‘We can’t wait until 2042’ writes UB expert about implementing new primary care guidelines for treating concussion/mild TBI

BUFFALO, N.Y. – Adults with concussion or mild traumatic brain injury (TBI) who are seen in the primary care setting or discharged from the emergency department are often told to wait to see if their symptoms resolve. But while symptoms often do resolve, some patients would significantly benefit by being treated early on with treatments developed and proven effective by brain injury experts.

New clinical practice guidelines for treating adults with concussion or mild traumatic brain injury and geared toward primary care providers are being published this month in the Annals of Family Medicine.

Worldwide, an estimated 42 million adults experience a concussion or mild TBI.

“There has been a lack of education for primary health care providers on the evidence-based physiological assessment and treatment approaches that can help these patients improve,” says John J. Leddy, MD, clinical professor of orthopaedics in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, whose editorial accompanies the clinical practice guidelines.

“The perception among some providers has been that the only way to treat a brain injury is to wait for it to get better,” he says. “Providers need education on how to best help patients that are not being treated by brain injury experts.”

Working group of TBI experts

The new, evidence-based guidelines for primary care providers were developed by a working group of TBI experts convened by the National Academies of Sciences, Engineering, and Medicine. The Action Collaborative on Traumatic Brain Injury Care was synthesized based on 18 existing clinical practice guidelines and covers assessment, education, referrals and treatment initiation in the first and subsequent few outpatient visits.

Leddy, who is also director of the Concussion Management and Research Center at UBMD Orthopaedics and Sports Medicine, says the new guidelines provide actionable recommendations that cover assessment, education and treatment initiation in the first and subsequent outpatient visits and advise primary health care providers on when to refer to brain injury experts.

“The guidelines inform primary care providers that concussion/mild TBI is a treatable condition, that the treatments should be based on symptoms and exam findings, and that they should be instituted earlier in recovery rather than later,” he says.

Effective treatments for adults with concussion and mild TBI include medications for headaches, specifically for post-traumatic migraine; cognitive behavioral therapy for insomnia; controlled physical activity and aerobic exercise for anxiety and fatigue; cervical physical therapy for associated neck pain, dizziness and cervicogenic headache; vestibular therapy for dizziness and balance problems; ocular therapy for convergence insufficiency; and psychotherapy for anxiety, depression and PTSD.

Over the past two decades, Leddy and his colleagues at UB have developed and prescribed aerobic exercise to speed recovery in individuals who’ve had a concussion, consistently demonstrating that individualized, correctly prescribed physical activity after a sport-related concussion provides the best evidence-based care.

The challenge: being adopted as routine medical practice

While these treatments are well-known to brain injury experts, Leddy’s editorial makes clear that getting them adopted into routine medical practice among primary care providers is a major challenge. He advocates for rapid dissemination of the guidelines so that more patients benefit sooner.

“The most cited ‘research-to-practice gap’ estimates that it takes about 17 years for new research evidence to be adopted into routine medical practice,” Leddy writes, noting that patients need to start benefiting from this new information as soon as possible.

The editorial explains that the group that drew up the new guidelines is working to disseminate them through a variety of instruments. These include co-publication in family medicine, brain injury and rehabilitation journals; establishing a network of TBI clinics as demonstration sites to create a learning health system with performance metrics; and empowering community champions to promote awareness through local presentations to health care professionals. The guidelines will also be accessible through the American Academy of Family Physicians mobile app.  

Leddy also recommends other approaches to knowledge translation that could make it easier for primary health care providers to integrate the recommendations into the electronic medical record so that they are more likely to become part of routine medical care for mild TBI patients.

The editorial concludes: “We shouldn’t have to wait 17 years.”