While full recovery is expected within 3 months after concussion/mTBI,^1,2, not all patients experience such rapid recovery, with minimally 15% or more experiencing persistent symptoms.^3,4 A more recent study showed 20 – 48% of veterans had persistent symptoms up to 60 months post-concussion.⁵ A number of factors influence the rate of recovery, including the mechanism and setting for the initial injury; for example, concussion/mTBI due to non-sport-related causes can be unexpected, emotionally charged, or associated with multiple or even life-threatening injuries. Other potential risk factors (see Table 1.1) may signal the need to monitor patient recovery more closely, given that these individuals are at higher risk for persistent symptoms and poorer outcome. ^6-8 For persons with persistent symptoms at 1 month post-injury, referral for specialized assessment in an interdisciplinary concussion clinic may be indicated. Patients with persistent symptoms 3 months post-injury should be referred for interdisciplinary treatment if available.

There is controversy regarding the diagnosis of persistent post-concussion symptoms because there is significant symptom overlap with other diagnoses that can result as a consequence of a traumatic experience, for example, depression, anxiety, and post-traumatic stress disorder, as well as the sequelae of pain related to comorbid conditions such as post-traumatic headache or whiplash-associated disorder (see Table 4.1, Appendix 4.1). Regardless of formal diagnosis (e.g., persistent post-concussion symptoms versus depression), persistent symptoms following mTBI have the potential to cause functional limitations and need to be addressed in a coordinated and directed fashion in order to assist recovery. Thus, the priority for primary care providers remains managing symptoms and encouraging patients to gradually return to activity guided by symptom tolerance to prevent delays in recovery. Patients who receive education and treatment earlier are more likely to have fewer persisting symptoms later.⁹ The assessment and monitoring of symptoms following mTBI may be facilitated using valid assessment tools, such as the Rivermead Post Concussion Symptoms Questionnaire (Appendix 1.5) or the Post Concussion Symptom Scale (Appendix 1.6).

It is also important to note that there is frequently an interplay of symptoms, social circumstances, and subsequent development of complications (e.g., depression) that can complicate and negatively influence recovery. The particular cluster of presenting symptoms will vary among patients, necessitating an individualized approach to management. Accordingly, one of the primary aims of the guideline is to assist in providing recommendations for management of these patients at risk using a symptom-based approach. See the individual sections for more specific treatment information.

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