Treat patients with traumatic brain injuries

By expanding your clinical skill set, you can become an essential part of the interdisciplinary team providing comprehensive care for patients with traumatic brain injuries.

A traumatic brain injuries (TBI) is often called the “invisible injury,” and for good reason.¹ While the dramatic impacts of severe TBI are well-known, the far more common mild TBI (mTBI), or concussion, often goes undiagnosed and undertreated.² As DCs, we are uniquely positioned to serve this patient population, addressing the musculoskeletal and neurological symptoms that are often overlooked.³

Understand the TBI spectrum

The first step in caring for TBI patients is to understand the full scope of the condition. A TBI is an alteration in brain function, or other evidence of brain pathology, caused by an external force. This pathology can range from a mild concussion to a severe, life-threatening injury. The true complexity of TBI lies in its varied and numerous symptoms, which the geography affected by the injury can impact.

Brain injuries result in diverse symptoms because different areas of the brain control unique functions. An injury to the frontal lobe,⁴ often called the brain’s control center, can significantly impair executive control and behavioral regulation, leading to difficulties with problem-solving, decision-making, emotional control and even verbal expression. Meanwhile, damage to the parietal lobe, the brain’s sensing and spatial center, is typically related to sensory processing issues, such as problems with tactile sensation, spatial orientation and eye-hand coordination. If the temporal lobe, the brain’s memory and language center, is affected, patients may struggle with memory, selective attention, language comprehension and emotional responses. Finally, since the occipital lobe is the dedicated visual center, injury here commonly results in difficulties processing visual stimuli.

Ultimately, understanding the location of the TBI helps a provider anticipate the specific mix of cognitive, emotional and functional challenges a patient is likely to face. A DC’s expertise in spinal health and neurological function makes them a key ally in managing these often-debilitating symptoms.

Assessment and diagnosis: Beyond the standard exam

A thorough and nuanced assessment is critical for identifying TBI. You should supplement your standard intake with specific questions about the patient’s injury history, including the mechanism of the traumatic event, and a detailed inquiry into their symptoms. This goes beyond physical pain to include changes in sleep, mood, memory and concentration.

During the physical examination, focus on objective measures. A detailed neurological exam is essential, including an evaluation of the cranial nerves and a comprehensive assessment of balance and vestibular function. You can use simple, in-office tools, such as the Balance Error Scoring System (BESS), or more advanced options such as computerized neurocognitive tests to provide a baseline and track progress over time. For concussions, a tool like the King-Devick test, which assesses saccadic eye movements, can be a useful objective measure.⁵

Evidence-based treatment and management

A DC’s treatment of a TBI patient is often multifaceted and extends beyond the typical chiropractic adjustment.

Spinal and extremity adjustments: Gentle, specific chiropractic adjustments can be highly effective in managing common TBI symptoms. The neck, in particular, is often a source of headaches and dizziness following a head injury due to its close connection to the vestibular system. A meta-analysis published in the journal BMC Musculoskeletal Disorders found manual therapy, including spinal manipulation, can be effective in treating post-concussion headaches and neck pain.

Vestibular rehabilitation: A significant portion of TBI patients experience vestibular symptoms such as vertigo and balance issues. DCs can incorporate vestibular rehabilitation exercises into their treatment plans. Simple, home-based exercises, such as gaze stabilization drills or targeted head movements, can significantly reduce dizziness and improve balance over time.

Soft tissue therapies: Myofascial pain and muscle tension are common after a head injury. Certain techniques, such as massage, myofascial release and instrument-assisted soft tissue mobilization, can help alleviate these symptoms, reducing muscle guarding and improving patient comfort.

Therapeutic exercise: Therapeutic exercises that focus on balance, coordination and proprioception are crucial. Start with low-impact exercises and gradually increase intensity as the patient’s symptoms allow. Examples include standing on unstable surfaces, using balance boards and performing simple gait drills.

Document and code compliantly for traumatic brain injuries

If it’s not documented, it didn’t happen; especially when an insurer reviews a complex case such as a TBI.

Initial injury details: Always document the mechanism of injury (MOI), even if it’s months old. How did the trauma happen (fall, motor vehicle accident, sports hit)? You need this to establish medical necessity for your initial work.

The subjective-objective bridge: Your subjective findings (patient reports of dizziness, pain, fog) must link directly to your objective findings. If the patient reports vertigo, your notes must show a positive vestibulo-ocular reflex or Dix-Hallpike test, for example, or a diagnostic test like the Rotary Chair Test.

Chiropractic focus: Clearly document the subluxation or spinal motion restriction you found and the body region you treated. The TBI diagnosis is the reason for the symptoms, but the subluxation/joint restriction is the reason for the adjustment.

Objective measures: Use and document validated tools. In addition to the King-Devick test, other great options include the Dizziness Handicap Inventory (DHI), the Neck Disability Index (NDI) and objective balance testing (such as the Romberg or computerized posturography).

Red flag documentation: Explicitly state you screened for and ruled out “red flags” (such as persistent vomiting, slurred speech or worsening cognitive function) that require an immediate medical referral. Document the referral if you made one.

In terms of diagnosis, DCs cannot use the actual TBI diagnosis code (e.g., S06 series) as the primary or first-listed diagnosis because they are generally not the medical provider diagnosing or managing the acute brain injury itself. However, Z-codes, which are used to report factors influencing health status and contact with health services, can and should be used by DCs.⁶

Your primary goal is to bill for the symptom or condition you are treating, followed by the TBI history code. Your primary ICD code should be the treatable condition; think cervicogenic headache (G44.89), vertigo/dizziness (R42) or acute/chronic neck pain (M54.2). This establishes medical necessity for your services. You must then include the code Z87.820 (personal history of traumatic brain injury) as a secondary (contextual) diagnosis. This code is a history code that provides essential context to the payer, explaining why a patient might have complex, chronic or recurrent musculoskeletal and neurological symptoms (such as headaches, vertigo or neck pain) that you are treating.

For CPT codes, you’ll use the standard chiropractic manipulative treatment (CMT) codes (98940–98943), making sure to document the specific spinal level adjusted. If you provide specific TBI rehab, you’ll use codes such as 97112 (neuromuscular re-education) for activities such as gaze stabilization and balance drills or 97530 (therapeutic activities) for improving functional performance. Both 97112 and 97530 are time-based codes, meaning you must provide at least eight minutes of a specific service to bill one unit of that code.

Of course, if the TBI is new, evaluation and management (E/M) coding will also come into play. E/M codes are used to bill for the time and complexity involved in assessing and managing a patient’s health issue, rather than just the procedure (such as an adjustment). You’d use an E/M code when the visit time is primarily dedicated to complex medical decision-making (MDM) or the total time spent on the encounter. This is appropriate for TBI cases during the initial evaluation to perform a detailed history, exam and critical safety screening (ruling out red flags) or when managing moderate- to high-complexity symptoms that require extensive care coordination (e.g., discussing the case with a neurologist) or diagnostic testing.

Collaborative care and continuing education

No single provider can manage all aspects of a TBI. It is imperative to work within an interdisciplinary team that may include neurologists, physical therapists, occupational therapists and neuropsychologists. The ability to recognize when to refer a patient for specialized care is a hallmark of a great clinician. Red flags, such as worsening headaches, repeated vomiting, slurred speech or a seizure, should prompt an immediate referral to the emergency room or a neurologist.

To expand your expertise, consider these vetted, continuing education options focused on TBI:

Carrick Institute: Offers an extensive neurology-focused curriculum, including courses specifically on concussion and TBI.⁷
American Chiropractic Association (ACA): Provides online and in-person seminars on sports injury and concussion management, often presented by leading experts in the field.⁸
International Concussion Society: Offers certifications and educational resources for healthcare professionals on concussion diagnosis and treatment.⁹
Brain Injury Association of America (BIAA): Provides extensive continuing education designed primarily for healthcare professionals and direct care providers working with individuals who have brain injuries.

By pursuing specialized training, you can build a network of providers, ensuring your patients receive the comprehensive care they need.

Patient education and home care

Empowering the patient is a key component of TBI recovery. Care should include and emphasize patient education on topics such as:

Brain rest: Stress the importance of physical and cognitive rest in the initial phases of recovery.
Symptom tracking: Encourage patients to keep a journal to monitor their symptoms, which can provide invaluable data for tracking progress and adjusting treatment plans.
Lifestyle modifications: Explain the role of nutrition, hydration and sleep hygiene in the healing process.

Final thoughts: Bring attention to the invisible injury

Treating the complex, unseen symptoms of traumatic brain injuries allows you to step into the role of clinical expert, but your greatest skill is bringing the invisible injury to light through proper care, documentation and education. By coupling your mastery of the brain-body connection with an airtight compliance strategy, you make the patient’s experience undeniable. This approach ensures you provide life-changing care and also fosters a resilient practice that excels in both clinical outcomes and compliance.

Erin Stubblefield, DC, CPPM, graduated from Palmer College of Chiropractic in Davenport, Iowa, in 2006. After practicing privately for several years, she transitioned to full-time teaching. Currently, Stubblefield is a specialist with KMC University and the owner of Sunflower Consulting LLC, a healthcare consulting and management group. She resides outside of Kansas City and is a published author and continuing education presenter. For further information, you can reach her at drerin@kmcuniversity.com.

References

Traumatic brain injury and concussion. Facts about TBI. August 2025. US Department of Health and Human Services. US Centers for Disease Control and Prevention. https://www.cdc.gov/traumatic-brain-injury/data-research/facts-stats/. Accessed December 3, 2025.
Giza CC, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology. 2013;80(24):2250–2257. https://pmc.ncbi.nlm.nih.gov/articles/PMC3721093/. Accessed December 3, 2025.
Reid SA, et al. Vestibular rehabilitation for dizziness and balance problems following traumatic brain injury. BMC Musculoskel Disord. 2017. Accessed December 3, 2025.
What is a brain injury? Functions of the Brain. Brain Injury Association of America. https://www.biausa.org. Accessed December 3, 2025.
About the King-Devick Test. King-Devick Test Inc. https://www.kingdevicktest.com. Accessed December 3, 2025.
Billing and Coding Guidelines for Chiropractic Services. Centers for Medicare and Medicaid Services (CMS). https://www.cms.gov. Accessed December 3, 2025.
Traumatic Brain Injury Program. The Carrick Institute. https://www.carrickinstitute.com. Accessed December 3, 2025.
Concussion and TBI resources. American Chiropractic Association. https://www.aca.org. Accessed December 3, 2025.
International Concussion Society. https://www.concussion.org. Accessed December 3, 2025.