Marshall 2015

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ISSN: 0269-9052 (print), 1362-301X (electronic)
Brain Inj, Early Online: 1–13

! 2015 Informa UK Ltd. DOI: 10.3109/02699052.2015.1004755
ORIGINAL ARTICLE
Updated clinical practice guidelines for concussion/mild traumatic brain

injury and persistent symptoms
Shawn Marshall1,2, Mark Bayley3,4, Scott McCullagh5,6, Diana Velikonja5,6, Lindsay Berrigan7, Donna Ouchterlony8, &
Kelly Weegar1
1
Ottawa Hospital Research Institute, Ottawa, ON, Canada, 2Department of Medicine, University of Ottawa, Ottawa, ON, Canada, 3Toronto
Rehabilitation Institute, University Health Network, Toronto, ON, Canada, 4Department of Medicine, University of Toronto, Toronto, ON, Canada,
5
Hamilton Health Sciences, Hamilton, ON, Canada, 6Department of Pscyhiatry, McMaster University, Hamilton, ON, Canada, 7St. Francis Xavier
University, Antigonish, NS, Canada, and 8St. Michael’s Hospital, Toronto, ON, Canada
Brain Inj Downloaded from informahealthcare.com by Kainan University on 04/16/15
Abstract Keywords
Objective: To introduce a set of revised guidelines for the management of mild traumatic brain Concussion, diagnosis, guideline
injury (mTBI) and persistent symptoms following concussive injuries. recommendations, management,
Quality of evidence: The Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms mild traumatic brain injury, persistent
were made available in March 2011 based on literature and information up to 2008. A search for post-concussive symptoms
new clinical practice guidelines addressing mTBI and a systematic review of the literature
evaluating treatment of persistent symptoms was conducted. Healthcare professionals History
representing a range of disciplines from Canada and abroad attended a consensus conference
to revise the original guidelines in light of new evidence. Received 14 July 2014
For personal use only.
Main message: A modified Delphi process was used to create 96 recommendations addressing Revised 13 November 2014
the diagnosis and management of mTBI and persistent symptoms, including post-traumatic Accepted 4 January 2015
headache, sleep disturbances, mental health disorders, cognitive difficulties, vestibular and Published online 14 April 2015
vision dysfunction, fatigue and return to activity/work/school. Numerous resources, tools and
treatment algorithms were also included to aid implementation of the recommendations.
Conclusion: The revised clinical practice guideline reflects the most current evidence and
is recommended for use by clinicians who provide care to people who experience PPCS
following mTBI.
Introduction While the diagnosis of concussion is often related to a sport

aetiology, any form of trauma may be the cause. In contrast,
Mild traumatic brain injury (mTBI) is a significant cause of
mTBI is defined by a Glasgow Coma Scale score [8] of 13–15
morbidity, with many survivors of mTBI dealing with
and limited post-traumatic amnesia, to permit differentiation
significant symptoms up to years beyond the usual recovery
from moderate and severe injuries. Nonetheless, the defin-
period of 3 months [1–3]. As one of the most common
itions overlap considerably and most would agree that
neurological disorders, mTBI has an estimated annual inci-
concussion lies on the ‘milder’ end of the mTBI spectrum [9].
dence of 500/100 000 in the US [4]; a 2009 Canadian study
In most cases, patients who experience mTBI of any
suggested the annual incidence in Ontario (Canada) lies
aetiology will recover fully, typically within days to several
between 493–653/100 000, depending on whether the diag-
weeks. However, 10–15% of individuals with mTBI will
nosis was made by primary care providers or based upon a
continue to experience persisting symptoms even after 1 year
secondary review by an expert [5]. The actual incidence of
[10, 11], which can include post-traumatic headache, sleep
mTBI is likely in excess of 600/100 000, as many persons
disturbance, disorders of balance, cognitive impairments,
who suffer a mTBI do not seek hospital-based care [6].
fatigue, dizziness and mood or affective disorders. The
Various terms are used synonymously with mTBI includ-
diagnosis of post-concussion syndrome has been surrounded
ing mild head injury, minor head trauma and concussion,
by debate and controversy [12, 13], as there is significant
which is defined as physiologic disruption of brain function
symptom overlap with other diagnoses and complications of
resulting from traumatic force transmitted to the head [7].
trauma, such as depression, anxiety and post-traumatic stress
disorder. Regardless of formal diagnosis and course of
Correspondence: Shawn Marshall, MD, FRCPC, The Ottawa recovery following mTBI, persistent symptoms following
Hospital Rehabilitation Centre, 505 Smyth Rd., Ottawa, ON K1H
8M2, Canada. Tel: 613-737-7350 ext 75590. Fax: 613-737-9638. E-mail: mTBI can cause functional limitations, heightened emotional
[email protected] distress and delayed return to activity, work or school [14, 15].
2 S. Marshall et al. Brain Inj, Early Online: 1–13
While research on the economic burden of persistent symp- but to a lesser extent because the purpose of this document is
toms is relatively sparse, the associated costs of these to provide guidance on the assessment and treatment of those
psychosocial outcomes following TBI are significant [16]. with persistent symptoms. Therefore, since early management
The National Center for Injury Prevention and Control in the can influence the development and continuation of persistent
US [17] estimated that the annual cost burden of mTBI was symptoms, the most critical issues regarding early manage-
$16.7 billion USD, out of the annual cost burden of $56 ment have been addressed. The target users for the present
billion for TBI. Based on the results from their literature guideline are healthcare professionals providing service to
review of TBI costs, Humphreys et al. [16] estimated that the individuals who have experienced a mTBI, including family
direct cost per each patient with mTBI was £28 300, which is physicians, primary healthcare providers, neurologists, physi-
equal to $35 000–$ 42 000 USD per patient (depending on atrists, psychiatrists, psychologists/neuropsychologists, coun-
the date of conversion). Comparative Canadian numbers are sellors, physiotherapists, occupational therapists and nurses.
not currently available. Nevertheless, these statistics demon-
strate that there could be substantial savings to society and for
Directives for use
the individual through successful rehabilitation of persistent
symptoms. Early diagnosis and management of mTBI should improve
In addition, the public and media worldwide are increas- patient outcomes and reduce the impact of persistent physical,
ingly recognizing persistent symptoms as potential long-term behavioural/emotional and cognitive symptoms [14, 27–29].
sequelae from mTBI [18–20]. Likewise, sport physicians and The present guidelines offer recommendations for the
physicians in the military are placing greater emphasis on assessment and management of this patient group.
adequate and graded rest following mTBI, aimed in part at the Clinicians should assess, interpret and subsequently manage
prevention of chronic symptoms [7, 21–24]. Despite the symptoms, taking into consideration other potential pre-
increased acceptance and understanding of the long-term injury, injury and post-injury biopsychosocial factors and
consequences of persistent symptoms, there is little high- conditions that may have contributed to the symptoms.
quality evidence for healthcare practitioners to guide the Because of the overlap of symptoms with other clinical
provision of care for patients with these symptoms. In contrast disorders, differential diagnoses must be carefully pursued.
to acute assessment and management of mTBI, few resources Acute assessment should include standardized assessment of
(e.g. clinical practice guidelines) are available to primary care post-traumatic amnesia and immediate complications of TBI,
providers who assess and manage persistent symptoms. In such as haemorrhage and potential neurologic deterioration.
2008, a research team affiliated with the Ontario Neurotrauma Early sub-acute management of the patient should include
Foundation sought to define the best practices in the assessment of symptoms combined with education and
management of individuals who incur a mTBI and experience reassurance that the symptoms generally do resolve within
persistent symptoms. The outcome was a set of new days to weeks. Furthermore, guidance should be provided on
guidelines made available in early 2011, delineating evi- stress reduction and gradual return to activities and life roles.
dence-based, best practice treatment for those who do not Since patients may not always be cognizant of their symptoms
experience spontaneous recovery [25]. In order to maintain and the impact on their functioning, the family and/or other
the relevance and utility for healthcare providers, these caretaker(s) should also be informed about expected symp-
guidelines were recently revised by updating the search for toms and the anticipated course of recovery.
new clinical practice guidelines (CPGs), performing a
systematic review of the literature evaluating treatment of Development
persistent symptoms and convening a panel of experts to
Leadership
develop consensus on evidence informed recommendations
[26]. The overall purpose of this updated CPG is to improve The current guideline update was led by a team composed of
patient care by providing an up-to-date framework that can be clinicians with substantial experience in treating mTBI, as
implemented by healthcare professionals to effectively iden- well as previous experience in developing CPGs. The mTBI
tify and treat individuals with persistent symptoms. Other expert consensus group (see Acknowledgements section) was
aims included modifying the guideline format based on expanded for the current update to ensure greater represen-
feedback from stakeholders and frontline users of the original tation of the various healthcare professions servicing the
guidelines in order to improve accessibility and utility and mTBI population, domain of expertise and geographic
working with stakeholders to generate further ideas for location. A wide range of disciplines were represented,
knowledge translation. including emergency medicine, family medicine, sports
medicine, neurology, physical medicine and rehabilitation,
radiology, psychiatry, psychology, physical therapy and
Scope
occupational therapy. Representatives of relevant organiza-
The present revised guidelines are appropriate for use with tions, such as the Ontario Neurotrauma Foundation (sponsor-
adults (18 years) who have experienced mTBI. The ing organization), the Ontario Brain Injury Association and
guideline is not appropriate for use with patients who have the International Brain Injury Association, as well as people
incurred penetrating brain injuries, birth injuries, brain who had experienced persistent symptoms following mTBI,
damage from stroke or other cerebrovascular accidents, were also included in the expert consensus group. In regard to
shaken baby syndrome or moderate-to-severe closed head domain of expertise, individuals recognized as experts in the
injuries. The guideline does address acute, early management, treatment of the various spheres of symptoms (i.e. physical,
DOI: 10.3109/02699052.2015.1004755 Updated guidelines for mTBI/persistent symptoms 3
behavioural and cognitive), quality-of-life, outcomes follow- were excluded from further review if they: (1) were more than
ing mTBI and knowledge translation were involved in the 4 years old (because it would have already been captured in
project; specifically, experts in the management of persistent the prior literature review in 2008 for the first edition), (2) did
sleep and vision disturbances were recruited for the guideline not address mTBI, (3) were found to be reviews only and did
update, as these domains were targeted for improvement in not include practice recommendations, (4) only addressed
the updated guidelines. In terms of the variety of aetiologies pre-hospital and/or acute care or (5) only addressed paediatric
associated with mTBI, individuals with expertise in sports, care. Nine new guidelines/guideline updates met the inclusion
trauma, as well as military and veteran’s health were criteria and recommendations relevant to mTBI were
represented. Lastly, with regard to geographic location, extracted. Although released after the comprehensive search
panel members were recruited predominantly from Ontario for guidelines was conducted, two additional guidelines for
and elsewhere in Canada, but also from the US and Australia. the management of sport-related concussion (from the
A formal schema identifying these factors was created before Concussion in Sport Group [7] and the American Academy
the meeting to assist in establishing balanced representation. of Neurology [21]) were also considered in the current
guideline update, given their relevance to the target popula-
tion. The guidelines evaluated in the process of developing
Literature review
the current guideline are shown in Table I.
A new systematic search (January 2008–June 2012) for Next, an extensive search of the literature was conducted
existing CPGs addressing mTBI and a systematic review of to capture all published research evaluating the effectiveness
the literature evaluating treatment of persistent symptoms of treatments or interventions intended to manage persistent
were conducted. First, a comprehensive search for existing symptoms following mTBI. A professional librarian working
CPGs published in English that were relevant to TBI and at the Ottawa Hospital Research Institute (Ottawa, Ontario,
included recommendations for the care of individuals with Canada) was consulted to develop a systematic search
mild injuries was done. This allowed the project team to strategy, ensuring a thorough search was conducted for all
identify quality recommendations that could be adapted to databases. Bibliographic databases (MEDLINE, PubMed,
minimize repetition of previously completed work. The search EMBASE, PsycINFO, CINAHL and Cochrane Library) were
for existing CPGs was conducted using six bibliographic searched using the following keywords: brain injury, head
databases (MEDLINE, PubMed, EMBASE, PsycINFO, injury, traumatic brain injury and concussion. The stepwise
CINAHL, Cochrane Library), guideline search sites (e.g. search strategies employed for each database are given in
National Guidelines Clearing House, Scottish Intercollegiate Appendix D of the complete guideline document [26].
Guidelines Network), websites of relevant organizations (e.g. Results were included for further review if they were
Canadian Medical Association, National Institute of Clinical published in English and at least 50% of the sample was
Excellence) and a general web search (first 50 websites composed of patients with mTBIs (concussion)/persistent
screened in Google and Google Scholar). The following symptoms following mTBI. Studies examining penetrating
keywords were used in combination for all searches: brain brain injuries, birth injuries, brain damage incurred from
injuries, head injuries, traumatic brain injury, concussion, stroke or other cerebrovascular accidents, shaken baby
guidelines, practice guidelines and best practice. In addition, syndrome or moderate-to-severe closed head injuries that
articles related to mTBI were further reviewed for citations of did not meet the above inclusion criteria were excluded from
CPGs addressing mTBI. Documents obtained via the search further review. Also, studies examining only acute symptoms
Table I. Existing traumatic brain injury guidelines evaluated in the process of developing the current guideline.
Group Guideline
American Academy of Neurology [21] Evaluation and Management of Concussion in Sport
American College of Sports Medicine [30] Concussion (Mild Traumatic Brain Injury) and the Team Physician:
A Consensus Statement
American Association of Neuroscience Nurses/Association of Care of the Patient with Mild Traumatic Brain Injury
Rehabilitation Nurses [31]
Concussion in Sport Group [7]* Consensus Statement on Concussion in Sport: the 4th International
Conference on Concussion in Sport, Zurich 2012
New South Wales Ministry of Health [32] Adult Trauma Clinical Practice Guidelines: Initial Management of Closed
Head Injury in Adults, 2nd edition
Scottish Intercollegiate Guidelines Network [33] Early Management of Patients with a Head Injury: A National Clinical
Guideline
Silverberg and Iverson [34] Recommendations for Activity Resumption Following Concussion in
Athletes, Civilians and Military Service Members
Stergiou-Kita et al. [35] A Guideline for Vocational Evaluation Following Traumatic Brain Injury:
A Systematic and Evidence-Based Approach
US Department of Veterans Affairs/Department of Defense [23] Clinical Practice Guideline: Management of Concussion/Mild Traumatic
Brain Injury
Workplace Safety and Insurance Board of Ontario [36] Mild Traumatic Brain Injury Program of Care
*The Summary and Agreement Statement of the 3rd International Conference on Concussion in Sport, Zurich 2008, was identified in the
comprehensive search for existing guidelines, but was later replaced with the release of the Consensus Statement on Concussion in Sport from the 4th
International Conference on Concussion in Sport, Zurich 2012.
Figure 1. PRISMA Group flow diagram [37]:

Results from the systematic review of the
Identification
literature (2008–June 2012) evaluating treat- Records identified through
ment of persistent symptoms. database searching
(n = 28 517)
Records after duplicates removed

(n = 27 408)
Screening
Records screened Records excluded
(n = 839) (n = 26 569)
Eligibility Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n = 137) (n = 113)
Included
Studies included in the

qualitative synthesis
(n = 24)
(i.e. not persistent) resulting from mTBI, non-systematic Guidelines for Research and Evaluation) instrument scores for
review papers (i.e. narrative reviews), clinical review papers, existing TBI guidelines, results of the systematic reviews of
letters to the editor, editorials without data, studies using non- the literature and the summary of recommendations and levels
human subjects and unpublished studies or data were not of evidence extracted from the existing guidelines identified
reviewed. However, the reference lists of narrative review in the updated search. Feedback received from various
papers were examined to ensure all relevant literature was sources about the first edition of the current guideline
included. was also discussed. The consensus group members broke
One reviewer screened through all of the article titles, out into four smaller groups, each given specific categories of
following which the initial reviewer and a second reviewer recommendations suitable to their area of expertise to review.
independently screened through the abstracts of those that The groups worked to review the original guideline recom-
remained. A third reviewer was consulted during the abstract- mendations and update, when applicable, with quality
and article-screening stages to resolve any discrepancies recommendations extracted from other recent guidelines.
between the original two reviewers’ decisions. After screening Recommendations were also revised based on current
by title, the number of relevant results obtained was 554 evidence/consensus.
for MEDLINE, 37 for PubMed, 75 for EMBASE, 69 for Following the consensus meeting and post-conference
PsycINFO, 73 for CINAHL and 31 for the Cochrane Library. feedback, 137 updated guideline recommendations remained,
Figure 1 represents an overview of all the articles screened at which the experts voted on independently using a modified
each step across all databases. After the abstracts and full Delphi voting technique [38]. If a recommendation met at
articles were screened through, 24 articles evaluating the least one of the following criteria, it was retained: (1) based
effectiveness of treatments/interventions for persistent symp- on level A evidence, (2) received a minimum of 85%
toms following mTBI were added to the evidence base. endorsement by the expert consensus group or (3) represented
an important care issue (i.e. addressed a topic relevant to a
large proportion of the mTBI population and clearly repre-
Practice recommendations
sented a current gap in treatment guidance). After these
The expert consensus group convened for a 1-day conference criteria were applied, 123 recommendations remained. Based
in November 2012 in Toronto, Ontario, Canada. Process on comments received from experts during the voting process,
information, data and identified guideline recommendations the project team further reviewed this list and culled for
for this meeting were available to consensus panel members redundancy and recommendations identified as low priority
in advance of the meeting through networking software for implementation, in order to reduce the number to a more
(www.alfresco.com). Conference presentations addressed the manageable list for healthcare providers. A final total of 96
methodological factors critical to the development of evi- unique recommendations comprise the current guideline
dence-based best practice care, AGREE II (Appraisal of (Table II).
Table II. Recommendations from the Guidelines for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms, second edition [26].
Recommendation Grade*
1. Diagnosis and assessment of mTBI
1.1. Concussion/mTBI in the setting of closed head injury should be diagnosed as soon as possible because early recognition is A
associated with better health outcomes for patients [14].
1.2. On presentation, the primary care provider should conduct a comprehensive review of every patient who has sustained mTBI A
(see Appendix 1.1). The assessment should include taking a history, examination, cognitive screen, post-concussive symptom
assessment and review of mental health (see Table 1.2) [14].
1.3. The need for early neuroimaging should be determined according to the Canadian CT Head Rule (see Figure 1.1). For A
patients who fulfil these criteria, CT scanning is the most appropriate investigation for the exclusion of neurosurgically
significant lesions, such as haemorrhage. Plain skull x-rays are not recommended [32].
1.4. Standardized measurement of post-traumatic amnesia (PTA) should be routinely performed to assist with the monitoring, A
diagnosis, early management and prognosis of patients who have experienced mTBI (see Appendix 1.2) [14].
1.5. Patients with mTBI can be safely discharged for home observation after an initial period of in-hospital observation if they A
meet the following clinical criteria [32]:
– Normal mental status (alertness/behaviour/cognition) with clinically improving post-concussive symptoms after observation
until at least 4 hours post-injury.
– No clinical risk factors indicating the need for CT scanning or normal CT scan result if performed due to presence of risk
factors.
– No clinical indicators for prolonged hospital observation such as:
– clinical deterioration
– persistent abnormal GCS or focal neurological deficit
– persistent abnormal mental status

– persistent clinical symptoms (vomiting/severe headache)
– presence of known coagulopathy (clinical judgement required)
– persistent drug or alcohol intoxication (clinical judgement required)
– presence of multi-system injuries (clinical judgement required)
– presence of concurrent medical problems (clinical judgement required)
– age 465 (clinical judgement required)
1.6. Patients with mTBI can be safely discharged for home observation after an initial period of observation if they meet the C
following discharge advice criteria [32]:
– Discharge summary prepared for primary care (or family) doctor.
– Written and verbal brain injury advice (Appendices 1.3 and 1.4) given to patient (and) nominated responsible person)
covering:
– Symptoms and signs of acute deterioration and when to seek urgent follow–up
– Lifestyle advice to assist recovery
– Typical post-concussive symptoms and reassurance about anticipated recovery
– Reasons for seeking routine follow-up
1.7. If the patient re-attends an emergency department/urgent care service with symptoms related to the initial injury, the following C
should be conducted [14]:
– Full re-evaluation, including an assessment for ongoing post-traumatic amnesia (PTA)
– CT scan, if indicated
– Emphasis and encouragement to the patients to attend their family physician for follow-up after discharge.
1.8. Clinicians should assess, monitor and document persisting somatic, cognitive and emotional/behavioural symptoms following C
mTBI using a standardized assessment scale (Appendix 1.5) [14].
2. Management of mTBI
2.1. Initial treatment of a patient with concussion/mTBI is based upon a thorough evaluation of signs and symptoms, pre-injury C
history (e.g. pre-morbid conditions) and concurrent potential contributing factors (e.g. co-morbid medical conditions,
medications, mental health difficulties, impact of associated concurrent injuries).y
2.2. Persons who complain about somatic, cognitive or behavioural difficulties after mTBI should be assessed and treated C
symptomatically, even if it has been a prolonged time after injury [23].
2.3. The patient should be advised that a full recovery of symptoms is seen in the majority of cases [14]. A
2.4. A patient experiencing reduced cognitive functioning in the first few days following injury, with education and support, A
should be expected, in the majority of cases, to have these symptoms resolve and pre-injury cognitive functioning return
within days or up to 3 months [14].
2.5. For patients who have (1) co-morbidities or identified health or risk factors (Table 1.1) and do not improve by 1 month or (2) C
persistent symptoms at 3 months post-injury, it is recommended that these patients be referred for more comprehensive evaluation to
a specialized brain injury environment (see Appendix 2.1) [14].
2.6. The primary care provider should consider the risk of depression or other mental health disorders in patients who have experienced B
mTBI, which may be influenced by psychosocial factors and psychological responses to the injury [14].
2.7. Multiple concussions should be considered a flag or signal that warrants a more intensive management strategy.y C
2.8. On presentation to healthcare providers, education about symptoms, including an advice card (Appendices 1.3 and 1.4) A
provided in writing and explained verbally, and reassurance should be provided to all patients and family members.
Education should ideally be delivered at the time of initial assessment or minimally within 1 week of injury/first assessment
[14, 39].
2.9. Individualized telephone or in-person follow-up with education on symptom management and encouragement to resume everyday A
activities should be provided over the 12 weeks after injury [40].
2.10. Education should be provided in printed material (Appendices 1.3 and 1.4) combined with verbal review and consist of [23]: A (a–d)
a. Symptoms and expected outcomes.
b. Normalizing symptoms (education that current symptoms are expected and common after injury event). C (e)
c. Reassurance about expected positive recovery.
d. Gradual return to activities and life roles.
e. Techniques to manage stress.
(continued )
Table II. Continued
3. Sports-related concussion
3.1. Patients with sport-related concussion may develop symptoms acutely or sub-acutely. If any one of the following signs/symptoms are C
observed/reported at any point following a blow to the head or elsewhere on the body leading to impulsive forces transmitted to the
head, concussion should be suspected and appropriate management instituted [7, 39].
a. symptoms: somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g. lability)
b. physical signs (e.g. loss of consciousness, amnesia)
c. behavioural changes (e.g. irritability)
d. cognitive impairment (e.g. slowed reaction times)
e. sleep disturbance (e.g. insomnia).
Refer to Table A for a comprehensive list of signs for possible concussion.
3.2. When a player shows any features of a concussion [7]: C
a. The player should be medically evaluated by a physician or other licensed healthcare provider onsite using standard
emergency management principles and particular attention should be given to excluding a cervical spine injury.
b. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no
healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician
arranged.
c. Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT3
(Appendices 3.1 and 3.2) or other similar tool.
d. The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial
few hours following injury.

e. A player with diagnosed or suspected concussion should not be allowed to return to play or practice on the day of injury. ‘If
in doubt, sit them out’.
3.3. The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded C
programme of exertion prior to medical clearance and return to play [7].
– An initial period of rest in the acute symptomatic period following injury (24–48 hours) may be of benefit.
– A sensible approach involves the gradual return to school and social activities (prior to contact sports) in a manner that does not
result in a significant exacerbation of symptoms.
3.4. A range of ‘modifying’ factors may influence the investigation and management of concussion and, in some cases, may predict the C
potential for prolonged or persistent symptoms. These modifiers would be important to consider in a detailed concussion history
and should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion
(see Table 3.1) [7].

3.5. Physicians or other licensed healthcare providers are encouraged to evaluate the concussed athlete for mood symptoms such as C
depression and anxiety, as these symptoms are common in all forms of traumatic brain injury [7].
3.6. Return to play protocol following a concussion follows a stepwise process as outlined in Table 3.2. With this stepwise progression, C
the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24
hours so that an athlete would take 1 week to proceed through the full rehabilitation protocol once he or she is asymptomatic at rest
and with provocative exercise. If any post-concussion symptoms occur while in the stepwise programme, then the patient should
drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed [7].
3.7. An important consideration in return to play is that athletes who have experienced concussion not only should be symptom free, but C
also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion [7].
4. General recommendations regarding diagnosis/assessment of persistent symptoms
4.1. Clinicians should assess, monitor and document persisting somatic, cognitive and emotional/behavioural symptoms following C
mTBI using a standardized assessment scale (Appendix 1.5) [14].z
4.2. The assessment and management of an individual with persistent mTBI-related symptoms should be directed toward the specific C
symptoms, regardless of their aetiology or elapsed time from injury [23].
4.3. The assessment should include a review of currently prescribed medications, over-the-counter medications/supplements and C
substance use, including alcohol.y
4.4. Persistent symptoms following mTBI can be non-specific. Therefore, careful and thorough differential diagnoses should be C
considered as similar symptoms are common in chronic pain, depression, anxiety disorders and other medical and psychiatric
disorders (see Table 4.1 and Appendix 4.1).y
5. General recommendations regarding management of persistent symptoms
5.1. Patients should be advised that they are likely to experience one or more symptoms as a consequence of the concussion/mTBI A
that may persist for a short period of time and that this is usually expected (normal course) [14].
5.2. The patient should be advised that a full recovery of symptoms is seen in the majority of cases [14].z A
5.3. Significant, prolonged complaints after mTBI should lead primary care providers to consider that many factors may A
contribute to [the persistence of] post-concussive symptoms (Table 1.1). All potential contributing factors should be
investigated and a management strategy considered [14].
5.4. Persons with mTBI and complicating health-related or contextual factors should be considered for early referral to a C
multidisciplinary treatment clinic (Appendix 2.1) capable of managing post-concussive symptoms because these factors have been
associated with poorer outcomes.y
5.5. The clinician should consider having a knowledgeable and supportive second-person informant (e.g. partner, family member, close C
friend, etc.) accompany the patient with mTBI to the initial assessment and to ongoing meetings if required to help the patient better
understand the condition and provide an opportunity to discuss any coping difficulties [23].
5.6. Low-level exercise for those who are slow to recover may be of benefit, although the optimal timing following injury for initiation of C
this treatment is currently unknown. However, 1 month post-injury has been proposed [34].
5.7. New onset pain and concussive injuries are often co-morbid. Comprehensive evaluation and management of the pain should be C
considered as it may contribute to negatively influencing other symptoms associated with mTBI.y
5.8. Education should be provided in printed material (Appendices 1.3 and 1.4) combined with verbal review and consist of [23]: A (a–d)
a. Symptoms and expected outcomes.
b. Normalizing symptoms (education that current symptoms are expected and common after injury event). C (e)
(continued )
Table II. Continued
c. Reassurance about expected positive recovery.
d. Gradual return to activities and life roles.
e. Techniques to manage stress.z
6. Post-traumatic headache
Assessment
6.1. Take a focused headache history (Table 6.1) in order to identify the headache sub-type(s) that most closely resembles the C
patient’s symptoms. To aid in determining the specific phenotype of headache disorder present, refer to the ICHD-II
classification criteria in Appendix 6.3. Unfortunately, some post-traumatic headaches are unclassifiable.y
6.2. Establish the degree of headache-related disability (i.e. missed work/school, decreased productivity, missed social/recreational C
activities, bedridden) to assist in stratifying a treatment approach (see Appendix 6.5).y
6.3. Perform a neurologic exam and musculoskeletal exam including cervical spine examination (refer to Appendix 6.6).y C
Non-pharmacological treatment
6.4. Education should be provided on lifestyle strategies and simple, self-regulated intervention strategies that may minimize headache C
occurrence. For more details on lifestyle management, see Appendix 6.7.y
6.5. Consideration should be given to non-pharmacological therapies targeted to the presumed source of the headache, including C
relaxation therapy, biofeedback, massage therapy, manual therapy of the spine, acupuncture, vision therapy and cognitive
behavioural therapy.y
Pharmacological treatment
6.6. All patients with frequent headaches should be required to maintain an accurate headache and medication calendar in order to C
accurately gauge symptoms and guide management.y
6.7. Based upon the patient’s headache characteristics, consideration may be given to using acute headache medications, limited to 515 C
days per month, including:
1. Over-the-counter or prescription NSAIDs (e.g. Tylenol);
2. Acetylsalicylic acid;
3. Acetaminophen; and
4. Combination analgesics (with codeine or caffeine).y
6.8. For patients with post-traumatic headaches that are migrainous in nature, the use of migraine-specific abortant triptan class B
medications (i.e. almotriptan, eletriptan, sumatriptan, rizatriptan, zolmitriptan, etc.) may be effective but should be limited to 510
days per month [41].
6.9. Narcotic analgesics should be avoided or restricted to ‘rescue therapy’ for acute attacks when other first- and second-line therapies C
fail or are contraindicated.y
6.10. Prophylactic therapy should be considered if headaches are occurring too frequently or are too disabling or if acute headache C
medications are contraindicated, poorly tolerated or being used too frequently (see Appendix 6.8).y
6.11. Post-traumatic headaches may be unresponsive to conventional treatments. If headaches remain inadequately controlled, referral to C
a neurologist, pain management specialist or traumatic brain injury clinic is recommended.y
7. Persistent sleep/wake disturbances
Assessment
7.1. Every person with concussion/mTBI who has identified sleep problems should be screened for sleep/wake disturbances (e.g. C
insomnia, excessive daytime sleepiness; Appendices 7.2 and 7.3).y
7.2. Screen for medical conditions, current medication use, co-morbid psychopathology and risk factors for sleep disturbances, which C
may influence the sleep/wake cycle (Table 7.1).y
7.3. Refer for sleep specialist consultation, ideally with experience in assessing mTBI, and polysomnography (e.g. sleep study, Multiple C
Sleep Latency Test, Maintenance of Wakefulness Test) if sleep disturbances persist or if there is suspicion of sleep-related breathing
disorders, nocturnal seizures, periodic limb movements or narcolepsy.y
Treatment
7.4. Treating sleep/wake disturbances may positively affect other persistent symptoms (e.g. mood, anxiety, pain, fatigue, cognitive C
problems). Sleep/wake disturbances should, thus, be assessed and managed even in the presence of other problems.y
7.5. All patients with persistent sleep/wake complaints should be placed on a programme of sleep hygiene in addition to other C
interventions (or as part of a programme of cognitive-behavioural therapy). See Appendix 7.4 for a sleep hygiene programme and
Appendix 7.5 for behavioural recommendations for optimal sleep.y
7.6. Cognitive-Behavioural Therapy (CBT) for Insomnia is established as the treatment of choice for either primary insomnia or B
insomnia co-morbid to a medical or psychiatric condition [42].
7.7. If medications are to be used, then the aim should be to use medications that will not produce dependency and have minimal adverse C
effects for mTBI patients. The aim is to establish a more routine sleep pattern. Medications should be used on a short-term basis
only.
– Medications that can be used include trazodone, mirtazapine and tricyclic antidepressants (e.g. amitryptyline).
– Benzodiazapines should generally be avoided; however, newer non-benzodiazepine medications (e.g. zopiclone, eszopiclone) may
have fewer adverse effects and may be considered for short-term use [43, 44].
7.8. Other non-pharmacologic treatment options that have been found to be useful in the treatment of insomnia include [45]: C
– Daily supplements of magnesium, melatonin and zinc.
– Consider other interventions such as acupuncture, exercise and mindfulness-based stress reduction.
8. Persistent mental health disorders
Assessment
8.1. Given their prevalence and potential impact, all patients with persistent symptoms following concussion/mTBI should be C
screened for mental health symptoms and disorders, including:
– depressive disorders (Appendix 8.2)
– anxiety disorders, including post–traumatic stress disorder (PTSD) (Appendices 8.3 and 8.4)
– irritability and other personality changes
(continued )
Table II. Continued
– substance use disorders (Appendix 8.5)
– somatoform disordersy
8.2. The use of self-report questionnaires can aid in the assessment and monitoring of common mental health disorders.y C
8.3. Referral to a psychiatrist/mental health team should be obtained if [39]: C
– the presentation is complex and/or severe;
– the risk of suicide is judged significant;
– initial treatment is not effective within 2 months;
– failure of or contraindication to usual medication strategies;
– presence of prominent/major risk factors known to potentially affect the course of recovery (see Table 1.1).
Non-pharmacological treatment
8.4. Treatment of emotional/behavioural symptoms following mTBI should be based upon individual factors, patient preference and C
symptom severity and co-morbidity; it may include psychotherapeutic and/or pharmacological treatment modalities. See Algorithm
8.1 which outlines care pathways for different severities [23, 46]. See Algorithm 8.1 which outlines care pathways for different
severities.
a. Mild, moderate: consider management by a local healthcare provider or referral to a psychologist or psychiatrist if unable to manage.
b. Severe: consider referral to a psychologist or psychiatrist as required.
8.5. While awaiting specialist referral, the initial steps of treatment should not be delayed, nor symptoms left unmanaged. General C
measures can be instituted and common symptoms such as headache, sleep disturbance, dizziness and pain addressed in an ongoing
manner.y
8.6. Cognitive-Behavioural Therapy (CBT) has well-established efficacy for treatment of primary mood and anxiety disorders; as such, it A
may be appropriate in the treatment of mood and anxiety symptoms following mTBI [47].
Pharmacological treatment
8.7. When prescribing any medication for patients who have sustained a mTBI, the following should be considered [23]: C
a. Use caution when initiating pharmacologic interventions to minimize potential adverse effects on arousal, cognition, motivation and
motor co-ordination.
b. Start at the lowest effective dose and titrate slowly upwards, based upon tolerability and clinical response. Allow adequate time and
duration for drug trials.
c. Avoid making more than one medication change at a time (i.e. when adding new medications or changing doses). Doing ‘one thing
at a time’ will enable more accurate assessment of drug benefits and potential adverse effects.
d. Follow-up should occur at regular intervals: initially more frequently while increasing medication to monitor tolerability and
efficacy.
For more details regarding pharmacotherapy after mTBI, refer to Table 8.1.
8.8. An SSRI is generally recommended as the first-line pharmacological treatment for mood and anxiety syndromes after mTBI. In C
some cases, however, the combination of sedative, analgesic and headache prophylaxis effects from a tricyclic (TCA) may be
desirable, yet these agents may generally be considered second-line. Other second-line options include mirtazapine, an alternate
SSRI or an SNRI [46].
8.9. After successful treatment of depression with an SSRI, the optimal duration of continuation/maintenance treatment remains A
inconclusive [48].
8.10. SSRIs are also recommended as first-line pharmacotherapy for PTSD after mTBI; the SNRI venlafaxine may be considered C
second-line. Both can improve the core symptom of re-experiencing, hyperarousal and avoidance. Marked sleep disruption may
require adjunctive treatment with trazodone, mirtazapine or prazosin. Prazosin in particular can decrease trauma-related
nightmares. Benzodiazepines do not reduce the core symptoms of PTSD; their long-term use to manage PTSD is not recommended
[49–51].
9. Persistent cognitive difficulties
Assessment
9.1. A patient sustaining a concussion/mTBI should be evaluated for cognitive difficulties using a focused clinical interview, in C
conjunction with a validated post-concussive questionnaire (Appendix 1.5) and cognition screening tool (Appendix 9.1).y
9.2. Certain conditions can affect cognition, such as ADHD, learning disabilities, anxiety or mood disorders, pain, fatigue, sleep C
disturbance, neuroendocrine dysfunction or substance abuse. These conditions can be co-morbid with mTBI and should be
considered and evaluated as necessary.y
9.3. A patient experiencing reduced cognitive functioning in the first few days following injury, with education and support, A
should be expected, in the majority of cases, to have these symptoms resolve and pre-injury cognitive functioning return
within days, up to 3 months [14].z
9.4. Patients who have cognitive symptoms that are not resolving and continue to interfere in daily functioning (e.g. school, work) A
should be considered for referral for neuropsychological assessment. The evaluation may assist in clarifying appropriate
treatment options based on individual patient characteristics and conditions [52, 53].
Treatment
9.5. Rehabilitation of cognitive impairments should be initiated if: C
i. The individual exhibits persisting cognitive impairments on formal evaluation or
ii. The learning of compensatory strategies is necessary in order to facilitate the resumption of functional activities and work [36].
9.6. For cognitive sequelae following mTBI, the cognitive rehabilitation strategies that should be considered include compensatory A
strategies and remediation approaches [54].
9.7. If persisting cognitive deficits are identified by neuropsychologists or other health professionals, efforts should be made to inform C
employers or teachers of possible temporary accommodations to tasks or schedules (see Section 12) so as to avoid excessive anxiety
related to cognitive difficulties and experiencing of repeated errors or setbacks in work or school.y
(continued )
Table II. Continued
10. Persistent vision and vestibular (balance/dizziness) dysfunction

Vestibular (balance/dizziness) dysfunction
10.1. Evaluation should include a thorough neurologic examination that emphasizes vision, vestibular, balance and co-ordination and C
hearing [23]. See Table 10.1 for specific exam details.
10.2. If symptoms of benign positional vertigo are present, the Dix-Hallpike Manoeuvre (see Appendix 10.1) should be used for A
assessment [55].
10.3. A canalith repositioning manoeuvre (Appendix 10.1) should be used to treat benign positional vertigo if the Dix-Hallpike A
Manoeuvre is positive [55].
10.4. For persons with functional balance impairments and screening positive on a balance measure, consideration for further balance C
assessment and treatment by a qualified healthcare professional may be warranted pending clinical course.y
10.5. Vestibular rehabilitation therapy is recommended for unilateral peripheral vestibular dysfunction [55]. A
10.6. When the patient identifies a problem with hearing the following steps should be followed [23]: C
1. Perform an otologic examination.
2. Review medications for ototoxicity.
3. Refer to audiology for hearing assessment if no other apparent cause is found.
10.7. When the patient identifies a problem with nausea, the following steps should be followed [23]: C
1. Define triggers and patterns of nausea and conduct appropriate investigations as required.
2. Assess medication list for agents that may cause or worsen GI symptoms.
3. Perform oropharyngeal examination.
4. Assess vision and vestibular/balance systems.

Persistent vision dysfunction
10.8. Take an appropriate case history, including questions on visual blur, scanning/reading ability, light sensitivity, diplopia, eyestrain, C
motion sensitivity and spatial deficits (indicating loss of visual field integrity). See Table 10.2 for a detailed description of
symptoms and their related vision dysfunction.y
10.9. Perform tests of visual acuity, extra-ocular motility, vergence, visual fields, pupils and fundoscopy. See Appendix 10.2 for an C
explanation of screening techniques.y
10.10. Other functional vision changes should be given consideration for referral to a qualified optometrist specializing in neuro- B
optometric rehabilitation for vision therapy [56].
11. Persistent fatigue
11.1. Determine whether fatigue is a significant symptom by taking a focused history and reviewing the relevant items from administered C
questionnaires (Appendix 11.1).y
11.2. Characterize the dimensions of fatigue (e.g. physical, mental, impact on motivation) and consider alternative or contributing, C
treatable causes that may not be directly related to the injury. Please refer to Table 11.1 for further information about primary and
secondary causes, as well as appropriate treatment strategies for different types of fatigue.y
11.3. If identified as a significant symptom, some key considerations that may aid in the management of persistent fatigue can include C
[39]:
– Aiming for a gradual increase in activity levels that will parallel improvement in energy levels.
– Reinforce that pacing activities across the day will help patients to achieve more and to avoid exceeding tolerance levels.
– Encouraging good sleep hygiene (especially regularity of sleep/wake schedules and avoidance of stimulants and alcohol) and proper
relaxation times.
– Using a notebook or a diary to plan meaningful goals, record activity achievement and identify patterns of fatigue.
– Acknowledging that fatigue can be exacerbated by low mood or stress.
Provide patients with a pamphlet containing advice on coping strategies for fatigue (see Appendix 11.3).
12. Return to activity considerations
General principles regarding rest & return-to-Activity
12.1. Immediately following any concussion/mTBI, individuals who present with and/or report post-injury symptoms should have a C
period of rest to facilitate a prompt recovery and should be provided with recommendations to avoid activities that would increase
their risk for sustaining another concussion. This is particularly important during the recovery period [23].
12.2. Bed rest exceeding 3 days is not recommended [34]. C
12.3. Individuals with mTBI should be encouraged to gradually return to normal activity (work, physical, school, duty, leisure) based C
upon their tolerance [23].
12.4. If a person’s normal activity involves significant physical activity, exertion testing can be conducted that includes stressing the C
body (e.g. graded treadmill exercise test). If exertion testing results in a return of symptoms, a monitored progressive return to
normal activity as tolerated should be recommended [23].
12.5. Low-level exercise for those who are slow to recover may be of benefit, although the optimal timing following injury for initiation C
of this treatment is currently unknown. However, 1 month post-injury had been proposed [34].z
Additional return to work considerations
Vocational screening
12.6. In instances where there is high risk for injury/re-injury and/or there is a possibility that the individual may not be able to safely and C
competently complete specific work-related tasks and duties, a more in-depth assessment of symptoms should be conducted and
necessary accommodations and work restrictions identified [23].
12.7. Individually based work restriction should apply if [23]: C
– There is a work specific task that cannot be safely or competently completed based on symptoms
– The work/duty environment cannot be adapted to the patient’s symptom-based limitation
– The deficits cannot be accommodated
– Symptoms re-occur
(continued )
Table II. Continued
Examples of vocational modifications include:
– Modification of the length of the work day
– Gradual work re–entry (e.g. starting at 2 days/week and expanding to 3 days/week)
– Additional time for task completion
– Change of job
– Environmental modifications (e.g. quieter work environment; enhanced level of supervision)
Vocational evaluation
12.8. Individuals who continue to experience persistent impairments following mTBI or those who have not successfully resumed pre- B
injury work duties following injury should be referred for a fuller in-depth vocational evaluation by clinical specialists and teams
(e.g. occupational therapist, vocational rehabilitation counsellor, occupational medicine physician, neuropsychologist, speech
language pathologist) with expertise in assessing and treating concussion/mTBI. This evaluation should include an assessment of
the person, occupational and job demands, work environment, environmental supports and facilitators and barriers to successful
work/return to work (see Appendix 12.1) [35].
Community re-integration & future vocational planning
12.9. A referral to a structured programme that promotes community integration (e.g. volunteer work) may also be considered for B
individuals with persistent post-concussive symptoms that impede return to pre-injury participation in a customary role [23].
Additional return-to-school considerations
12.10. On presentation, the primary care provider should conduct a comprehensive review of every patient who has sustained A
mTBI (see Appendix 1.1). The assessment should include taking a history, examination, cognitive screen, post-concussive
symptom assessment and review of mental health (see Table 1.2) [14].z
12.11. If symptomatic within the first 72 hours, the student should refrain from attending school and from participating in all academic C
activities, including apprenticeship, practicum and shop-related activities, in order to support cognitive rest and facilitate
recovery.y
12.12. If asymptomatic within the first 72 hours, the student can attend school but should not undergo evaluations (tests/exams) or should C
write with accommodations (such as separate space/breaks). The student should also be monitored for the emergence of potential
symptoms.y
12.13. After 72 hours post-injury, the individualized profile of the student’s symptoms should be considered: C
– If the student is symptom-free, then he/she should go back to academic and/or programme-related activities gradually as tolerated,
as long as the student remains asymptomatic.
– If still experiencing symptoms after 72 hours post-injury, the student should refrain from attending academic and/or programme-
related activities for one full week. The healthcare provider (with permission) should also notify student services or the special needs
department that a concussion has occurred (see Appendix 12.2) and that the student will require time off and may require
accommodations and support for re-integration.y
12.14. If symptoms are still functionally debilitating at 1 week post-injury, the student should refrain from attending academic and/or C
programme-related activities for another week. The healthcare provider should notify student services or the special needs
department that the student is still symptomatic and accommodations and support for re-integration will be required.y
12.15. After 2 weeks following an mTBI, the student should start attending school (non-physical activities) very gradually as tolerated C
and with accommodations, even if he/she is still experiencing symptoms. Student services or the special needs department should
be identified to notify teachers/professors to subsequently monitor progress with the student and adjust the return-to-school plan,
as necessary.y
12.16. If re-integration into school is ineffective or unproductive at 4 weeks (i.e. symptoms plateau/continue to get worse), consider the C
following:
– Greater accommodations: work with the professor/instructor or appropriate administrator and the student to look at the cognitive
demands of various classes, with consideration of the student’s current symptoms, to determine if appropriate accommodations can
be made in the following areas as necessary: curriculum, environment, activities and timetable (see Appendix 12.3).
– Move the student’s courses to audit status, allowing them to participate in some academic activity without significant pressure from
course requirements and examination.
– Review whether the student should continue in the programme for that term if there will be substantially negative consequences to
their grades and programme participation.y
*Grade A evidence includes at least one randomized controlled trial, meta-analysis or systematic review; grade B evidence includes at least one cohort
comparison, case study or other type of experimental study; grade C evidence includes expert opinion or the experience of a consensus panel.
yRecommendation based on consensus of mTBI Expert Consensus Group.
zNot an original recommendation (i.e. repeated elsewhere in the guideline).
Appendices, tables and figures referred to in the table are located in the full guideline document [26]. Recommendations in boldface are key
recommendations for implementation, based on priority votes from the mTBI Expert Consensus Group.
The following system was used for grading levels of originally developed this grading system for the first edition
evidence and was applied to the guideline recommendations: of the guideline [25].
grade A evidence included at least one randomized controlled A draft of the guideline was circulated for external review
trial, meta-analysis or systematic review; grade B evidence to recognized experts in the field and stakeholders who did
included at least one cohort comparison, case study or other not participate in the development process. The external
type of experimental study; and grade C evidence included reviewers were requested to provide input about the validity
expert opinion or the experience of a consensus panel. The and relevance of the guideline. This feedback was incorpo-
project team (i.e. the authors of the current manuscript) rated into the final draft.
The complete guideline document can be obtained from Additionally, the expert consensus group was expanded in
the Ontario Neurotrauma Foundation’s website (http:// the current guideline to ensure greater representation of the
onf.org/documents/guidelines-for-concussion-mtbi-persistent- various healthcare professions treating mTBI as well as
symptoms-second-edition), where detailed information about domain of expertise. Experts in persistent vision and sleep/
the source of individual recommendations is provided in a wake disturbances sections were added to the team.
supplementary document. Each section within the guideline Accordingly, both topic areas have been expanded in the
also includes background information pertaining to each current update, with additional resources developed by
topic, providing context for the specific recommendations. experts in these fields (e.g. behavioural recommendations of
Each section also includes relevant resources (e.g. list of risk sleep restriction and stimulus control that can be implemented
factors influencing recovery following mTBI) and various by primary care providers treating persistent sleep/wake
tools that can aid in assessment and treatment of symptoms disturbances, as well as screening techniques for vision
(e.g. patient advice sheet, standardized questionnaires) are dysfunction).
provided in the Appendices (http://www.concussionsontario. To assist with implementation of the guidelines, treatment
org/guidelines-for-concussionmtbi-persistent-symptoms- algorithms were created and added to the current update with
second-edition/). the aim of standardizing and improving decision-making in
assessment and application of interventions for mTBI. One of
the algorithms was adapted from an existing mTBI guideline
Key changes in the current update
for acute assessment and management of mTBI [32], while
During the voting process for the updated guidelines, experts the remaining algorithms were developed by the project team
were asked to prioritize the 20 most important recommenda- based on the updated recommendations and evidence.
tions for implementation using a ranking process involving Specifically, algorithms have been provided for: acute
four votes for each of five rank categories (1 [high] to 5 assessment and management of mTBI; general recommenda-
[highest]), for a total of 20 prioritization votes. Guideline tions for the management of persistent symptoms; return-
recommendations with a summed prioritization score greater to-work/school considerations; and management of persistent
than 20 are highlighted in boldface in the current guideline as post-traumatic headache, mental health disorders and sleep/
key recommendations for implementation. This prioritization wake disturbances. These algorithms were further revised by
process is designed to help the treating healthcare provider to the expert consensus panel and external reviewers prior to
evaluate and implement the guideline recommendations, as inclusion in the final guideline.
it can direct where and how initial efforts should be made to Other key modifications in the current update include
change practice. interactive hyperlinking within the electronic guideline for
A further change is the emphasis on direction for easier navigation to resources that can aid in the implemen-
management of post-secondary students following an mTBI tation of the recommendations and links to video demonstra-
and for those with persistent symptoms. The impact that tions of suggested assessment procedures (e.g. neurological
mTBI symptoms have on students’ ability to manage their and musculoskeletal examination). The current guidelines are
academic programmes is gaining greater recognition in also available to download in a variety of lengths, including a
academic and clinical communities. In particular, there is a full-length version containing the methodology and accom-
growing body of literature indicating that cognitive exertion panying appendices, a clinical version (without methodology)
can exacerbate mTBI symptoms and impede recovery [57]. and individual modules by symptom topic area, to meet the
A number of guidelines focus primarily on cognitive wide-ranging needs of healthcare providers treating patients
management strategies for elementary and secondary school with persistent symptoms after mTBI.
students, but they have limited applicability for the post-
secondary student because the nature of programme require-
Limitations
ments as well as the accommodations and concessions
available to the student differ at the post-secondary level. Our guidelines remain constrained by the limits in supporting
Accordingly, the current guideline update includes a section evidence for many of the topic areas for which practice
on return-to-school management strategies, which were recommendations were considered necessary and relevant.
developed to address the unique issues faced by students The body of evidence upon which the current guideline is
who are either entering post-secondary institutions with an based includes high quality evidence (e.g. randomized
identified mTBI and/or have sustained an mTBI in the course controlled trials, meta-analysis) for the acute assessment
of their post-secondary programme. Above all, recommenda- and management of mTBI; however, recommendations for the
tions focus on the management of the cognitive demands of management of persistent symptoms post-injury are primarily
post-secondary education, as this is considered to be pivotal supported by expert consensus opinion (grade C), owing to
in maximizing successful academic re-integration. Early limited high-quality studies evaluating treatment for persistent
and regular communication between the student, care symptoms following mTBI and limited guideline recommen-
providers, teachers and academic administrators regarding dations on chronic management. Thus, further research is
progress and any changes in symptoms is also needed on the effectiveness of treatments or interventions
emphasized. However, these recommendations are based intended to manage persistent symptoms following mTBI.
solely on expert consensus opinion. This area represents an Areas that require immediate attention include: persistent
important gap in mTBI knowledge that should be addressed sleep/wake disturbances and fatigue, vision dysfunction, post-
by future research. traumatic headache and return to activity/work/post-
secondary school following mTBI. Research is also required cohort. Journal of Neurology, Neurosurgery & Psychiatry 2012;83:
1086–1091.
to determine the best methods for guideline uptake and 2. Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny
implementation across different types of healthcare profes- KI. Disability in young people and adults one year after head injury:
sionals in various settings. Prospective cohort study. British Medical Journal 2000;320:
1631–1635.
3. Whitnall L, McMillan TM, Murray GD, Teasdale GM. Disability in
Conclusion young people and adults after head injury: 5-7 year follow up of a
prospective cohort study. Journal of Neurology, Neurosurgery &
The second iteration of the Guidelines for Concussion/Mild Psychiatry 2006;77:640–645.
Traumatic Brain Injury & Persistent Symptoms provides an 4. Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J.
up-to-date framework for healthcare professionals treating Mild traumatic brain injury in the United States, 1998–2000. Brain
Injury 2005;19:85–91.
patients with concussion/mTBI with the intent of either 5. Ryu WH, Feinstein A, Colantonio A, Streiner DL, Dawson DR.
preventing or minimizing the impact of persistent symptoms. Early identification and incidence of mild TBI in Ontario. Canadian
Although ongoing research is needed to improve the Journal of Neurological Sciences 2009;36:429–435.
evidence-base supporting various interventions for mTBI 6. Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L,
Kraus J, Coronado VG, WHO Collaborating Centre Task Force on
and the presence of persisting symptoms, the recommenda-
Mild Traumatic Brain Injury. Incidence, risk factors and prevention
tions listed within the guideline serve to address a large gap in of mild traumatic brain injury: Results of the WHO Collaborating
the current literature on treatment following mTBI. Centre Task Force on Mild Traumatic Brain Injury. Journal of
Rehabilitation Medicine 2004;43:28–60.
7. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorak J,
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stood: Toronto doctor. Toronto, Canada: The Toronto Star
The authors report no conflicts of interest. The Ontario [Internet]; 2013. Available online at: http://www.thestar.com/life/
Neurotrauma Foundation initiated and funded the develop- health_wellness/2013/07/22/longterm_effects_of_concussions_mi-
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What are the main symptoms that can persist after mTBI?

What are the main symptoms that can persist after mTBI?

What percentage of individuals with mTBI may continue experiencing symptoms after 1 year?

What percentage of individuals with mTBI may continue experiencing symptoms after 1 year?

http://informahealthcare.

Brain Inj, Early Online: 1–13

Updated clinical practice guidelines for concussion/mild traumatic brain

Introduction While the diagnosis of concussion is often related to a sport

Figure 1. PRISMA Group flow diagram [37]:

Records after duplicates removed

Eligibility Full-text articles assessed Full-text articles excluded,

Studies included in the

– persistent abnormal mental status

Table II. Continued

few hours following injury.

(see Table 3.1) [7].

Table II. Continued

10. Persistent vision and vestibular (balance/dizziness) dysfunction

4. Assess vision and vestibular/balance systems.

Table II. Continued

Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS,

Medical Publishing LLC; 2012.

toms in patients with mild head injury. European Journal of

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