Ontario Neurotrauma Foundation

Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms

3rd Edition, for Adults over 18 years of age

Ontario Neurotrauma Foundation

General Recommendations Regarding Management of Persistent Symptoms

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Consistent with general expectations of both patients and healthcare professionals, symptoms following mTBI are anticipated to resolve in a timely fashion in the majority of cases; evidence is emerging that some people (15% or greater) continue to have persistent symptoms.1-3 There is wide variation in how people recover after concussion/mTBI4 even when experiencing similar injuries.2 This guideline has been developed to assist in managing those individuals who continue to have persistent symptoms or delayed recovery following concussion/mTBI.

While there are few treatments for the early stage of concussion recovery, it is notable that providing psychoeducational intervention and supportive reassurance about concussive symptoms, expectations of recovery and strategies for symptom reduction are highly effective for reducing persisting symptoms.5-7 Furthermore there is evidence that complete rest exceeding 48 to 72 hours may slow recovery. Primary care providers must carefully monitor for patients who do not follow the anticipated pattern of recovery. For those who have had complete symptom resolution, no intervention apart from the provision of injury prevention strategies is required. However, for those with persistent symptoms or decline in function, emphasis needs to be placed on regular monitoring by healthcare professionals and identification of potentially treatable symptoms.

Obtaining a history of medical problems, performing a careful physical examination, an extensive review of concussion symptoms, and considering the response to exertion testing is essential when developing the differential diagnosis of persistent post-concussion symptoms.8,9 Through this process, the primary care provider may be able to link symptoms of persistent post-concussion symptoms to one or more definable post-concussion disorders.10 An interdisciplinary process is often helpful and referrals to appropriate specialists should be considered if available.9

Development of complications post mTBI, such as depression, can also occur and further alter the course or pattern of recovery. In turn, efforts to update the patient’s family on the chosen intervention strategies should be considered, as their support is often a key component to maximizing patient independence and psychosocial adjustment. It is also important to approach the patient’s tolerance towards activity with vigilance, as going beyond his or her threshold may result in the worsening of symptoms. Periodic re-evaluation of the patient for worsening of symptoms or presence of new symptoms/ problems following mTBI is important for those with a more chronic course of recovery.

While patients with persisting symptoms following mTBI are sometimes portrayed as making claims solely for secondary gain (i.e., disability benefits or litigation), it should be noted that in fact many factors can affect symptom expression and accentuation, including levels of emotional distress, fatigue, and pain, as well as pre- and post-injury coping abilities.11,12 Accordingly, suspected symptom exaggeration or perceived compensation seeking should only reinforce the need for a comprehensive assessment and evidence-based treatment with evaluation of outcomes.

Persistent symptoms describe a constellation of nonspecific symptoms that may be linked to other conditions such as depression, pain, headache, sleep disturbance, vertigo, irritability, anxiety, difficulty with concentration and chronic fatigue, which do not necessarily reflect ongoing physiological brain injury. 1,13-15 Symptoms associated with persistent post-concussion symptoms are also common in populations who have not sustained a mTBI.15 Nonetheless, patients are often functionally affected by these symptoms, and therefore they should be addressed. This guideline has been designed to provide an approach that focuses on optimizing management of individual symptoms to enhance function following mTBI. By addressing symptoms in a coordinated manner, improvement in outcome can be achieved. See Algorithm 5.1, which outlines the key steps to management of persistent symptoms following mTBI.

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Management of Persistent Symptoms

New Key Section Level of evidence A B C Updated Evidence
5.1* A

A patient with a first-time concussion/mTBI should be advised through early education, support and/or assurance that a full recovery of their 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).

*NOT AN ORIGINAL RECOMMENDATION - REPEAT OF 2.3

5.2 A

Persistent symptoms after concussion/mTBI should lead primary care providers to consider that many factors may contribute to the persistence of post-concussive symptoms (see Table 1.1). All relevant factors (medical, cognitive, psychological and psychosocial) should be examined with regards to how they contribute to the patient’s symptom presentation and considered in the management strategies.

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

5.3 B

Persons with concussion/mTBI and identified factors typically associated with persistent symptoms (see Table 1.1) should be considered for early referral to an interdisciplinary treatment clinic including a physician with expertise in concussion/mTBI where available or interdisciplinary formal network of providers (see Appendix 2.5) capable of managing post-concussive symptoms because these factors have been associated with poorer outcomes.

5.4 C

If necessary for support, communication with healthcare professionals or understanding information provided, a support person accompanying the patient with post-concussive symptoms to assessment and treatment sessions is recommended.

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

5.5** A

After a brief period of rest during the acute phase (24–48 hours) after injury, patients can be encouraged to become gradually and progressively more active as tolerated (i.e., activity level should not bring on or worsen their symptoms).

Adapted from McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med 2017;51:838-847

** NOT AN ORIGINAL RECOMMENDATION - REPEAT OF 4.5

5.6 B

New onset pain and concussive injuries are often comorbid. Comprehensive evaluation and management of pain is important as it can be a factor in maintaining persistent symptoms or can overlap/exacerbate concussion/mTBI symptoms.

5.7*** A C

On presentation to healthcare professionals, patients and their support person should be provided with educational material that includes a verbal review and written 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:

  • Symptoms and expected outcomes (A)
  • Normalizing symptoms (education that current symptoms are expected and common after injury event) (A)
  • Reassurance about expected positive recovery (A)
  • Gradual return to activities and life roles (A)
  • Techniques to manage stress (C)

*** NOT AN ORIGINAL RECOMMENDATION - REPEAT OF 2.6

5.8 A

It is not recommended to use Hyperbaric Oxygen to treat symptoms post-concussion.

Appendix 1.3

Brain Injury Advice Card (Long Version)

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Appendix 1.4

Brain Injury Advice Cards (Short Versions)

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Appendix 2.5

Specialized Concussion Clinics/Centres in Ontario

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Algorithm 5.1

Management of Persistent 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

Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259.
Country: Canada
Design: Discussion/Review Article
Quality Rating: N/A *No checklists were appropriate to score this article design

Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions. Acad Emerg Med. 2017;24(1):75-82.
Country: Canada
Design: Randomized Control Trial
Quality Rating: PEDro: 8/11

Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Dev Neuropsychol. 2015;40(5):273-278.
Country: USA
Design: Pilot Randomized Control Trial
Quality Rating: PEDro: 6/11

Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307.
Country: Canada
Design: Systematic Review
Quality Rating: PRISMA: 10/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Weyer Jamora C, Schroeder SC, Ruff RM. Pain and mild traumatic brain injury: the implications of pain severity on emotional and cognitive functioning. Brain Inj. 2013;27(10):1134-1140.
Country: USA
Design: Case-Control
Quality Rating: DOWNS & BLACK: 14/32 *6 of the sections were not applicable

Chin LM, Keyser RE, Dsurney J, Chan L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Arch Phys Med Rehabil. 2015;96(4):754-759.
Country: USA
Design: Case Series
Quality Rating: DOWNS & BLACK: 14/32 *4 of the sections were not applicable

Chin LM, Chan L, Woolstenhulme JG, Christensen EJ, Shenouda CN, Keyser RE. Improved Cardiorespiratory Fitness With Aerobic Exercise Training in Individuals With Traumatic Brain Injury. J Head Trauma Rehabil. 2015;30(6):382-390.
Country: USA
Design: Case Series
Quality Rating: DOWNS & BLACK: 14/32 *4 of the sections were not applicable

Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehabil Res Pract. 2012;2012:705309.
Country: USA
Design: Retrospective Chart Review
Quality Rating: DOWNS & BLACK: 14/32 *4 of the sections were not applicable

Leddy J, Hinds A, Sirica D, Willer B. The Role of Controlled Exercise in Concussion Management. PM R. 2016;8(3 Suppl):S91-S100.
Country: USA
Design: Discussion/Review Article
Quality Rating: N/A *No checklists were appropriate to score this article design

McMahon P, Hricik A, Yue JK, et al. Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study. J Neurotrauma. 2014;31(1):26-33.
Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *6 of the sections were not applicable

Sasse N, Gibbons H, Wilson L, et al. Coping strategies in individuals after traumatic brain injury: associations with health-related quality of life. Disabil Rehabil. 2014;36(25):2152-2160.
Country: Germany
Design: Cross-Sectional
Quality Rating: DOWNS & BLACK: 12/32 *7 of the sections were not applicable

Tator CH, Davis HS, Dufort PA, et al. Postconcussion syndrome: demographics and predictors in 221 patients. J Neurosurg. 2016;125(5):1206-1216.
Country: Canada
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 13/32 *8 of the sections were not applicable

Sawyer K, Bell KR, Ehde DM, et al. Longitudinal Study of Headache Trajectories in the Year After Mild Traumatic Brain Injury: Relation to Posttraumatic Stress Disorder Symptoms. Arch Phys Med Rehabil. 2015;96(11):2000-2006.
Country: USA
Design: Longitudinal Perspective Cohort
Quality Rating: DOWNS & BLACK: 16/32 *5 of the sections were not applicable

Wojcik SM. Predicting mild traumatic brain injury patients at risk of persistent symptoms in the Emergency Department. Brain Inj. 2014;28(4):422-430.
Country: USA
Design: Case-Control
Quality Rating: DOWNS & BLACK: 16/32 *7 of the sections were not applicable

Walker WC, Franke LM, Cifu DX, Hart BB. Randomized, Sham-Controlled, Feasibility Trial of Hyperbaric Oxygen for Service Members With Postconcussion Syndrome: Cognitive and Psychomotor Outcomes 1 Week Postintervention. Neurorehabil Neural Repair. 2014;28(5):420-432.
Country: USA
Design: Randomized Control Trial
Quality Rating: DPEDro: 11/11

Cifu DX, Hart BB, West SL, Walker W, Carne W. The effect of hyperbaric oxygen on persistent postconcussion symptoms. J Head Trauma Rehabil. 2014;29(1):11-20.
Country: USA
Design: Randomized Control Trial
Quality Rating: DPEDro: 10/11

Cifu DX, Walker WC, West SL, et al. Hyperbaric oxygen for blast-related postconcussion syndrome: three-month outcomes. Ann Neurol. 2014;75(2):277-286.
Country: USA
Design: Randomized Control Trial
Quality Rating: DPEDro: 11/11

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