Guidelines - Mild Traumatic Brain Injury & Persistent Symptoms

This tool provides information to facilitate the management of mild traumatic brain injury (mTBI) and persistent symptoms in adults.

Focused examination

1. Patient History 

  • Rule out risk factors for major structural or other pathologies. If required, refer to an appropriate healthcare provider or co-manage.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address any prognostic factors that may delay recovery.

Major structural or other pathologies (red flags):

  • Headaches that worsen, seizures, focal neurologic signs, looks very drowsy/can’t be awakened, repeated vomiting, slurred speech, can’t recognize people or places, increasing confusion or irritability, weakness or numbness in arms or legs, neck pain, unusual behavioural change, change in state of consciousness

Examples of other conditions/co-morbidities:

  • physical conditions: back pain, headache

  • Psychological conditions: depression, anxiety

  • co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Pre-existing/concurrent medical conditions or post-injury symptoms

  • Personal, psychosocial, or environmental factors

2. Physical Examination

  • Rule out major structural or other pathologies.

    • Use the Canadian C-spine Rule to rule out cervical spine fractures and dislocations associated with acute trauma​​.

  • Assess mental status and cognition, physical status, cranial nerves, extremity tone, strength, and reflexes, gait and balance, deterioration/improvement since injury.

  • Identify clinical signs of mTBI.

Clinical signs of mTBI:

  • Loss of or decreased level of consciousness <30 minutes;

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

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

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

  • Behavioural/emotional symptoms: drowsiness, fatigue/lethargy, irritability, depression, anxiety, sleeping more than usual, difficulty falling asleep;

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

3. Management 

  • Offer information on nature, management, and the course of mTBI.

  • Discuss the range of effective interventions with the patient and, together, select a therapeutic intervention.

Patient Handouts

Sleep Hygiene Infographic.jpg
Sleep Hygiene Infographic - FRENCH.jpg

Initial Management of Symptoms

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

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

Specific Management of Persistent Symptoms (>3 months duration)

Provide structured patient education (reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

Post-traumatic headache

  • Consider education (e.g., stimulus control, sleep hygiene, dietary modification, environment modification)

  • Consider maintaining a headache diary

  • Consider pharmaceutical interventions for acute pain and prevention of headache attacks

Sleep-wake disturbances

  • Consider sleep hygiene

  • Consider behavioural interventions

  • Consider melatonin in conjunction with reduced evening light exposure and light therapy in the morning

  • Consider magnesium and zinc supplementation 

  • Consider acupuncture

  • Consider stress management strategies

Mental health disorders

  • Consider cognitive behavioural therapy for patients with persistent mood and anxiety issues

Cognitive difficulties

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

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

  • Consider implementing accommodations, modifications, support for work/school

Vestibular (balance/dizziness) and vision dysfunction

  • Consider epley manoeuvre if dix-hallpike is positive

  • Consider vestibular rehabilitation therapy

  • Consider vision therapy

Fatigue

  • Consider gradual increases in activity levels

  • Consider cognitive and physical activity pacing and fragmentation across the day

  • Consider sleep hygiene

  • Consider using a diary to plan meaningful goals, record activity achievement and identify patterns of fatigue

  • Consider coping strategies

  • Consider medical referrals 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

*Interventions are recommended if guidelines used terms such as ‘recommended for consideration’ (e.g., ‘offer’, ‘consider’), ‘strongly recommended’, ‘recommended without any conditions required’, or ‘should be used’. Recommendations from low-quality evidence are not listed.

Care Pathway for the management of mTBI in adults

(click here for French version)

4. Reevaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors that may delay recovery.

5. Referrals and Collaboration

  • Refer the patient to an appropriate healthcare provider for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms.

Return to Activity/Work/School

  • Avoid activities with increased risk of sustaining another concussion, particularly in the first 7-10 days post-trauma

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

  • Advise that transient symptom exacerbation with increased activity are common

  • Communicate restrictions/limitations to the patient’s employer (with patient’s consent) to facilitate appropriate accommodation

  • 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

  • Together, the employer and employee should formulate a progressive return to work plan

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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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