Sensory sensitivity
Following an initial period of relative rest, people experiencing sensory sensitivity can be encouraged to gradually engage in activities that cause minimal worsening of symptoms (i.e. no more than a 2-point increase on the 10-point scale ranging from 0-10), so long as the symptoms resolve shortly afterwards.322 People with mTBI/concussion may consider short-term usage of noise cancelling headphones or reduced screen brightness when gradually returning to functional activities. Lingering symptoms should not prevent activities of daily living.322
Persisting sensory sensitivity warrants further diagnostic consideration, see differential diagnoses of persisting symptoms Table X. If present pre-injury, evaluation for social communication disorders such as autistic spectrum disorder may be warranted and appropriate referral.
Occupational therapists experienced in this area can help guide a graded desensitization or graduated exposure program.
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29
Balance, dizziness, and visual and hearing dysfunction
Balance, dizziness and vision dysfunction following mTBI/concussion are common. This is highlighted by the fact that approximately 60% of athletes report such symptoms following sport-related mTBI/concussion.323 Acute vestibular and vision dysfunction may be associated with delayed recovery and return to activity. Examination may identify problems such as benign paroxysmal positional vertigo (BPPV), hearing deficits or vestibular migraine, which may require specific treatment.323-326 The use of an objective screening tool can assist in decision-making regarding referral for further assessment for people not showing improvement.
Vision
Symptoms affecting vision following mTBI/concussion include but are not limited to blurred vision, photosensitivity, double vision, headache, fatigue and difficulty reading. Symptoms may be exacerbated by bright lights or overwhelming visual environments.327, 328
EBR (conditional)323-326 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
323. Ferris LM, Kontos AP, Eagle SR, Elbin RJ, Clugston JR, Ortega J, et al. Optimizing VOMS for identifying acute concussion in collegiate athletes: Findings from the NCAA-DoD CARE consortium. Vision Res. 2022;200:108081. doi: 10.1016/j.visres.2022.108081.
324. Mucha A, Collins Michael W, Elbin RJ, Furman Joseph M, Troutman-Enseki C, DeWolf Ryan M, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions. Am J Sports Med. 2014;42(10):2479-86. doi: 10.1177/0363546514543775.
325. Whitney SL, Eagle SR, Marchetti G, Mucha A, Collins MW, Kontos AP, et al. Association of acute vestibular/ocular motor screening scores to prolonged recovery in collegiate athletes following sport-related concussion. Brain Inj. 2020;34(6):840-5. doi: 10.1080/02699052.2020.1755055.
326. Yorke AM, Smith L, Babcock M, Alsalaheen B. Validity and reliability of the vestibular/ocular motor screening and associations with common concussion screening tools. Sports Health. 2017;9(2):174-80. doi: 10.1177/1941738116678411.Adapted29 EBR (conditional)327, 328 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
327. Barnett BP, Singman EL. Vision concerns after mild traumatic brain injury. Curr Treat Options Neurol. 2015;17(2):329. doi: 10.1007/s11940-014-0329-y.
328. Simpson-Jones ME, Hunt AW. Vision rehabilitation interventions following mild traumatic brain injury: a scoping review. Disabil Rehabil. 2019;41(18):2206-22. doi: 10.1080/09638288.2018.1460407.Adapted30 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29
Balance
Visual reflexes, inner ear, musculoskeletal, nervous system or brain may contribute to dizziness, headaches, and balance problems. Vestibular rehabilitation and where appropriate, additional cervical spine therapy may improve balance and dizziness.327, 328
EBR (conditional)327, 328 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
327. Barnett BP, Singman EL. Vision concerns after mild traumatic brain injury. Curr Treat Options Neurol. 2015;17(2):329. doi: 10.1007/s11940-014-0329-y.
328. Simpson-Jones ME, Hunt AW. Vision rehabilitation interventions following mild traumatic brain injury: a scoping review. Disabil Rehabil. 2019;41(18):2206-22. doi: 10.1080/09638288.2018.1460407.Adapted30
Benign paroxysmal positional vertigo (BPPV)
In people who continue to experience prolonged vertigo or dizziness despite 3 particle repositioning manoeuvres, referral to an interdisciplinary concussion team or neuro-otologist or physiotherapist with competency-based training in vestibular rehabilitation may be a consideration.
CBR 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9. Adopted30 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9. Adopted30 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29
Psychosocial assessment
CBR 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9. Adapted30
Hearing
Hearing problems as a predominant post-concussion symptom are uncommon following mTBI/concussion, and should alert the HCP to consider a possible alternative diagnosis. A detailed history can assist in ruling out common causes of hearing complications, which may include basilar skull fracture and excessive ear wax.
EBR (conditional)336, 337 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
336. Santhanam P, Meehan A, Orrison WW, Wilson SH, Oakes TR, Weaver LK. Central auditory processing disorders after mild traumatic brain injury. Undersea Hyperb Med. 2019;46(3):261-9. doi:
337. Knoll RM, Herman SD, Lubner RJ, Babu AN, Wong K, Sethi RKV, et al. Patient-reported auditory handicap measures following mild traumatic brain injury. Laryngoscope. 2020;130(3):761-7. doi: 10.1002/lary.28034.Adapted29
CBR 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9. Adapted30
Benign paroxysmal positional vertigo
The Epley Manoeuvre can be used to treat the anterior and posterior canals in the case of a canalithiasis. There are many subtypes of BPPV that may require further assessment or alternate canalith repositioning manoeuvres and referral to a health professional for treatment (usually a physiotherapist with competency-based training in vestibular rehabilitation). If severe symptoms are provoked by pressure (i.e. val salva) or accompanied by a change in hearing, referral to an otolaryngologist or neuro-otologist is warranted.
EBR (conditional)187, 329-332 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
187. Rytter HM, Graff HJ, Henriksen HK, Aaen N, Hartvigsen J, Hoegh M, et al. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation. JAMA Netw Open. 2021;4(11):e2132221. doi: 10.1001/jamanetworkopen.2021.32221.
329. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014(12):CD003162. doi: 10.1002/14651858.CD003162.pub3.
330. Soberg HL, Andelic N, Langhammer B, Tamber AL, Bruusgaard KA, Kleffelgaard I. Effect of vestibular rehabilitation on change in health-related quality of life in patients with dizziness and balance problems after traumatic brain injury: A randomized controlled trial. J Rehabil Med. 2021;53(4):jrm00181. doi: 10.2340/16501977-2823.
331. Wong CK, Ziaks L, Vargas S, DeMattos T, Brown C. Sequencing and integration of cervical manual therapy and vestibulo-oculomotor therapy for concussion symptoms: retrospective analysis. Int J Sports Phys Ther. 2021;16(1):12-20. doi: 10.26603/001c.18825.
332. Langevin P, Fremont P, Fait P, Dube MO, Bertrand-Charette M, Roy JS. Cervicovestibular rehabilitation in adults with mild traumatic brain injury: a randomized clinical trial. J Neurotrauma. 2022;39(7-8):487-96. doi: 10.1089/neu.2021.0508.Adapted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29 EBR (conditional)327, 328 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
327. Barnett BP, Singman EL. Vision concerns after mild traumatic brain injury. Curr Treat Options Neurol. 2015;17(2):329. doi: 10.1007/s11940-014-0329-y.
328. Simpson-Jones ME, Hunt AW. Vision rehabilitation interventions following mild traumatic brain injury: a scoping review. Disabil Rehabil. 2019;41(18):2206-22. doi: 10.1080/09638288.2018.1460407.Adapted30 Demonstrations of the Dix-Hallpike test and Epley manoeuvre are provided by the RACGP
Balance disturbance
EBR (strong)333-335 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
333. Galeno E, Pullano E, Mourad F, Galeoto G, Frontani F. Effectiveness of vestibular rehabilitation after concussion: a systematic review of randomised controlled trial. Healthcare (Basel). 2022;11(1). doi: 10.3390/healthcare11010090.
334. Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011;7(4):184-96. doi: 10.3988/jcn.2011.7.4.184.
335. Schlemmer E, Nicholson N. Vestibular rehabilitation effectiveness for adults with mild traumatic brain injury/concussion: A mini-systematic review. Am J Audiol. 2022;31(1):228-42. doi: 10.1044/2021_AJA-21-00165.Adapted29
Hearing disturbance
Though there is no evidence for specific treatments for tinnitus (i.e. perception of sound that does not have an external source, so other people cannot hear it), clinical experience suggests that self-management strategies may aid with symptom coping.
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29
Prolonged symptoms post-concussion are often non-specific and may be attributed to multiple contributors. For example, clinical context suggests that prolonged vestibular, vision and balance symptoms may be influenced by factors such as mental health issues, neurological causes, uncorrected refractive error, binocular vision issues.
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29