Guidelines - Concussion/mTBI

Scope and Purpose of Guideline

Objective: Diagnosis, assessment, and management of mild traumatic brain injury (mTBI)/concussion and persistent symptoms in adults.

Target population: 

  • Adults (≥18 years) who have experienced concussion.

CCGI Guideline Summary

 

Key Recommendations - Diagnosis/Assessment of Concussion

 

Rule out red flags:

Refer to emergency department with sudden onset of any of:

  • Headaches that worsen

  • Seizures

  • Focal neurologic signs

  • Looks very drowsy/can’t be awakened

  • Repeated vomiting

  • Slurred speech

  • Cannot recognize people or places

  • Increasing confusion or irritability

  • Weakness or numbness in arms/legs

  • Neck pain

  • Unusual behavioural change

  • Change in state of consciousness

Comprehensive Assessment:

  • Clinical signs of concussion (any one sign or combination of):

    • Loss of or decreased level of consciousness <30 min;​

    • Lack of memory for events immediately before/after injury (post-traumatic amnesia) <24 hours;

    • Altered mental state e.g., confusion, disorientation, slowed thinking;

    • Physical symptoms (see below).

  • Health history – assess/review the following:

    • Current symptoms and health concerns

      • ​Physical: headache, nausea, vomiting, blurred or double vision, seeing stars or lights, balance problems, dizziness, sensitivity to light/noise, tinnitus, vertigo.​

      • Behavioural/Emotional: drowsiness, fatigue/lethargy, irritability, depression, anxiety, sleeping more than usual, difficulty falling asleep.

      • Cognitive: feeling “slowed down”, “in a fog” or “dazed”, difficulty concentrating or remembering.

    • Setting and mechanism of injury

    • Severity/duration of altered consciousness and immediate symptoms

    • Concurrent injuries

    • Pre-injury history: e.g., prior concussion(s), premorbid or concurrent conditions (physical or mental health conditions or difficulties, ADHD)

    • Medications

    • Factors that may delay recovery

      • Medical Factors (pre-existing/concurrent medical conditions or post-injury symptoms that are associated with poor outcomes post mTBI).​

      • Contextual Factors (personal, psychosocial, or environmental factors that may negatively influence recovery post mTBI).

Physical Exam:

  • Assess the following:

    • Mental status and cognition​

    • Physical status

    • Cranial nerves

    • Extremity tone, strength, and reflexes

    • Gait and balance

    • Deterioration/improvement since injury

Key Recommendations - Initial Management of Concussion

 

Principles: 

  • Focus on education, reassurance, self-management, active (vs. passive) time-limited care.

  • Management is symptom-based: treat specific symptoms including concurrent injuries according to evidence-based practice.

  • Address comorbidities.

  • Monitor for signs/symptoms that may require urgent medical referral.

  • Insufficient evidence to recommend complete rest beyond 24-48 hours.

  • Encourage return to activity/work/school even with symptoms (as tolerated).

Symptom treatment hierarchy: target symptoms that can be more easily managed or could delay recovery first, before focusing on more complex or difficult to treat symptoms. Some symptoms may exacerbate others.

  • Primary symptoms (to be addressed early):

    • Depression/anxiety/irritability​

    • Sleep disturbance

    • Post-traumatic headache

  • Secondary symptoms

    • Balance, dizziness/vertigo​

    • Cognitive impairment

    • Fatigue

    • Tinnitus/noise intolerance

Overall approach:

  • Acute (0-4 weeks): Education, reassurance, sub-symptom threshold training, non-pharmacological interventions. Consider cognitive behavioural therapy if patient has psychosocial barriers to recovery (e.g., negative expectation of recovery, high anxiety).

  • Sub-acute (4-12 weeks): Manage specific symptoms (potentially interdisciplinary), graduated return to activity/work/school, refer to physician if patient is not improving or is worsening.

  • Persistent (≥3 months): Interdisciplinary management focused on returning to pre-injury activities.

Education and self-management:

  • Provide verbal and printed information to patients and support persons at initial assessment and ongoing as required.

  • Include information on:

    • Symptoms and expected outcomes: expect full recovery in majority of patients within a few days, weeks or months.​

    • Normalizing symptoms: current symptoms are expected and common

    • Gradual return to activities as tolerated: does not result in a significant or prolonged exacerbation of symptoms.

    • Techniques to manage stress.

Tools:

Sub-system threshold training/activities: involves training or activities at the patient’s tolerance level that aims to achieve maximal participation in pre-injury activities while minimizing symptom exacerbations. When symptom exacerbations occur, patients should be advised to temporarily reduce their physical and cognitive demands and resume graduated return-to-activity at a slower pace.

Brain Injury Advice Card – Long version

Brain Injury Advice Card – Short version

Key Recommendations - Persistent Symptoms After Concussion (>3 months)

 

General Assessment: 

  • Document symptoms using standardized concussion scales or others specific to treatment (e.g., Numerical Rating Scale and Neck Disability Index for neck pain).

  • Review currently prescribed medications, over-the-counter medications/supplements and substance use, including alcohol, marijuana and other recreational drugs.

  • Consider differential diagnoses (persisting physical, cognitive, or psychological post-concussion symptoms can be nonspecific).

General Management:

  • Consider all factors that may contribute to persistence of symptoms.

  • Interdisciplinary collaboration.

  • Hyperbaric oxygen is not recommended.

Key Recommendations - Specific Assessment & Management of Persistent Symptoms After Concussion (>3 months)

 

Post-traumatic Headache: 

Assessment:

  • Comprehensive health history

  • Identify headache subtype(s) that most closely resemble(s) the patient’s symptoms (ICHD-III Beta).

  • Perform neurological and musculoskeletal exam

Management:

  • Tailor treatment to clinical features of headache and patient preferences.

  • Educate patients:

    • Stimulus control (e.g., caffeine/tobacco/alcohol)​

    • Strategies such as: sleep hygiene, dietary modification, manual therapy and exercise, relaxation, environment modification

    • Maintaining a headache diary

    • Pharmacological interventions for acute pain and prevention of headache attacks (refer to physician)

Sleep-wake disturbances:

Assessment:

  • Screen for pre-existing sleep disturbances/disorders and the following which may influence the sleep/wake cycle:

    • Medical conditions: e.g., endocrine dysfunction, metabolic, pain-provoking.​

    • Current medication use.

    • Comorbid psychopathology: e.g., mood or anxiety disorder.

    • Unhealthy habits: e.g., lack of exercise, variable sleep-wake. schedule, excessive napping, excessive time spent in bed, exercising close to bedtime; use of nicotine, caffeine, energy drinks, processed foods and processed sugars, alcohol, drugs, medications.

    • Physical: e.g., alterations in menstrual cycle, comorbid conditions, pain.

Management:

  • Educate and reassure that sleep alterations are common in acute stages

  • Treatment of sleep disorders may help to improve other post-concussive symptoms (mood, anxiety, pain, fatigue, cognitive problems)

  • Sleep hygiene

  • Behavioural interventions

  • Melatonin (take 2 hours before bedtime in conjunction with reduced evening light exposure and light therapy in the morning)

  • Magnesium and zinc supplementation (as per physician/dietician directions)

  • Acupuncture

  • Stress management strategies

  • Medical referral for pharmacological treatments

  • Medical referral if sleep disturbances persist

Mental Health Disorders:

Assessment:

Management:

  • Cognitive behavioural therapy for patients with persistent mood and anxiety issues

  • If a mental health disorder is present: treat according to clinical practice guidelines for that disorder

  • Refer to medical provider for pharmacological management

Cognitive Difficulties:

Assessment:

  • Assess and track symptoms using a validated post-concussion symptoms questionnaire (e.g., Rivermead, PCSS).

  • Assess impact of cognitive difficulties on activity/work/school/community participation

Management:

  • Educate patients that cognitive difficulties might be intensified by comorbidities (e.g., ADHD, learning disabilities, anxiety or mood disorders, pain, fatigue, sleep disturbance, neuroendocrine dysfunction, substance abuse, existing medications).

  • Refer to medical provider if symptoms are not resolving and continue to interfere in daily functioning beyond 4 weeks.

  • Implement/use neurorehabilitation strategies for patients with persisting cognitive impairments, and to facilitate resumption of activity/work/school/community participation.

  • Implement work/school accommodations, modifications, support.

Vestibular (balance/dizziness) and vision dysfunction:

Assessment:

  • Assess vision, vestibular, balance and coordination, hearing, cervical spine (physical exam).

  • Assess for benign paroxysmal positional vertigo (BPPV) (Dix-Hallpike).

Management:

Tools:

 

 

 

 


Clinicians may use either (based on preference):

 

 

Clinicians may use either (based on preference):

 

Neurorehabilitation strategies aim to aid recovery from a nervous system injury and to minimize and/or compensate for any functional alterations.

 

Additional Resources Provided by CCGI:

 

Key Recommendations - Return to Activity/Work/School

 

Assessment: 

Healthcare Professional:

  • Identify medical restrictions: that could pose risk of sustaining injury or pose potential risk to others

  • Identify limitations: due to physical, cognitive, emotional symptoms

  • Identify and document symptom triggers

Employer:

  • Review information on restrictions, limitations and symptom triggers

  • Review information on job demands

  • Identify opportunities for accommodations/work modification

Management:

  • Avoid activities that could increase risk of sustaining another concussion during the recovery period, particularly in the first 7-10 days post-trauma.

  • Gradually resume normal activity based upon tolerance and conditional on not posing risk for further injury to self or others.

  • Advise that transient symptom exacerbations with increased activity are common.

  • Communicate restrictions/limitations to the patient’s employer (with patient’s consent) to facilitate appropriate accommodation. Examples of accommodations include:

    • Assistance with commuting to and from work​

    • Flexible work hours (e.g., starting later or ending earlier)

    • Gradual work re-entry (e.g., starting at 2 half days/week and expanding gradually)

    • Additional time for task completion

    • Quiet space available for worker to take breaks throughout the day

    • Job change

    • Environmental modifications (e.g., quieter work environment, enhanced level of supervision, decreased computer work, ability to work from home; only day shift hours)

  • Refer for interdisciplinary vocational assessment if patient has not successfully resumed pre-injury work.​

  • If patient cannot return to pre-injury employment, consider alternative meaningful activities that promote community integration (e.g., educational activities, volunteer work)

Employer and worker:

  • Formulate progressive RTW plan​

Return to post-secondary school

Within 24-48 hours post-injury:

  • Asymptomatic:

    • Attend school as tolerated, undergo tests/exams with accommodations if required (e.g., separate space, paced breaks, rooms where lights can be altered, additional time); monitor for potential symptoms.​

  • Symptomatic:

    • Refrain from attending school and from participating in academic and sports activities to decrease the risk for symptom exacerbation.​

    • Offer psychoeducation and modified at-home study tasks as tolerated.

    • Students should be able to tolerate school and life responsibilities prior to participating in sports or activities that put them at risk.

After 24-48 hours post-injury:

  • Asymptomatic:

    • Return to academic/program related activities as tolerated.​

  • Symptomatic:

    • Refrain from attending academic and/or program-related activities for one full week and up to two full weeks if symptoms remain functionally debilitating.​

    • Connect with academic accessibility/disability services to request accommodations and receive additional support.

    • Monitor for symptoms; provide support and education.

    • Notify (with permission) accessibility/disability services about student’s concussion; student may require time off, or accommodations and support for reintegration (potentially for the coming weeks or months).

Tools:

Psychoeducation definition: treatment designed to educate patients regarding expected symptoms, recovery, symptom management, or general self-care.

Additional Resource Provided by CCGI: 

 

 

Fatigue:

Assessment:

  • Assess frequency, intensity, time of day, aggravating factors, dimensions of fatigue (e.g., physical, mental, impact on motivation).

Management:

  • Acknowledge that fatigue can be exacerbated by low mood or stress

  • Gradual increase in activity levels

  • Cognitive and physical activity pacing and fragmentation across the day.

  • Sleep hygiene

  • Diary to plan meaningful goals, record activity achievement and identify patterns of fatigue

  • Coping strategies

  • Medical referral: for blood test screening if appropriate (CBC, TSH, electrolytes); for secondary causes of fatigue: affective disorder (e.g., depression, anxiety); sleep disorder; metabolic causes (e.g., hypothyroidism, anemia); electrolyte abnormality (e.g., hyponatremia, hypocalcemia); polypharmacy or medication adverse effect.

Key Recommendations - Sport-related Concussion

 

Assessment: 

  • ​Any symptom or signs of a concussion:

    • Evaluate onsite using standard emergency management principles

    • Rule out cervical spine injury

    • Sideline assessment (SCAT5) by healthcare profession (non- healthcare professionals use Concussion Recognition Tool 5)

Management:

  • Player should not be left alone following the injury; monitor serially for increasing signs/symptoms of deterioration over the initial few hours.

  • Insufficient evidence for prescribing complete rest

    • Initial period of rest in the acute symptomatic period following injury (24-48 hours) may be beneficial.​

    • After a brief period of rest, a sensible approach involves the gradual return to activity/school (prior to contact sports) as tolerated

Return-to-play and return-to-school:

  • Player with suspected concussion should not be allowed to return-to-play on the day of injury.

  • Graduated return-to-play protocol.

Referrals and Collaborations

 

Refer to medial care if:

  • Red flags present

  • If patient’s health condition/treatment goals are outside of the chiropractic scope of practice

  • If patient’s health condition is not improving within expected time frames or worsening

  • There are other major comorbid conditions present (e.g., depression, PTSD)

  • Facebook Social Icon
  • Twitter Social Icon
  • YouTube Social  Icon
  • LinkedIn Social Icon

CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

OnTEchU logo_transparent.png