Diagnosis/Assessment of Prolonged Symptoms

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Most patients will recover from concussion-related symptoms within the first few weeks following injury; however, a smaller percentage (15-20%) of individuals will experience prolonged symptoms beyond one month1. A number of factors influence the rate of recovery from a concussion, including the mechanism and setting for the initial injury. For example, concussion due to non-sport-related causes can be unexpected, emotionally charged, or associated with multiple or even life-threatening injuries2. Some individuals have higher risk factors for prolonged symptoms and poorer outcomes (see Table 1.1) which may signal the need to monitor patient recovery more closely.3,4 For persons with prolonged symptoms at 1 month post-injury, referral for specialized assessment and/or interdisciplinary concussion services/clinics may be indicated 5-7. 

There is controversy regarding the diagnosis of prolonged symptoms post-concussion because there is significant symptom overlap with other conditions which may result as a consequence of a traumatic experience. For example, differential diagnoses such as depression, anxiety, and post-traumatic stress disorder, as well as the sequelae of pain related to comorbid conditions such as post-traumatic headache or whiplash-associated disorder should be considered 8-10. 

The diagnosis and assessment of prolonged symptoms needs to be addressed in a coordinated fashion in order to facilitate symptom improvement and potential recovery. The assessment and monitoring of symptoms may be facilitated using valid assessment tools.

References supporting introduction:

  1. Theadom A, Parag V, Dowell T, McPherson K, Starkey N, Barker-Collo S, et al. Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. Br J Gen Pract J R Coll Gen Pract. 2016;66(642):e16–23. 24. 
  2. Varner C, Thompson C, de Wit K, Borgundvaag B, Houston R, McLeod S. Predictors of persistent concussion symptoms in adults with acute mild traumatic brain injury presenting to the emergency department. CJEM. 2021;23(3):365–73. 
  3.  Ponsford J, Willmott C, Rothwell A, et al. Factors influencing outcome following mild traumatic brain injury in adults. J Int Neuropsychol Soc. 2000;6(5):568-579.
  4. Kashluba S, Paniak C, Casey JE. Persistent symptoms associated with factors identified by the WHO Task Force on Mild Traumatic Brain Injury. Clin Neuropsychol. 2008;22(2):195-208.
  5.  Möller, M. C., Lexell, J., & Wilbe Ramsay, K. Effectiveness of specialized rehabilitation after mild traumatic brain injury: A systematic review and meta-analysis. Journal of rehabilitation medicine. 2021;53(2). 
  6. Rytter, H. M., Graff, H. J., Henriksen, H. K., Aaen, N., Hartvigsen, J., Hoegh, M., Nisted, I., Næss-Schmidt, E. T., Pedersen, L. L., Schytz, H. W., Thastum, M. M., Zerlang, B., & Callesen, H. E. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation. JAMA network open. 2021;4(11), e2132221. 
  7. DeGraba, T. J., Williams, K., Koffman, R., Bell, J. L., Pettit, W., Kelly, J. P., Dittmer, T. A., Nussbaum, G., Grammer, G., Bleiberg, J., French, L. M., & Pickett, T. C. Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions. Frontiers in neurology. 2021;11, 580182.  
  8.  Rakers SE, Timmerman ME, Scheenen ME, et al. Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury: A 6-Month Prospective Cohort Study. Arch Phys Med Rehabil. 2021;102(10):1965-1971.e2. doi:10.1016/j.apmr.2021.06.004
  9. Losoi H, Silverberg ND, Wäljas M, et al. Recovery from Mild Traumatic Brain Injury in Previously Healthy Adults. J Neurotrauma. 2016;33(8):766-776. doi:10.1089/neu.2015.4070
  10. Eman Abdulle A, van der Naalt J. The role of mood, post-traumatic stress, post-concussive symptoms and coping on outcome after MTBI in elderly patients. Int Rev Psychiatry. 2020;32(1):3-11. doi:10.1080/09540261.2019.1664421
4.1

Prolonged physical, cognitive, and/or psychological symptoms following concussion can be nonspecific and may overlap. Therefore, careful and thorough differential diagnoses should be considered as similar symptoms are common in chronic pain, depression, anxiety disorders, sleep disorders and other medical and psychiatric disorders (e.g., headache, pain, fatigue, concentration problems, etc.) (see Table 4.1 and Appendix 4.1).

Symptoms following concussion may be impacted by non-injury factors and may exacerbate pre-existing conditions. Regardless of the timing of symptom onset, the clinician must consider the potential for overlap of symptoms among conditions such as pain, sleep disturbances, or mood disorders. 

References supporting context:

  1. Hsu HH, Lai WH, Yu HT, et al. Long-Term Presentation of Postconcussion Symptoms and Associated Factors: Analysis of Latent Class Modeling. Arch Clin Neuropsychol. 2021;36(1):62-73. 
  2. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October  2016. Br J Sports Med. 2017;51(11):838-847.
Level of Evidence A
Last updated  
4.2

Prolonged symptoms following concussion should be documented using a standardized symptom assessment scale (i.e., Rivermead Post-Concussion Symptoms Questionnaire or the Sport Concussion Assessment Tool (SCAT-5)) at follow-up appointments until concussion symptoms improve or stabilize.

A large proportion of patients will recover from concussion-related symptoms within the first few weeks following injury; however, a smaller percentage (~20-30%) of individuals will experience prolonged symptoms (i.e, >1 month). Prolonged symptoms should be assessed using a standardized symptom inventory. There are multiple recommended assessment tools with the aim of assessing recovery and guiding intervention in this population. For patient convenience, these patient reported outcome measures (PROMs) may be administered in different settings (i.e., pre-visit questionnaires, waiting room questionnaire, in-clinic administration) and formats (i.e., paper, computer-based).

References supporting context:

  1. Dwyer B, Katz DI. Postconcussion syndrome. Handb Clin Neurol. 2018;158:163-178.
  2. Theadom A, Parag V, Dowell T, McPherson K, Starkey N, Barker-Collo S, et al. Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. Br J Gen Pract J R Coll Gen Pract. 2016;66(642):e16-23.
  3. Varner C, Thompson C, de Wit K, Borgundvaag B, Houston R, McLeod S. Predictors of persistent concussion symptoms in adults with acute mild traumatic brain injury presenting to the emergency department. CJEM. 2021;23(3):365-73.
  4. Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016;315(10):1014-25.
Level of Evidence C
Last updated  
4.3

The assessment and management of an individual with prolonged concussion-related symptoms should be directed towards specific symptoms identified with a standardized assessment tool. The patient’s most prominent symptoms or impairments should be directly assessed, including:

  • Headache (i.e., physical examination of the head and cervical spine) 
  • Mood (i.e., depression, anxiety, post-traumatic stress disorder (View Appendix 8.3 and 8.4) and other trauma and stressor-related disorders)
  • Sleep
  • Vestibular function and balance and/or oculomotor function (VOMS or mVOMS)
  • Cognitive symptoms (memory loss, attention)
  • Headache (i.e., physical examination of the head and cervical spine)

Headache, mood and insomnia are often considered the most debilitating symptoms following concussion and frequently impede the ability to administer active rehabilitation interventions such as vestibular or cognitive-based therapies. These symptoms should be prioritized for assessment and managed with targeted interventions.

References supporting context:

  1. Quinn, D. K., Mayer, A. R., Master, C. L., & Fann, J. R. Prolonged Postconcussive Symptoms. The American Journal of Psychiatry. 2018;175(2), 103-111.
Level of Evidence B
( Headache )
Level of Evidence C
( Mood )
Level of Evidence C
( Sleep )
Level of Evidence B
( Vestibular )
Level of Evidence C
( Cognition )
Level of Evidence A
( Neck Pain )
Last updated  
4.4

The assessment of prolonged symptoms should include a review of currently prescribed medications (and adherence), over-the-counter medications/supplements and substance use, including alcohol, cannabis and other drugs.

It is important to review with patients what they are taking as they may not recognize that some of their symptoms could be exacerbated by medications or substances. Lack of adherence to prescribed medication use or over the counter medication dosing and use can also impact potential for recovery. Another frequent concern is the  potential for commonly encountered complications such as medication overuse headache with the use of simple analgesics.

References supporting context:

  1. Halstead M. E. (2016). Pharmacologic Therapies for Pediatric Concussions. Sports Health, 8(1), 50-52.
  2. Wakerley BR. Medication-overuse headache. Pract Neurol. 2019;19(5):399-403.
Level of Evidence C
Last updated  
4.5

Patients should be encouraged to become gradually more active and should be educated about tolerance levels. Specifically, for any activity (physical or cognitive),  they should recognize the point at which mild symptoms have onset and push to or beyond that point in a manner that does not result in a significant or prolonged exacerbation of symptoms.

There is insufficient evidence that prescribing complete rest may ease discomfort by mitigating post-concussion symptoms and/or that rest may promote recovery by minimizing brain energy demands following concussion (i.e., do not promote bed rest). Patients should gradually return to activity as tolerated. With repetition, the patient will ideally be able to advance the duration of these activities. Consider using a narrative analogy with your patient regarding ankle sprain and recovery. For example, if the patient were to rest until all pain is gone, symptoms may be prolonged and there is elevated risk for re-injury. However, if the patient were to return to regular activity immediately post-injury, the injury may worsen. Returning to activity as tolerated in this context would consist of walking on an injured ankle with mild discomfort while functionally improving with time. Therefore, following an initial period of relative rest, the patient is encouraged to gradually engage in activities which cause minimal worsening of symptoms, so long as the symptoms resolve shortly afterwards. Lingering symptoms should not prevent activities of daily living or persist in affecting functioning the following day. Examples of activities may include walking, reading, cleaning the home or completing puzzles. The patient can take part in these activities until mild onset of symptoms occurs, prompting them to rest. This tolerance level may be extended for the following session.

References supporting context:

  1. Ettenhofer, M. L., Remigio-Baker, R. A., Bailie, J. M., Cole, W. R., & Gregory, E. Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members. Neurotrauma Reports. 2020;1(1), 137-145.
  2. Maerlender, A., Rieman, W., Lichtenstein, J., & Condiracci, C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Developmental Neuropsychology. 2015;40(5), 273-278.
  3. Schweizer TA, Baker AJ, eds. Tackling the Concussion Epidemic. Springer International Publishing; 2022.
Level of Evidence B
Last updated  
Appendix 1.5
Rivermead Post Concussion Symptoms Questionnaire
Appendix 1.6
Post Concussion Symptom Scale
Appendix 4.1
ICD-10 Definitions for Differential Diagnosis Related to mTBI
appendix-4-1.pdf
Table 4.1
Differential Diagnoses Related to mTBI
Table 1.1
Risk Factors Influencing Recovery Post mTBI
Appointment Tracker
Appendix 3.1
Sport Concussion Assessment Tool 5th Edition
appendix-3-1.pdf
Appendix 8.1
PHQ-9
appendix-8-1.pdf
Appendix 8.2
GAD-7
appendix-8-2.pdf
Appendix 8.3
PC-PTSD-5
appendix-8-3.pdf
Appendix 8.4
PCL-5
appendix-8-4.pdf
VOMS Assessment
Vestibular/Ocular-Motor Screening (VOMS) for Concussion
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Büttner, F., Howell, D. R., Doherty, C., Blake, C., Ryan, J., & Delahunt, E. Headache- and Dizziness-Specific Health-Related Quality-of-Life Impairments Persist for 1 in 4 Amateur Athletes Who Are Cleared to Return to Sporting Activity Following Sport-Related Concussion: A Prospective Matched-Cohort Study. The Journal of orthopaedic and sports physical therapy. 2020;50(12), 692–701.     

STROBE: 19/23

Associated with recommendations 4.1 and 4.3 headache and vestibular bullets

Cheever, K., McDevitt, J., Phillips, J., & Kawata, K. The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review. Sports medicine. 2021;51(9), 1875–1891. 

AMSTAR 2: 12/20

Associated with recommendations 4.1 and 4.3 neck pain bullet

Hromas GA, Houck ZM, Asken BM, et al. Making a Difference: Affective Distress Explains Discrepancy Between Objective and Subjective Cognitive Functioning After Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2021;36(3):186-195.   

STROBE: 18/23

Associated with recommendations 4.1 and 4.3 mood, sleep, and cognition bullets

Ngwenya, L. B., Gardner, R. C., Yue, J. K., Burke, J. F., Ferguson, A. R., Huang, M. C., Winkler, E. A., Pirracchio, R., Satris, G. G., Yuh, E. L., Mukherjee, P., Valadka, A. B., Okonkwo, D. O., & Manley, G. T. (2018). Concordance of common data elements for assessment of subjective cognitive complaints after mild-traumatic brain injury: a TRACK-TBI Pilot Study. Brain injury. 2018;32(9), 1071–1078.   

STROBE: 18/23

Associated with recommendations 4.1 and 4.3 mood bullet

Teymoori, A., Gorbunova, A., Haghish, F. E., Real, R., Zeldovich, M., Wu, Y. J., Polinder, S., Asendorf, T., Menon, D., Center-Tbi Investigators And Participants, & V Steinbüchel, N. Factorial Structure and Validity of Depression (PHQ-9) and Anxiety (GAD-7) Scales after Traumatic Brain Injury. Journal of clinical medicine. 2020;9(3), 873.   

STROBE 16/23

Associated with recommendations 4.1 and 4.3 mood bullet

Donders J, Pendery A. Clinical Utility of the Patient Health Questionnaire-9 in the Assessment of Major Depression After Broad-Spectrum Traumatic Brain Injury. Arch Phys Med Rehabil. 2017;98(12):2514-2519. 

STROBE 16/23

Associated with recommendations 4.1 and 4.3 mood bullet

Langer, L. K., Comper, P., Ruttan, L., Saverino, C., Alavinia, S. M., Inness, E. L., Kam, A., Lawrence, D. W., Tam, A., Chandra, T., Foster, E., & Bayley, M. T. Can Sport Concussion Assessment Tool (SCAT) Symptom Scores Be Converted to Rivermead Post-concussion Symptoms Questionnaire (RPQ) Scores and Vice Versa? Findings From the Toronto Concussion Study. Frontiers in sports and active living. 2021;3, 737402.   

STROBE: 14/23

Associated with recommendations 4.2 and 4.3

Medvedev, O. N., Theadom, A., Barker-Collo, S., Feigin, V., & BIONIC Research Group. Distinguishing between enduring and dynamic concussion symptoms: applying Generalisability Theory to the Rivermead Post Concussion Symptoms Questionnaire (RPQ). PeerJ. 2018;6, e5676.   

STROBE: 19/23

Associated with recommendations 4.2 and 4.3

Snell DL, Iverson GL, Panenka WJ, Silverberg ND. Preliminary Validation of the World Health Organization Disability Assessment Schedule 2.0 for Mild Traumatic Brain Injury. J Neurotrauma. 2017;34(23):3256-3261. 

STROBE: 18/23

Associated with recommendations 4.2 and 4.3

Büttner, F., Howell, D. R., Doherty, C., Blake, C., Ryan, J., & Delahunt, E. Clinical Detection and Recovery of Vestibular and Oculomotor Impairments Among Amateur Athletes Following Sport-Related Concussion: A Prospective, Matched-Cohort Study. The Journal of head trauma rehabilitation. 2021;36(2), 87–95.   

STROBE: 19/23

Associated with recommendation 4.3 vestibular bullet

Parrington, L., King, L. A., Hoppes, C. W., Klaiman, M. J., Michielutti, P., Fino, P. C., Dibble, L. E., Lester, M. E., & Weightman, M. M. Exploring Vestibular Ocular Motor Screening in Adults With Persistent Complaints After Mild Traumatic Brain Injury. The Journal of head trauma rehabilitation. 2022;37(5), E346–E354.   

STROBE: 17/23

Associated with recommendation 4.3 vestibular bullet

Shaikh N, Theadom A, Siegert R, Hardaker N, King D, Hume P. Rasch analysis of the Brain Injury Screening Tool (BIST) in mild traumatic brain injury [published correction appears in BMC Neurol. 2021 Nov 10;21(1):444]. BMC Neurol. 2021;21(1):376.

STROBE 16/23

Associated with recommendation 4.3

Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehabil Res Pract. 2012;2012:705309.  

DOWNS & BLACK: 14/32

Associated with recommendation 4.5

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

PEDro: 8/11

Associated with recommendation 4.5

Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307. 

PRISMA: 10/27

Associated with recommendation 4.5

Chin LM, Chan L, Woolstenhulme JG, Christensen EJ, Shenouda CN, Keyser RE. Improved Cardiorespiratory Fitness With Aerobic Exercise Training in Individuals With Traumatic Brain Injury. J Head Trauma Rehabil. 2015;30(6):382-390.  

DOWNS & BLACK: 14/32

Associated with recommendation 4.5

Chin LM, Keyser RE, Dsurney J, Chan L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Arch Phys Med Rehabil. 2015;96(4):754-759.  

DOWNS & BLACK: 14/32

Associated with recommendation 4.5