Initial Management

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Acutely following injury, it is essential that a management plan be initiated for each patient including: information regarding monitoring for potential acute complications requiring re-assessment, education regarding expected symptoms and course of recovery, and recommendations for healthcare follow-up post-injury.1 See Algorithm 2.1, which outlines the key steps for initial management of concussion. 

Treatment should be individualized and based on individual patient symptoms and physical examination findings.2 Pre-injury or current psychiatric difficulties, such as depression or anxiety, may place a patient at increased risk for persistent symptoms.2 

Referral to specialist services and/or interdisciplinary treatment may be required early on for these patients. Information pertinent to care pathway and referrals may also be found at the following links: Post Concussion Care Pathway, Referral Indicators, Concussion Symptom Management, and Scope of Practice for Healthcare Professionals (Scope of Practice is information for Ontario only). Referral to specialists should also be considered if symptoms exhibit an atypical pattern or cannot be linked to a concussion event, and/ or when there are other major comorbid conditions present (e.g., depression, PTSD). 

The majority of patients will be discharged home; it is advised that a person who remains symptomatic post concussion should not drive.3-6 

In addition to providing verbal information and reassurance to patients, it is also advised that written patient information sheets are delivered (e.g. see Appendix 1.4).7 

It is recommended that after a brief period of rest during the acute phase (24–48 hours) post-injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds8. 

References supporting introduction:

  1. McAllister TW, Arciniegas D. Evaluation and treatment of postconcussive symptoms. NeuroRehabilitation. 2002;17(4):265-283.
  2. Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma. 2015;32(8):517-526. 
  3. Preece MH, Horswill MS, Geffen GM. Driving after concussion: the acute effect of mild traumatic brain injury on drivers’ hazard perception. Neuropsychology. 2010;24(4):493-503. 
  4. Preece MH, Geffen GM, Horswill MS. Return-to-driving expectations following mild traumatic brain injury. Brain Inj. 2013;27(1):83-91. 
  5. Baker A, Unsworth CA, Lannin NA. Fitness-to-drive after mild traumatic brain injury: mapping the time trajectory of recovery in the acute stages post injury. Accid Anal Prev. 2015;79:50-55.
Management of mTBI
2.1

Initial medical management of a patient with concussion should be based on a thorough history and physical examination, and concurrent potential contributing factors, such as co-morbid medical conditions and mental health conditions. 

Context

A thorough assessment of a patient with concussion should be carried out by a physician or nurse practitioner to both assess concussion and to exclude potential further neurosurgical complications. The examination performed should include:

  • Pre-injury history (e.g., prior concussion(s), premorbid conditions) 
  • Concurrent potential contributing factors (e.g., comorbid medical conditions, ADHD, medications, mental health difficulties, impact of associated concurrent injuries)
  • Evaluation of current signs and symptom burden
  • Consideration of all available diagnostic tests (if performed)
  • Evaluation of potential associated physical injuries through examination (e.g., neck injury)
Level of Evidence B
( acute symptom burden )
Level of Evidence B
( co-morbid medical conditions )
Level of Evidence B
( mental health conditions )
Last updated  
2.2

A patient with concussion should be advised that the majority of patients typically experience full recovery and return to usual activities within one month. Some patients may experience prolonged symptoms beyond this timeframe. Information and reassurance should be provided through both written and verbal education.

Context

Providing early education and support to patients has been demonstrated to positively influence recovery.

References supporting context:

  1. Eliyahu L, Kirkland S, Campbell S, Rowe BH. The Effectiveness of Early Educational Interventions in the Emergency Department to Reduce Incidence or Severity of Postconcussion Syndrome Following a Concussion: A Systematic Review. Acad Emerg Med. 2016;23(5):531-542.
  2. Remigio-Baker, R. A., Gregory, E., Cole, W. R., Bailie, J. M., McCulloch, K. L., Cecchini, A., Stuessi, K., Andrews, T. R., Mullins, L., & Ettenhofer, M. L. Beliefs about the influence of rest during concussion recovery may predict activity and symptom progression within an active duty military population. Archives of Physical Medicine and Rehabilitation. 2020;101(7), 1204–1211.
Level of Evidence B
( recovery and return to activity )
Level of Evidence B
( information and reassurance )
Last updated  
2.3

Patients who have persistent symptoms of more than one month should be considered for referral to interdisciplinary concussion services/clinics.

Context

An interdisciplinary concussion clinic is defined as a location or network where patients with concussion are assessed by a qualified practitioner able to make a diagnostic decision, including direct access to a physician with experience in concussion management and an allied team of interdisciplinary practitioners. Treatments at an interdisciplinary concussion clinic should include specific assessment, follow-up, and treatment timepoints. Organization of an interdisciplinary concussion clinic should follow specific outlined standards.

References supporting context:

1. Standards for high quality post-concussion services and concussion clinics. Concussions Ontario. (2017). Retrieved from https://concussionsontario.org/concussion/resources/standards-for-concussion-clinics 

Level of Evidence C
Last updated  
Providing Education After mTBI
2.4

Primary health care providers should routinely monitor for and manage depression and anxiety after concussion. Referral to a mental health specialist should be considered if needed.

Context: There is evidence to show that pre-injury psychiatric history or diagnosis of a psychiatric disorder is a predictor of persistent symptoms following concussion. Additionally, patients experiencing prolonged symptoms following concussion are at an increased risk of developing new or worsening mental health symptoms. Primary health care providers should identify and treat changes in mood in order to appropriately facilitate recovery following a concussion.

References supporting context:

  1. Booker, J., Sinha, S., Choudhari, K., Dawson, J., & Singh, R. Description of the predictors of persistent post-concussion symptoms and disability after mild traumatic brain injury: The shefbit cohort. British Journal of Neurosurgery. 2019;33(4), 367–375.
  2. Campbell-Sills, L., Jain, S., Sun, X., Fisher, L. B., Agtarap, S. D., Dikmen, S., Nelson, L. D., Temkin, N., McCrea, M., Yuh, E., Giacino, J. T., & Manley, G. T. Risk factors for suicidal ideation following mild traumatic brain injury: A track-TBI study. Journal of Head Trauma Rehabilitation. 2020;36(1).
  3. Cnossen, M. C., Winkler, E. A., Yue, J. K., Okonkwo, D. O., Valadka, A. B., Steyerberg, E. W., Lingsma, H. F., Manley, G. T., & the TRACK-TBI Investigators. Development of a prediction model for post concussive symptoms following mild traumatic brain injury: A track-tbi pilot study. Journal of Neurotrauma. 2017;34(16), 2396–2409.
  4. Le Sage, N., Chauny, J.-M., Berthelot, S., Archambault, P., Neveu, X., Moore, L., Boucher, V., Frenette, J., de Guise, E., Ouellet, M.-C., Lee, J. S., McRae, A., Lang, E., Émond, M., Mercier, É., Tardif, P.-A., Swaine, B., Cameron, P., & Perry, J. Pocs rule : Derivation and validation of a clinical decision rule for early prediction of persistent symptoms after a mild traumatic brain injury. Journal of Neurotrauma. 2022.
  5. Yue, J. K., Cnossen, M. C., Winkler, E. A., Deng, H., Phelps, R. R., Coss, N. A., Sharma, S., Robinson, C. K., Suen, C. G., Vassar, M. J., Schnyer, D. M., Puccio, A. M., Gardner, R. C., Yuh, E. L., Mukherjee, P., Valadka, A. B., Okonkwo, D. O., Lingsma, H. F., & Manley, G. T. Pre-injury comorbidities are associated with functional impairment and post-concussive symptoms at 3- and 6-months after mild traumatic brain injury: A track-TBI study. Frontiers in Neurology. 2019;10.
Level of Evidence B
( monitoring and treating depression and anxiety )
Level of Evidence C
( referral )
Last updated  
2.5

Scheduled telephone and/or in-person medical follow-up should be arranged with a primary health care provider within 1 to 2 weeks of concussion. The focus of these sessions should be to provide education regarding symptom management as well as strategies to encourage a gradual and active resumption of everyday activities as tolerated.

Level of Evidence B
Last updated  
2.6

Patients should be advised that symptoms such as blurred vision, dizziness, fatigue, impaired cognition, and headache may impact their ability to drive. Patients should only resume driving following concussion when their symptoms subside sufficiently to permit safe driving.

Level of Evidence B
( symptoms )
Level of Evidence C
( symptoms subsiding )
Last updated  
Assessment (Appendix 8.1)
Patient Health Questionnaire (PHQ-9)
appendix-8-1.pdf
Assessment (Appendix 8.2)
Generalized Anxiety Disorder Questionnaire (GAD-7)
appendix-8-2.pdf
Care Information
Manitoba Adult Concussion Network Post-Concussion Education Sheet
Management (Algorithm 2.1)
Initial Management of Symptoms Following mTBI
Management (Appendix 2.2)
The Parkwood Pacing Graphs
appendix-2-2.pdf
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Madhok DY, Yue JK, Sun X, et al. Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study. Brain Sci. 2020;10(5):269.

STROBE: 17/23

Associated with recommendations 2.1 and 2.4

Nelson, L. D., Furger, R. E., Ranson, J., Tarima, S., Hammeke, T. A., Randolph, C., Barr, W. B., Guskiewicz, K., Olsen, C. M., Lerner, E. B., & McCrea, M. A. Acute clinical predictors of symptom recovery in emergency department patients with uncomplicated mild traumatic brain injury or non-traumatic brain injuries. Journal of Neurotrauma. 2018;35(2), 249-259.

STROBE: 19/23

Associated with recommendation 2.1

Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A, Schonberger M. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology. 2012;26(3):304-313. 

Downs and Black: 20/32

Associated with recommendations 2.1 and 2.4

Schmidt, B. R., Moos, R. M., Könü-Leblebicioglu, D., Bischoff-Ferrari, H. A., Simmen, H.-P., Pape, H.-C., & Neuhaus, V. Higher age is a major driver of in-hospital adverse events independent of comorbid diseases among patients with isolated mild traumatic brain injury. European Journal of Trauma and Emergency Surgery. 2018;45(2), 191-198.

STROBE: 18/23

Associated with recommendation 2.1

Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma. 2015;32(8):517-526.

PRISMA: 15/27

Associated with recommendations 2.1 and 2.4

Sutton, M., Chan, V., Escobar, M., Mollayeva, T., Hu, Z., & Colantonio, A. (2019). Neck injury comorbidity in concussion-related emergency department visits: A population-based study of sex differences across the life span. Journal of Women's Health. 2019; 28(4), 473-482.

STROBE: 19/23

Associated with recommendation 2.1

Yue, J. K., Cnossen, M. C., Winkler, E. A., Deng, H., Phelps, R. R., Coss, N. A., Sharma, S., Robinson, C. K., Suen, C. G., Vassar, M. J., Schnyer, D. M., Puccio, A. M., Gardner, R. C., Yuh, E. L., Mukherjee, P., Valadka, A. B., Okonkwo, D. O., Lingsma, H. F., & Manley, G. T. Pre-injury comorbidities are associated with functional impairment and post-concussive symptoms at 3- and 6-months after mild traumatic brain injury: A track-TBI study. Frontiers in Neurology. 2019;10. 

STROBE: 16/23

Associated with recommendations 2.1 and 2.4

Coffeng SM, Jacobs B, de Koning ME, Hageman G, Roks G, van der Naalt J. Patients with mild traumatic brain injury and acute neck pain at the emergency department are a distinct category within the mTBI spectrum: a prospective multicentre cohort study. BMC Neurol. 2020;20(1):315.

STROBE: 22/23

Associated with recommendation 2.1

Cnossen MC, Winkler EA, Yue JK, Okonkwo DO, Valadka AB, Steyerberg EW, Lingsma HF, Manley GT; TRACK-TBI Investigators. Development of a Prediction Model for Post-Concussive Symptoms following Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. J Neurotrauma. 2017 Aug 15;34(16):2396-2409. 

STROBE: 20/23

Associated with recommendations 2.1 and 2.4

Roy D, Peters ME, Everett A, et al. Loss of consciousness and altered mental state predicting depressive and post-concussive symptoms after mild traumatic brain injury. Brain Inj. 2019;33(8):1064-1069.

STROBE: 18/23

Associated with recommendation 2.1

Cnossen MC, van der Naalt J, Spikman JM, et al. Prediction of Persistent Post-Concussion Symptoms after Mild Traumatic Brain Injury. J Neurotrauma. 2018;35(22):2691-2698.

STROBE: 22/23 

Associated with recommendations 2.1 and 2.2

Eliyahu L, Kirkland S, Campbell S, Rowe BH. The Effectiveness of Early Educational Interventions in the Emergency Department to Reduce Incidence or Severity of Postconcussion Syndrome Following a Concussion: A Systematic Review. Acad Emerg Med. 2016;23(5):531-542.

PRISMA: 21/27

Associated with recommendations 2.2 and 2.5

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 and Black: 20/32

Associated with recommendation 2.2

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.

PRISMA: 17/27

Associated with recommendations 2.2 and 2.5

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 2.2

Hoek AE, Joosten M, Dippel DWJ, et al. Effect of Video Discharge Instructions for Patients With Mild Traumatic Brain Injury in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2021;77(3):327-337.

Downs and Black: 22/28

Associated with recommendation 2.2

D’Silva, L., Devos, H., Hunt, S. L., Chen, J., Smith, D., & Rippee, M. A. Concussion symptoms experienced during driving may influence driving habits. Brain Injury. 2020;35(1), 59-64.

STROBE: 13/23

Associated with recommendation 2.6

Lempke, L. B., Lynall, R. C., Hoffman, N. L., Devos, H., & Schmidt, J. D. Slowed driving-reaction time following concussion-symptom resolution. Journal of Sport and Health Science. 2021;10(2), 145-153.

STROBE: 16/23

Associated with recommendation 2.6

Schmidt, J. D., Hoffman, N. L., Ranchet, M., Miller, L. S., Tomporowski, P. D., Akinwuntan, A. E., & Devos, H. Driving after concussion: Is it safe to drive after symptoms resolve? Journal of Neurotrauma. 2017;34(8), 1571-1578.

STROBE: 15/23

Associated with recommendation 2.6