Management of Prolonged Symptoms

Doctor image

Symptoms following concussion are anticipated to resolve in a within the first few weeks post-injury in the majority of cases. However, a proportion of individuals (15% or greater) may continue to have prolonged symptoms.1,2 There is wide variation in how people recover after concussion even when experiencing similar injuries.2,3 

Primary care providers must carefully monitor for patients who do not follow the anticipated pattern of recovery. For those who have had complete symptom resolution, no intervention apart from the provision of injury prevention strategies is required. However, for those with prolonged symptoms or decline in function, emphasis needs to be placed on regular monitoring by healthcare professionals and identification of potentially treatable symptoms. Development of comorbidities post-concussion, such as depression, may also occur informing a more complex symptom profile and further altering the course of recovery 3,4,5. Therefore, Periodic monitoring of the patient’s symptoms following concussion is important for those with a more chronic course of recovery.

By addressing symptoms in a coordinated manner, improvement in outcome can be achieved. See Algorithm 5.1, which outlines the key steps to management of persistent symptoms following concussion.

References supporting introduction:

  1. Leddy JJ, Baker JG, Willer B. Active Rehabilitation of Concussion and Post-concussion Syndrome. Phys Med Rehabil Clin N Am. 2016;27(2):437-454.
  2. Theadom A, Parag V, Dowell T, et al. Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. Br J Gen Pract. 2016;66(642):e16-23.
  3. Lingsma HF, Roozenbeek B, Steyerberg EW, Murray GD, Maas AI. Early prognosis in traumatic brain injury: from prophecies to predictions. Lancet Neurol. 2010;9(5):543-554. 
  4. Iverson KM, Pogoda TK, Gradus JL, Street AE. Deployment-related traumatic brain injury among Operation Enduring Freedom/Operation Iraqi Freedom veterans: associations with mental and physical health by gender. J Womens Health (Larchmt). 2013;22(3):267-275. 
  5. Rice SM, Parker AG, Rosenbaum S, Bailey A, Mawren D, Purcell R. Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review. Sports Med. 2018;48(2):447-465. 
5.1

Individuals with symptoms that persist after 1 month should be informed and reassured that a symptom-based approach will facilitate recovery and that the majority of patients achieve symptom resolution. This education should be provided in written, verbal and/or pictorial formats.

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 beyond one month. Individuals with prolonged symptoms should recover with treatments targeted towards their symptoms. Education about concussion should be provided in multiple formats to ensure information is accessible and comprehensible (View Concussion Information for Patients and Families).

References supporting context:

  1. Dwyer B, Katz DI. Postconcussion syndrome. Handb Clin Neurol. 2018;158:163-178.
  2. 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.
  3. 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.
  4. 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.
  5. 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
( Education )
Level of Evidence A
( Symptom-based approach )
Level of Evidence A
( Majority symptom resolution )
Level of Evidence C
( Education format )
Last updated  
5.2

Due to the complex interplay of concurrent symptoms (physical, cognitive, communication, emotional), it is recommended to first focus on managing headache, sleep and mood symptoms.

Many factors contribute to the persistence of post-concussive symptoms (see Table 1.1). Prolonged symptoms post-concussion are often non-specific and may be attributed to multiple etiologies unrelated to the injury itself. Primary care providers should therefore address specific symptoms based on a full assessment of current complaints. It is recommended to first focus on those symptoms that are most severe and impact daily functioning. Headache, insomnia and disturbances in mood are often the most debilitating prolonged symptoms of concussion and should be prioritized and managed with targeted interventions. Impairments in cognition and physical symptoms (e.g., dizziness) are also common following concussion and should be managed appropriately. When present, these symptoms prevent the full engagement in other evidence-based therapies (e.g., physiotherapy, cognitive rehabilitation).

Level of Evidence B
( Headache )
Level of Evidence C
( Sleep )
Level of Evidence A
( Mood )
Last updated  
5.3

5.3a: After a brief period of rest during the acute phase (24-48 hours) post-injury, patients with concussion should be encouraged to gradually resume normal activity (activities of daily living, work, school, duty, leisure) based upon their tolerance, as long as the activity does not pose a risk for concussion.

5.3b: Explain to patients that transient symptom worsening with increased activity is common. If symptom worsening is more than mild or prolonged then a monitored, slower progression in return to normal activity should be implemented.

*NOT AN ORIGINAL RECOMMENDATION–ADAPTED FROM 12.2

Evidence suggests that while an initial period of rest following injury (24-48 hours) may be of benefit, there is currently insufficient evidence that prescribing complete rest may ease discomfort or promote recovery during the post-acute period. Prolonged inactivity during the post-acute period following injury has been shown to slow recovery, while a progressive and gradual return to normal activity promotes recovery.

References supporting context:

  1. Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. J Head Trauma Rehabil. 2016;31(4):233-241.
  2. Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-264.
  3. 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.
  4. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934.
Level of Evidence A
( 5.3a )
Level of Evidence A
( 5.3b )
Last updated  
5.4

Patients should be encouraged to perform a variety of types and intensities of physical activity based on their tolerance. Activities should include:

  • Moderate to vigorous aerobic physical activities
  • Light routine physical activities, including standing

After a brief period of rest during the acute phase (24-48 hours) post-injury, a gradual return to physical activity should be encouraged. Evidence suggests that individuals meeting physical activity guidelines (150 minutes of moderate to vigorous aerobic exercise per week; 2011 Canadian Physical Activity Guidelines) postinjury have reported higher quality of life and reduced symptom burden. While literature is limited in the concussion population, patients are encouraged to eventually meet the new recommendations outlined by the Canadian 24-Hour Movement Guidelines, symptoms permitting. Examples of different activities at various intensities may include the following:

  • Light physical activity: yoga (avoidance of head-down positions), archery, fishing from river band, bowling, horseshoes, golf, and easy walking.
  • Moderate aerobic physical activity: fast walking (may be more well tolerated than running/jogging), baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, alpine skiing, and dancing.
  • Vigorous aerobic physical activity: running, jogging, soccer, squash, basketball, cross-country skiing, roller skating, vigorous swimming, and vigorous long-distance bicycling.

References supporting context:

  1. Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J App Sport Sci. 1985;10(3):141-146.
  2. Mercier, L. J., Kowalski, K., Fung, T. S., Joyce, J. M., Yeates, K. O., & Debert, C. T. Characterizing Physical Activity and Sedentary Behavior in Adults With Persistent Postconcussive Symptoms After Mild Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation. 2021;102(10), 1918-1925.e1.
  3. Rytter, H. M., Westenbaek, K., Henriksen, H., Christiansen, P., & Humle, F. Specialized interdisciplinary rehabilitation reduces persistent post-concussive symptoms: a randomized clinical trial. Brain Injury. 2019;33(3), 266-281.
Level of Evidence A
( Moderate to vigorous aerobic physical activities )
Level of Evidence A
( Light physical activities )
Last updated  
5.5

Patients who have prolonged symptoms for more than one month should be considered for referral to interdisciplinary concussion services/clinics (See Appendix 2.5).

*NOT AN ORIGINAL RECOMMENDATION—REPEAT OF 2.3

There is evidence that interdisciplinary approaches to concussion treatment may be effective. Patients with persistent symptoms may benefit from referral to an interdisciplinary concussion clinic wherein practitioners from multiple disciplines coordinate care by providing diagnostic, educational, physical, cognitive, functional and emotional support. These services may include concurrent psychoeducation, neuropsychology, physiotherapy, occupational therapy and cognitive rehabilitation.

References supporting context:

  1. Caplain, S., Chenuc, G., Blancho, S., Marque, S., & Aghakhani, N. Efficacy of Psychoeducation and Cognitive Rehabilitation After Mild Traumatic Brain Injury for Preventing Post-concussional Syndrome in Individuals With High Risk of Poor Prognosis: A Randomized Clinical Trial. Frontiers in neurology. 2019;10, 929.
  2. 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.
  3. Howe, E. I., Fure, S., Løvstad, M., Enehaug, H., Sagstad, K., Hellstrøm, T., Brunborg, C., Røe, C., Nordenmark, T. H., Søberg, H. L., Twamley, E., Lu, J., & Andelic, N. Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up. Frontiers in Neurology.  2020;11, 561400.
  4. Rytter, H. M., Westenbaek, K., Henriksen, H., Christiansen, P., & Humle, F. Specialized interdisciplinary rehabilitation reduces persistent post-concussive symptoms: a randomized clinical trial. Brain Injury. 2019;33(3), 266-281.
  5. Thastum, M. M., Rask, C. U., Næss-Schmidt, E. T., Tuborgh, A., Jensen, J. S., Svendsen, S. W., Nielsen, J. F., & Schröder, A. Novel interdisciplinary intervention, GAIN, vs. enhanced usual care to reduce high levels of post-concussion symptoms in adolescents and young adults 2-6 months post-injury: A randomised trial. EClinicalMedicine. 2019;17, 100214.
Level of Evidence A
Last updated  
5.6

Neck pain and other bodily pain significantly interfering with patient functioning should be appropriately investigated and treated concurrently with other concussion-related symptoms.

Comprehensive evaluation and management of pain is important as it can be a factor in maintaining persistent symptoms and/or can overlap/exacerbate concussion symptoms. Due to the mechanism of injury, neck pain is a frequent comorbid condition encountered following concussion and can be a barrier to recovery. For example, the same mechanism of injury can cause concussion of the brain and whiplash of the neck, and thus many concussed patients also have whiplash. If both conditions are present both need to be treated concurrently.

References supporting context:

  1. Cheever K, McDevitt J, Phillips J, Kawata K. The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review. Sports Med. 2021;51(9):1875-1891.
Level of Evidence A
Last updated  
5.7

Patients should be advised in a compassionate manner that involvement in litigation is associated with slower recovery.

Patients involved in litigation may require closer follow-up as evidence suggests it is a strong risk factor for prolonged recovery. Factors involved in the litigation process can include perceived injustice, psychological distress due to the litigation process, and delayed access to services as part of the complication of being in a litigious/insurance funded system. Patients should be aware of these potential risk factors and address them proactively if possible.

References supporting context:

  1. Hanks, R. A., Rapport, L. J., Seagly, K., Millis, S. R., Scott, C., & Pearson, C. Outcomes after Concussion Recovery Education: Effects of Litigation and Disability Status on Maintenance of Symptoms. Journal of Neurotrauma. 2019;36(4), 554-558.
  2. Harrington R, Foster M, Fleming J. Experiences of pathways, outcomes and choice after severe traumatic brain injury under no-fault versus fault-based motor accident insurance. Brain Inj. 2015;29(13-14):1561-1571.
  3. Hubbard JE, Hodge SD Jr. The Litigation Complexity of Posttraumatic Headaches. Curr Pain Headache Rep. 2021;25(6):39.
Level of Evidence B
Last updated  
5.8

It is not recommended to use Hyperbaric Oxygen to treat symptoms post-concussion.

Level of Evidence A
Last updated  
Appendix 1.4
Brain Injury Advice Cards (Short Versions)
appendix-1-4.pdf
Algorithm 5.1
Management of Persistent Symptoms following mTBI
Table 1.1
Risk Factors Influencing Recovery Post mTBI
Management
Concussion Information for Patients and Families
Management
Vicious Cycle of Post-Concussion Syndrome
Management
Specialized Concussion Clinics/Centres in Ontario
appendix-2-5.pdf
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Beaton MD, Hadly G, Babul S. Stakeholder Recommendations to Increase the Accessibility of Online Health Information for Adults Experiencing Concussion Symptoms. Front Public Health. 2021;8:557814.   

CASP: 9/9 

Associated with recommendation 5.1 (education format)

Belanger, H. G., Toyinbo, P., Barrett, B., King, E., & Sayer, N. A. Concussion coach for postconcussive symptoms: a randomized, controlled trial of a smartphone application with Afghanistan and Iraq war Veterans. The Clinical neuropsychologist. 2021;1–27.   

Downs and Black: 23/28

Associated with recommendation 5.1 (symptom-based approach)

Caplain, S., Chenuc, G., Blancho, S., Marque, S., & Aghakhani, N. Efficacy of Psychoeducation and Cognitive Rehabilitation After Mild Traumatic Brain Injury for Preventing Post-concussional Syndrome in Individuals With High Risk of Poor Prognosis: A Randomized Clinical Trial. Frontiers in neurology. 2019;10, 929.  

Downs and Black: 22/28

Associated with recommendations 5.1 (symptom-based approach; education) and 5.5

Donnelly KZ, Goldberg S, Fournier D. A qualitative study of LoveYourBrain Yoga: a group-based yoga with psychoeducation intervention to facilitate community integration for people with traumatic brain injury and their caregivers. Disabil Rehabil. 2020;42(17):2482-2491. 8  

CASP: 8/9 

Associated with recommendation 5.1 (education)

Losoi H, Silverberg ND, Waljas M, et al. Recovery from Mild Traumatic Brain Injury in Previously Healthy Adults. J Neurotrauma. 2016;33(8):766-776.  

DOWNS & BLACK: 20/32

Associated with recommendation 5.1 (majority symptom resolution)

O'Neil ME, Carlson K, Storzbach D, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. VA Evidence-based Synthesis Program Reports. 2013.  

PRISMA: 18/27

Associated with recommendation 5.1 (majority symptom resolution)

Rakers, S. E., Timmerman, M. E., Scheenen, M. E., de Koning, M. E., van der Horn, H. J., van der Naalt, J., & Spikman, J. M. Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury: A 6-Month Prospective Cohort Study. Archives of physical medicine and rehabilitation. 2021;102(10), 1965–1971.e2.   

STROBE: 19/23

Associated with recommendations 5.1 (majority symptom resolution), 5.2 (sleep; mood), and 5.6

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.  

AMSTAR: 14/20

Associated with recommendations 5.1 (symptom-based approach), 5.3 (a), 5.5, and 5.6

McMahon P, Hricik A, Yue JK, et al. Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study. J Neurotrauma. 2014;31(1):26-33. 

DOWNS & BLACK: 14/32

Associated with recommendation 5.1 (majority symptom resolution)

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.   

CASP: 8/9

Associated with recommendation 5.2 (mood)

Kalmbach DA, Conroy DA, Falk H, et al. Poor sleep is linked to impeded recovery from traumatic brain injury. Sleep. 2018;41(10):zsy147.   

STROBE: 16/23 

Associated with recommendation 5.2 (sleep)

Weyer Jamora C, Schroeder SC, Ruff RM. Pain and mild traumatic brain injury: the implications of pain severity on emotional and cognitive functioning. Brain Inj. 2013;27(10):1134-1140.  

DOWNS & BLACK: 14/32

Associated with recommendations 5.2 (headache; mood) and 5.6

Sawyer K, Bell KR, Ehde DM, et al. Longitudinal Study of Headache Trajectories in the Year After Mild Traumatic Brain Injury: Relation to Posttraumatic Stress Disorder Symptoms. Arch Phys Med Rehabil. 2015;96(11):2000-2006. 

DOWNS & BLACK: 16/32

Associated with recommendation 5.2 (headache)

Cnossen, M. C., van der Naalt, J., Spikman, J. M., Nieboer, D., Yue, J. K., Winkler, E. A., Manley, G. T., von Steinbuechel, N., Polinder, S., Steyerberg, E. W., & Lingsma, H. F. Prediction of Persistent Post-Concussion Symptoms after Mild Traumatic Brain Injury. Journal of neurotrauma. 2018;35(22), 2691–2698.  

STROBE: 22/23 

Associated with recommendations 5.2 (mood) and 5.6

Si B, Dumkrieger G, Wu T, et al. Sub-classifying patients with mild traumatic brain injury: A clustering approach based on baseline clinical characteristics and 90-day and 180-day outcomes. PLoS One. 2018;13(7):e0198741.

STROBE: 18/23

Associated with recommendation 5.2 (mood)

Sullivan KA, Kaye SA, Blaine H, et al. Psychological approaches for the management of persistent postconcussion symptoms after mild traumatic brain injury: a systematic review. Disabil Rehabil. 2020;42(16):2243-2251.

AMSTAR 2: 14/20 

Associated with recommendation 5.2 (mood)

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 recommendations 5.3 (a) and 5.4 (moderate; light)

Carter, K. M., Pauhl, A. N., & Christie, A. D. The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis. Medicine and science in sports and exercise. 2021;53(9), 1835–1845.   

AMSTAR 2: 11/20 

Associated with recommendations 5.3 (a; b) and 5.4 (moderate; light)

Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Dev Neuropsychol. 2015;40(5):273-278.  

PEDro: 6/11 

Associated with recommendations 5.3 (b) and 5.4 (moderate)

Mercier, L. J., Kowalski, K., Fung, T. S., Joyce, J. M., Yeates, K. O., & Debert, C. T. Characterizing Physical Activity and Sedentary Behavior in Adults With Persistent Postconcussive Symptoms After Mild Traumatic Brain Injury. Archives of physical medicine and rehabilitation. 2021;102(10), 1918–1925.  

STROBE: 19/23 

Associated with recommendations 5.3 (a) and 5.4 (moderate; light)

Rytter, H. M., Westenbaek, K., Henriksen, H., Christiansen, P., & Humle, F. Specialized interdisciplinary rehabilitation reduces persistent post-concussive symptoms: a randomized clinical trial. Brain injury. 2019;33(3), 266–281.   

Downs and Black: 23/28 

Associated with recommendations 5.3 (a) and 5.5

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 recommendations 5.3 (a; b) and 5.4 (light)

Thastum, M. M., Rask, C. U., Næss-Schmidt, E. T., Tuborgh, A., Jensen, J. S., Svendsen, S. W., Nielsen, J. F., & Schröder, A. (2019). Novel interdisciplinary intervention, GAIN, vs. enhanced usual care to reduce high levels of post-concussion symptoms in adolescents and young adults 2-6 months post-injury: A randomised trial. EClinicalMedicine. 2019;17, 100214.  

Downs and Black: 24/28

Associated with recommendations 5.3 (a) and 5.5

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 5.4 (moderate)

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 5.4 (moderate)

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.   

STROBE: 17/23

Associated with recommendation 5.5

Howe, E. I., Fure, S., Løvstad, M., Enehaug, H., Sagstad, K., Hellstrøm, T., Brunborg, C., Røe, C., Nordenmark, T. H., Søberg, H. L., Twamley, E., Lu, J., & Andelic, N. (2020). Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up. Frontiers in neurology. 2020;11, 561400.   

Downs and Black: 23/28

Associated with recommendation 5.5

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).  

AMSTAR 2: 17/20

Associated with recommendation 5.5

Anderson J. The association between pain type, cognition and complaint after mild traumatic brain injury in prospectively studied premorbidly healthy adults admitted to hospital. Neuropsychology.  2020;34(1), 53–62.   

STROBE: 17/23

Associated with recommendation 5.6

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 recommendation 5.6

Hanks, R. A., Rapport, L. J., Seagly, K., Millis, S. R., Scott, C., & Pearson, C. Outcomes after Concussion Recovery Education: Effects of Litigation and Disability Status on Maintenance of Symptoms. Journal of neurotrauma. 2019;36(4), 554–558.   

Downs and Black: 22/28

Associated with recommendation 5.7

Tator CH, Davis HS, Dufort PA, et al. Postconcussion syndrome: demographics and predictors in 221 patients. J Neurosurg. 2016;125(5):1206-1216.  

DOWNS & BLACK: 13/32

Associated with recommendation 5.7

Nelson LD, Furger RE, Ranson J, et al. Acute Clinical Predictors of Symptom Recovery in Emergency Department Patients with Uncomplicated Mild Traumatic Brain Injury or Non-Traumatic Brain Injuries. J Neurotrauma. 2018;35(2):249-259.

STROBE: 19/23

Associated with recommendation 5.7

Cifu DX, Walker WC, West SL, et al. Hyperbaric oxygen for blast-related postconcussion syndrome: three-month outcomes. Ann Neurol. 2014;75(2):277-286.  

PEDro: 11/11

Associated with recommendation 5.8

Cifu DX, Hart BB, West SL, Walker W, Carne W. The effect of hyperbaric oxygen on persistent postconcussion symptoms. J Head Trauma Rehabil. 2014;29(1):11-20.  

PEDro: 10/11

Associated with recommendation 5.8

Walker WC, Franke LM, Cifu DX, Hart BB. Randomized, Sham-Controlled, Feasibility Trial of Hyperbaric Oxygen for Service Members With Postconcussion Syndrome: Cognitive and Psychomotor Outcomes 1 Week Postintervention. Neurorehabil Neural Repair. 2014;28(5):420-432.  

PEDro: 11/11

Associated with recommendation 5.8

Dong Y, Hu X, Wu T, Wang T. Effect of hyperbaric oxygenation therapy on post-concussion syndrome. Exp Ther Med. 2018 Sep;16(3):2193-2202. 

AMSTAR 2: 13/20

Associated with recommendation 5.8

Hart BB, Weaver LK, Gupta A, et al. Hyperbaric oxygen for mTBI-associated PCS and PTSD: Pooled analysis of results from Department of Defense and other published studies. Undersea Hyperb Med. 2019;46(3):353-383.

AMSTAR 2: 7/20

Associated with recommendation 5.8

Harch PG, Andrews SR, Rowe CJ, et al. Hyperbaric oxygen therapy for mild traumatic brain injury persistent postconcussion syndrome: a randomized controlled trial. Med Gas Res. 2020;10(1):8-20.

Downs and Black: 23/28

Associated with recommendation 5.8

Meehan A, Hebert D, Deru K, Weaver LK. Longitudinal study of hyperbaric oxygen intervention on balance and affective symptoms in military service members with persistent post-concussive symptoms. J Vestib Res. 2019;29(4):205-219.

Downs and Black: 20/28 

Associated with recommendation 5.8

Walker JM, Mulatya C, Hebert D, Wilson SH, Lindblad AS, Weaver LK. Sleep assessment in a randomized trial of hyperbaric oxygen in U.S. service members with post concussive mild traumatic brain injury compared to normal controls. Sleep Med. 2018;51:66-79.

Downs and Black: 23/28 

Associated with recommendation 5.8

Weaver LK, Wilson SH, Lindblad AS, et al. Hyperbaric oxygen for post-concussive symptoms in United States military service members: a randomized clinical trial. Undersea Hyperb Med. 2018;45(2):129-156.

Downs and Black: 24/28

Associated with recommendation 5.8