Guidelines - Concussion/mTBI

Scope and Purpose

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




Title of Guideline: Guideline for concussion/mild traumatic brain injury & persistent symptoms 3rd ed.

Author(s): Marshall S., et al. 

Year of Publication: ​2018

Link for Full Guideline: link

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



  • 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.


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: 


  • Comprehensive health history

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

  • Perform neurological and musculoskeletal exam


  • 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:


  • 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.


  • 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:



  • 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:


  • 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


  • 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:


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

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







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:



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

Additional Resource Provided by CCGI: 



Key Recommendations - Return to Activity/Work/School


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


  • Review information on restrictions, limitations and symptom triggers

  • Review information on job demands

  • Identify opportunities for accommodations/work modification


  • 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).



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


  • 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



  • ​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)


  • 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)

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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.

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