Whether a patient first presents to the Emergency Department (ED) or to the primary care provider’s (PCP’s) office, ruling out traumatic brain or spine injury that requires emergency intervention is the initial priority. Acutely following injury, it is essential that a management plan be initiated for each patient including: information regarding monitoring for potential acute complications requiring re-assessment, education regarding expected symptoms and course of recovery, and recommendations for healthcare follow-up post-injury.¹ Treatment should be individualized and based on individual patient symptoms and physical examination findings.² Pre-injury or current psychiatric difficulties, such as depression or anxiety, may place a patient at increased risk for persistent symptoms.² Referral to specialist services and/or interdisciplinary treatment may be required early on for these patients (see Appendix 2.1). Information pertinent to care pathway and referrals may also be found at the following links: Post Concussion Care Pathway, Referral Indicators, for Concussion Symptom Management and Scope of Practice for Healthcare Professionals (Scope of Practice is information for Ontario only). Referral to specialists should also be considered if symptoms exhibit an atypical pattern or cannot be linked to a concussion event, and/ or when there are other major comorbid conditions present (e.g., depression, PTSD). 

The majority of patients will be discharged home; it should be noted that a person who remains symptomatic post mTBI should not drive for at least 24 hours.^3-6 Even asymptomatic patients after 48 hours exhibited poorer vehicle control, especially when navigating curves suggesting that driving impairments may persist beyond when individuals with a concussion have returned to driving.⁷ Also, patients who did present symptoms compatible with a concussion/mTBI following a head trauma but who are completely asymptomatic by the time they are medically-assessed should be presumed to have sustained a concussion/mTBI and receive counselling as described below.

Although the majority of current treatments for concussion are in their infancy of development,⁸ there is preliminary evidence to support the effectiveness of active rehabilitation such as psychoeducational, psychological and cognitive interventions.^9-12 The primary forms of treatment have traditionally included a recommendation for physical and cognitive rest until symptoms subside along with other interventions, such as education, coping techniques, support and reassurance, neurocognitive rehabilitation and antidepressants.^9,13 However, the most recent world Sport-Related Concussion consensus statement indicated that there is currently insufficient evidence that prescribing complete rest achieves recovery by minimizing brain energy demands following concussion. It is recommended that after a brief period of rest during the acute phase (24–48 hours) post-injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds¹³ (see Appendix 2.6). This emphasizes an approach of “Activity as tolerated” (i.e., in a manner that does not result in a significant or prolonged exacerbation of symptoms). The potential benefit of integrating cognitive behavioral therapy to address thoughts and activities, with cognitive rehabilitation to address difficulties with cognitive abilities, such as attention and memory, has also been noted.^11,14 Currently, there is limited evidence to support the use of pharmacotherapy.¹³ Medications that may mask worsening symptoms or confuse changes in mental status should be avoided in the early phases of recovery.¹⁵

Several review articles have stated the importance of educational interventions addressing concussion knowledge, symptom interpretation, recovery expectations and thought patterns, and activity levels, in preventing and managing persistent symptoms after concussion.^10-12,16-18 Educational interventions for mTBI should validate the current symptomatology, while providing education on the anticipated course of recovery and the importance of gradually achieving realistic functional goals.¹⁹ There is also evidence to suggest that reassurance, in addition to education about symptoms, is more effective for lowering risk of persistent symptoms than education alone.¹³ Several studies have demonstrated that providing brief single session education-oriented treatment is superior to standard procedures,^10-12,19-21 and even as effective as more intensive interventions.^20,21 Education and training for identified patient’s family and caregivers are also important in aiding the patient’s recovery.²² In addition to providing verbal information and reassurance to patients, it is also advised that written patient information sheets are delivered (see Appendices 1.3 and 1.4).²³ See Algorithm 2.1, which outlines the key steps for initial management of mTBI.

Overall, management of concussion/mTBI should initially be managed in a standardized and consistent fashion recognizing that the majority of patients will proceed to complete recovery. Interdisciplinary teams are important, particularly for those patients with more complex or prolonged recovery.⁸ By applying the strategies outlined above consistently, both the acute and chronic complications of concussion can be mitigated.

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