing. The new research suggests that after an initial 48-hour period of relative rest (including reduced screen time), patients should gradually resume pre-injury activities as tolerated. The old standard of strict bed rest until symptom resolution has been replaced — evidence now shows prolonged rest may slow recovery and increase mental health complications. Clinicians may provide documentation (sick leave, school accommodations) to facilitate a graded return.
A return to some activities can be negatively impacted by light sensitivity or vision system disturbances, making a return to computer work or driving very difficult. Similarly, orthopedic injuries involving significant pain may impact the recognition of traumatic brain injury symptoms and otherwise impact the ability to return to certain types of activities due to the risk of increased injury.
6. Educate the Patient and Family
Clinicians should provide both written and oral education to patients and their caregivers, covering symptoms, prognosis, self-management strategies, and lifestyle advice regarding sleep, alcohol, and physical activity. Education should be culturally and linguistically appropriate, and patients at elevated risk of prolonged recovery should not be told to expect a quick recovery, as this can cause distress if that outcome doesn't materialize. Given that larger TBI studies show the risk of persistent symptoms occur in up to 60% of all "mild" TBI cases, suggesting an expected recovery time is a poor choice.
7. Assess Risk for Persisting Symptoms
Clinicians should screen for risk factors that predict prolonged recovery or permanent TBI symptoms, including:
- Female sex
- Older age
- Pre-existing psychiatric conditions or prior TBIs
- High initial burden of post-concussion symptoms (measured via validated tools like the Rivermead Post-Concussion Symptoms Questionnaire)
- Mental health symptoms (depression, anxiety, PTSD)
- Psychosocial factors (fearful avoidance, pessimistic recovery expectations)
- Adverse social determinants of health
The strongest predictors are high early symptom burden.
It is important to note that "mental health symptoms" are often situational and arise from the TBI itself - not separate from it. Others are behavioral changes caused by the TBI, not independent mental health issues.
8. Prioritize Which Symptoms to Treat First
Clinicians should address symptoms that (1) are most bothersome, (2) are most likely to cascade into other problems if untreated, and/or (3) impede active rehabilitation. The most common priority symptoms in traumatic brain injury are headaches, poor sleep, and depression/anxiety. Since poor sleep worsens mood, causes fatigue, and results in the inability for the glymphatic system to clean the brain of metabolic waste after a TBI, this is an example of a self-reinforcing cycle. Similarly, there is a high degree of correlation between TBI, PTSD and Major Depressive Disorder. A failure to correctly diagnose these conditions and refer for care will result in an onset of these conditions after the injury.
9. First-Line Treatments for Post-Traumatic Headache
Management of post-traumatic headache (a hallmark TBI symptom) should be aligned with the dominant headache type:
Medication-overuse headache should be monitored, particularly in patients using analgesics more than 10 days per month.
10. Screen and Treat Mental Health Disorders
TBI significantly elevates risk for Major Depressive Disorder, anxiety disorders, and PTSD— with peak onset between 2 and 6 months post-injury. This delay is a common point of attack for insurers and defense doctors who deny TBI claims.
Clinicians should screen using validated tools (PHQ-2/PHQ-9 for depression; GAD-7 for anxiety; PCL-5 for PTSD) and initiate first-line treatment with psychotherapy, pharmacotherapy, or both. Disparities in access to psychotherapy are acknowledged, leaving these patients with a higher likelihood of permanent symptoms.
11. Referral to Specialty Care
Referral to an interdisciplinary TBI clinic or specialist (neurologist, physiatrist, physical therapist) should be considered when patients:
- Are at high risk for persisting symptoms
- Have disabling symptoms beyond 30 days post-injury
- Fail to respond to first-line primary care interventions
Up to 1 in 3 patients with non-hospitalized TBI will have symptoms persisting beyond 30 days. Specialty interventions may include vestibular rehabilitation, clinician-directed cognitive rehabilitation, advanced headache treatments (including migraine medications, botox injections and other methods), cognitive behavioral therapy for insomnia, and graded aerobic exercise programs.
Special Populations With Traumatic Brain Injury
Older Adults with TBI
Older adults have the highest TBI incidence rate, most commonly from falls. They are also the least likely to recover from a TBI.
Older patients face elevated risks of stroke, epilepsy, and neurodegenerative disease after a TBI. Fall prevention with TBIs and inner ear injuries that effect balance is a critical management priority due to the risk of death from a hip fracture.
Athletes
Sport-related concussion tends to involve younger, healthier individuals with faster recovery trajectories. A medically supervised stepwise return-to-play protocol is essential, with medical clearance defined as being symptom-free both at rest and with physical exertion. Athletes may minimize symptom reporting due to identity or scholarship pressures, making objective neuropsychological testing especially valuable.
Military Service Members
Service members face higher lifetime neurotrauma exposure and a more demanding return-to-duty standard. Blast-related TBI, while clinically managed similarly to non-blast TBI, may require specialty referrals for concurrent hearing loss, burns, and chemical exposure. Commanding officers — not clinicians — make final return-to-duty decisions.
Key Limitations of the Guideline
The authors acknowledge several important constraints on medical treatment of TBI:
- A disproportionate number of recommendations are rated Good practice (expert opinion) rather than based on strong randomized evidence, reflecting the immaturity of the primary TBI literature
- The guideline may have limited applicability outside North America, despite international participation in the Working Group
- The guideline is restricted to adults — pediatric TBI guidelines exist separately
- Monitoring will be needed to ensure recommendations do not widen existing health equity gaps for disadvantaged populations
Clinical Significance and Future Direction of the Medical Profession's Treatment of TBI
This guideline represents the first unified, evidence-adapted framework for medical traumatic brain injury treatments applicable to all TBI severities in adults. The ultimate goal of the guidelines, is to provide better care with the intention of creating faster recovery, improved quality of life, and reduced healthcare costs for TBI survivors.
If you are seeking a lawyer to handle your brain injury case, please contact us on this web site, or call our office at (503) 227-1233 for a free consultation.