The Centers for Disease Control and Prevention (CDC) has updated and revised its tool kit for mild traumatic brain injury (MTBI), “Heads Up: Brain Injury in Your Practice.” The updated resource is a welcome addition, neurologists told Neurology Today, at a time when increasing incidence of traumatic brain injury (TBI) in Iraq has raised public consciousness about the dangers of concussion.
The kit includes a booklet on diagnosis and management of MTBI, a patient assessment tool (the Acute Concussion Evaluation, or ACE), fact sheets for patients in English and Spanish on preventing concussion, an ACE care plan for a patient's recovery, a palm card for on-field management of sports-related concussion, and a CD-ROM with downloadable kit materials and additional MTBI resources.
Carmel Armon, MD, chief of neurology at Baystate Medical Center at Tufts University School of Medicine in Springfield, MA, and several other neurologists said the formal guidance for physicians offered by the CDC kit is laudable and much needed. But they offered suggestions for improvement. Its sheer breadth of material “requires motivation and perseverance to wade through it,” said Dr. Armon. Sherman C. Stein, MD, clinical professor of neurosurgery at the University of Pennsylvania School of Medicine, added that the 76-item ACE office checklist is impractical for a busy practitioner.
“What is needed,” he said, “is a brief set of evidence-based guidelines or some clinical decision rules to guide referrals and the return to work or school. Supporting documents can contain additional discussion and references.”
The CDC document recommends that referrals be made to a specialist for MTBI care if symptoms do not improve within three to five days, or sooner, if the symptoms are severe. It also suggests that specific information about TBI specialists are available through national brain injury associations, said NINDS Deputy Director Walter J. Koroshetz. “Perhaps this is a good time for neurologists interested and knowledgeable about MTBI to make their availability known,” he said.
Dr. Armon said that he would prefer that the kit provide data on the sensitivity, specificity, or predictive value of the assessment tool (ACE). Also, he said, the references for the development of the ACE form are heavily weighted towards sports-related MTBI, and it lacks data on applicability to concussions that occur in other settings, such as in the military, workplace, or car accidents.
Dr. Armon suggested that the AAN practice parameters on management of concussion in sports (Neurology 2007;48:581–585) be added to the list of sources.
The CDC collaborated with an Expert Work Group, Expert Review Panel, and 15 participating organizations, which did not include the AAN, American Association of Neurological Surgeons, or the American Academy of Pediatrics. Drs. Stein and Armon said that the addition of a neurologist or neurosurgeon would have been logical.
The kit is free and available online at www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm.