Ontario Neurotrauma Foundation

Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms

3rd Edition, for Adults over 18 years of age

Ontario Neurotrauma Foundation

Scope and Purpose

The Need for a Guideline

The Ontario Neurotrauma Foundation (ONF) initiated this project in 2008 with the overall objective to create a guideline that can be used by healthcare professionals to implement evidence-based, best-practice care of individuals who incur a mTBI and experience persistent symptoms. Persistent symptoms are not an uncommon complication of mTBI; 10% to 15% of individuals who incur concussion/mTBI will continue to experience significant symptoms beyond the typical recovery period of three months, 40-42 which can include post-traumatic headache, sleep disturbance, disorders of balance, cognitive impairments, fatigue and mood or affective disorders. The high incidence of mTBI translates into a significant number of individuals who may experience associated disability.

Clinical Questions

Prior to the First Edition, the best practice for treatment of those who do not experience spontaneous recovery was not clearly defined. Therefore, the following clinical questions needed to be addressed:

  1. Can an approach be devised to screen for and identify patients who are at high risk of persistent symptoms?
  2. Once identified, can a management plan be developed to treat the symptoms commonly associated with post-concussion disorder?

Overall Objectives

Overall Objectives

The purpose of this clinical practice guideline is to improve patient care by creating a framework that can be implemented by healthcare professionals to effectively identify and treat individuals who manifest persistent symptoms following concussion/mTBI.

Specifically, the aims of the guideline update were:

  • To update the Guidelines for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms: Second Edition in order to maintain their relevancy and utility for primary care providers (PCPs).
  • To modify the guideline format based on feedback from stakeholders and frontline users of the guideline in order to improve the accessibility and utility of the guideline.
  • To work with stakeholders to generate further ideas for knowledge translation.

Target Population

The present guideline is appropriate for use with adults (? 18 years) who have experienced mTBI (note that the ONF Pediatric Guidelines for Children and Youth were released in 2014). The present guideline is not appropriate for use with patients who have incurred penetrating brain injuries, birth injuries, brain damage from stroke or other cerebrovascular accidents, shaken baby syndrome, or moderate to severe closed head injuries. The guideline addresses early management to only a limited extent because the purpose of this document is to provide guidance on the assessment and treatment of persistent symptoms. Nonetheless, because early management can influence the development and maintenance of persistent symptoms, the most critical issues regarding early management have been incorporated. For more comprehensive guidance on pre-hospital and acute care, readers are directed to the NSW Ministry of Health Adult Trauma Clinical Practice Guidelines - Initial Management of Closed Head Injury in Adults 2nd Edition (2011)4 or the Scottish Intercollegiate Guidelines Network Early Management of Patients with a Head Injury - A National Clinical Guideline (2009).

Target Users

The present document is targeted toward healthcare professionals providing service to individuals who have experienced mTBI, including primary care providers (family physicians, nurse practitioners), neurologists, physiatrists, psychiatrists, psychologists, occupational therapists, speech-language pathologists, physiotherapists, chiropractors, social workers and counselors.

Directives for Use/Implementation

The consequences of mTBI can result in adverse physical, behavioural/emotional and cognitive symptomatology which, in turn, can impact an individual’s activities of daily living and participation in life roles. Early diagnosis and management of mTBI will improve a patient’s outcome and reduce the impact of persistent symptoms. The present guideline offers recommendations for the assessment and management of this patient group. Clinicians should assess, interpret and subsequently manage symptoms, taking into consideration other potential pre-injury, injury and post-injury biopsychosocial factors and conditions that may have contributed to an individual’s symptoms. Because of the overlap of symptoms with other clinical disorders, there is a necessity to carefully pursue differential diagnoses. Acute assessment should include standardized assessment of Post-Traumatic Amnesia (see Appendix 1.2), and immediate complications of traumatic brain injury such as intracranial bleeding and potential neurologic deterioration while subsequent management of the patient should include assessment and monitoring of symptoms, education and reassurance that the symptoms are common and generally resolve within days to weeks. Furthermore, guidance should be provided on the gradual resumption of usual activities and life roles. It should also be noted that patients may not always be well aware of their symptoms and/or the impact of symptoms on their functioning; this should be taken into consideration when examining patients. Primary care providers should also consider providing self-awareness training for patients, as well as education for family members and/ or other caretakers on expected symptoms, treatments, and course of recovery.

The format of this guideline is arranged so that an introduction to the topic is provided in the first part of each of the sections, followed by a table presenting the specific recommendations to be implemented. Core sections were written by the project team from the First and Second Editions and have since been reviewed and updated by current project team members. For certain sections, there were additional contributors with particular expertise in that topic area; these expert contributors have been indicated at the beginning of the sections where appropriate. Also, tables presenting resources (e.g., criteria for diagnosis of mTBI and post-concussion disorder) and indexing tools that can aid assessment and management of symptoms (e.g., patient advice sheet, standardized questionnaires, therapeutic options tables) are also included.

Clinicians are encouraged to prioritize treatments in a hierarchical fashion (see Table B). Individual guideline recommendations that should be prioritized for implementation are highlighted in the Key Recommendations section and throughout the guideline document with a key symbol . It is recommended that treatment be first targeted at specific difficulties that have both readily available interventions and the potential to yield significant symptomatic and functional improvement. That is, treat those symptoms that can be more easily managed and/or could delay recovery first, before focusing on more complex and/or difficult to treat symptoms. It is assumed that some post-concussive symptoms, such as cognitive difficulties, are more difficult to treat at least in part because they are multifactorial in origin and reflect the interactions between physiological and psychological factors, premorbid vulnerabilities, and coping style, as well as post-injury stressors. For example, if a patient is experiencing sleep disturbance, depression, cognitive dysfunction and fatigue, by targeting and successfully treating the sleep problems and depression first, improvement in other symptom domains (e.g., fatigue and cognitive dysfunction) may occur as well.