Ontario Neurotrauma Foundation

Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms

3rd Edition, for Adults over 18 years of age

Ontario Neurotrauma Foundation

Initial Management of Concussion/mTBI

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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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Management of Concussion/mTBI

New Key Section Level of evidence A B C Updated Evidence
2.1 C

Initial treatment of a patient with concussion/mTBI should be based upon a thorough evaluation of signs and symptoms, pre-injury history (e.g., prior concussion(s), premorbid conditions) and concurrent potential contributing factors (e.g., comorbid medical conditions, ADHD, medications, mental health difficulties, impact of associated concurrent injuries).

2.2 C

Persons who report somatic, cognitive and/or psychological difficulties after concussion/mTBI should be assessed and provided with symptom-based treatment even if it has been a prolonged time after injury.

Adapted from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2009).

2.3 A

A patient with a first-time concussion/mTBI should be advised through early education, support and/ or assurance that a full recovery of symptoms, including cognitive functioning, is typically seen within as early as a few days up to 1 to 3 months post-injury.

Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).

2.4 C

For patients who have 1) comorbidities or identified health or risk factors (see Table 1.1) and are not on a trajectory of improvement within the first month, or 2) persistent symptoms greater than 4 weeks post-injury, it is recommended that these patients be referred for more comprehensive interdisciplinary evaluation to specialized concussion services/clinics (see Appendix 2.1)

Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).

2.5 B

The primary care provider should routinely screen for the risk of depression and/or anxiety in the first few weeks after concussion/mTBI (see Appendices 8.1 & 8.2), which may be influenced by psychosocial factors and psychological responses to the injury. Patients who screen positive should be managed and referred to specialist services, if needed, since these conditions commonly complicate recovery.

Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).

Providing Education After mTBI

New Key Section Level of evidence A B C Updated Evidence
2.6 A C

On presentation to healthcare professionals, patients and their support persons should be provided with education that includes verbal and printed information (see Appendices 1.3 and 1.4). This information should be provided at the initial assessment and ongoing as required. Education should be tailored based on the patient’s history and symptoms and include information on:

a. Symptoms and expected outcomes (A)

b. Normalizing symptoms (education that current symptoms are expected and common after injury event) (A)

c. Reassurance about expected full recovery in the majority of patients within a few days, weeks or months (A)

d. Gradual return to activities as tolerated i.e., in a manner that does not result in a significant or prolonged exacerbation of symptoms and life roles (A)

e. Techniques to manage stress (C)

Adapted from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2009).

2.7 A

Scheduled telephone and/or in-person follow-up should be arranged. The focus of these sessions should be to provide education regarding symptom management as well as strategies to encourage a gradual and active resumption of everyday activities as tolerated. These sessions should be provided over the initial 12 weeks post-injury as required.

2.8 A

Cognitive behavioural therapy could be considered as a supplementary early intervention for patients with psychological risk factors (e.g., pre-injury mental health disorder, negative expectations for recovery, high post-injury anxiety), or as a treatment option for patients with multiple persisting symptoms.

Appendix 1.3

Brain Injury Advice Card (Long Version)

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Appendix 1.4

Brain Injury Advice Card (Short Version)

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Appendix 2.1

Specialized Concussion Clinics/ Centres in Ontario

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Post Concussion Care Pathway

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Referral Indicators

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Concussion Symptom Management

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Appendix 2.2

Parkwood Pacing Graphs

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Algorithm 2.1

Algorithm: Initial Management of Symptoms Following mTBI

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Table 1.1

Risk Factors Influencing Recovery Post mTBI

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Losoi H, Silverberg ND, Waljas M, et al. Recovery from Mild Traumatic Brain Injury in Previously Healthy Adults. J Neurotrauma. 2016;33(8):766-776.
Country: Finland
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 20/32 *4 of the sections were not applicable

O'Neil ME, Carlson K, Storzbach D, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. VA Evidence-based Synthesis Program Reports. 2013.
Country: USA
Design: Systematic Review
Quality Rating: PRISMA: 18/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Eliyahu L, Kirkland S, Campbell S, Rowe BH. The Effectiveness of Early Educational Interventions in the Emergency Department to Reduce Incidence or Severity of Postconcussion Syndrome Following a Concussion: A Systematic Review. Acad Emerg Med. 2016;23(5):531-542.
Country: Canada
Design: Systematic Review
Quality Rating: PRISMA: 21/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-264.
Country: Sweden
Design: Systematic Review
Quality Rating: PRISMA: 17/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Scheenen ME, Visser-Keizer AC, de Koning ME, et al. Cognitive Behavioral Intervention Compared to Telephone Counseling Early after Mild Traumatic Brain Injury: A Randomized Trial. J Neurotrauma. 2017;34(19):2713-2720.
Country: Netherlands
Design: Randomized Control Trial
Quality Rating: PEDro: 6/11 *4 of the sections were not indicated in the study

Silverberg ND, Hallam BJ, Rose A, et al. Cognitive-behavioral prevention of postconcussion syndrome in at-risk patients: a pilot randomized controlled trial. J Head Trauma Rehabil. 2013;28(4):313-322.
Country: Canada
Design: Randomized Control Trial
Quality Rating: PEDro: 9/11

Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma. 2015;32(8):517-526.
Country: Canada
Design: Systematic Review
Quality Rating: PRISMA: 15/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A, Schonberger M. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology. 2012;26(3):304-313.
Country: Australia
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 20/32 *4 of the sections were not applicable

Cassidy JD, Boyle E, Carroll LJ. Population-based, inception cohort study of the incidence, course, and prognosis of mild traumatic brain injury after motor vehicle collisions. Arch Phys Med Rehabil. 2014;95(3 Suppl):S278-285.
Country: Canada
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 17/32 *5 of the sections were not applicable

Snell DL, Hay-Smith EJ, Surgenor LJ, Siegert RJ. Examination of outcome after mild traumatic brain injury: the contribution of injury beliefs and Leventhal's common sense model. Neuropsychol Rehabil. 2013;23(3):333-362.
Country: Canada
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 15/32 *5 of the sections were not applicable

Potter SD, Brown RG, Fleminger S. Randomised, waiting list controlled trial of cognitive-behavioural therapy for persistent postconcussional symptoms after predominantly mild-moderate traumatic brain injury. J Neurol Neurosurg Psychiatry. 2016;87(10):1075-1083.
Country: United Kingdom
Design: Randomized Control Trial
Quality Rating: PEDro: 8/11 *3 of the sections were not indicated in the study

Bryant RA, Moulds M, Guthrie R, Nixon RD. Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry. 2003;160(3):585-587.
Country: Australia
Design: Case-Control
Quality Rating: DOWNS & BLACK: 21/32 *1 section was not applicable

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