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 in Box B (See ‘Differential Diagnosis’ section under ‘Persisting Symptoms’ page). 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.

• For people with noise, light and other sensory sensitivities, a graduated exposure program is recommended. People should receive education about sensory tolerance levels and be encouraged to gradually increase exposure to these stimuli. Specifically, they should recognise the point at which mild symptoms have onset and push to the point that does not result in a significant or prolonged exacerbation of symptoms to promote desensitisation (children and adults)

  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.

• Assessment and diagnosis

  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}

  • If vestibular, vision, balance and coordination symptoms are endorsed, they should be screened for and monitored at follow-up appointments using validated screening tools (children and adults)

    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

  • If changes in vision are reported using a validated screening tool, a detailed history, including visual history, should be taken and assessments performed of visual acuity, pupillary function, visual fields, fundoscopy, binocular vergence, and extra-ocular movements (children and adults)

    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

  • Practice point for children and adults
    An eye examination should be undertaken to rule out ocular injuries and/or pre-existing disease that may impact vision.

    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}

  • Perform oculomotor and vestibulo-ocular examination including:
    – assessment of convergence, accommodation, saccades and smooth pursuits
    – assessment of the vestibulo-ocular reflex such as the head impulse test and/or dynamic visual acuity (may require involvement of a vestibular rehabilitation physiotherapist)
    – age-appropriate assessment of postural stability and balance (e.g. standing balance test or Balance Error Scoring System.

    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.

  • Screen for benign paroxysmal positional vertigo (BPPV) if the person reports vertigo or dizziness that occurs for seconds following position changes and consider canalith repositioning manoeuvres (children and adults)

    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

  • Practice point for children and adults:
    After completing a neurological screen and clearing the cervical spine to move into the test position, perform the Dix-Hallpike Test. If positive for BPPV (i.e. reproduction of vertigo, typically for seconds, in addition to a characteristic pattern of nystagmus for the canal that is being assessed), a Particle Repositioning Manoeuvre may be appropriate (e.g. the Epley manoeuvre) (children and adults)

    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

  • If the Dix-Hallpike manoeuvre reproduces vertigo, and there is no evidence of nystagmus, a Roll test should be performed, and other differential diagnoses or referral should be considered. The Epley manoeuvre should still be considered for treatment (children and adults)

    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

  • Screen for and consider underlying psychosocial symptoms that may exacerbate symptoms of vestibular, vision, and oculomotor dysfunction (children and adults)

    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.

  • When a person with mTBI/concussion identifies a problem with hearing (i.e. intolerance to everyday sounds, hearing loss, tinnitus), a detailed history (including auditory history) should be taken, otologic examination (including otoscopy) performed, and referral for audiological assessment made if no apparent cause is found (children and adults)

    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

• Education

  For people experiencing visual, vestibular and oculomotor symptoms, temporary modifications and accommodations may be helpful as they return to education. Reassure people that these symptoms are usually temporary and will resolve over time. Specific modifications depend on the severity and pervasiveness of symptoms and could include refraining from driving if visual disturbance is severe, breaking chores/assignments into smaller tasks, decreasing reading duration for shorter intervals or using text to speech applications, taking frequent breaks, using caution where dizziness and balance is problematic when operating machinery or performing activities at height.

  • Provide general post-concussion education that outlines symptoms of mTBI/concussion, and provide suggestions regarding activity modification and includes academic accommodations to manage visual, vestibular and oculomotor symptoms (children and adults)

    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

• Treatment

  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.

  • When the Dix-Hallpike manoeuvre is positive, the Epley/canalith repositioning manoeuvre should be used to treat benign paroxysmal positional vertigo (children and adults)  

    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

  • If BPPV does not resolve within 1-3 treatments, consider referral to an otolaryngologist or health professional certified in vestibular rehabilitation (children and adults)

    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

  • Consider referral to an interdisciplinary concussion team or physiotherapist with competency-based training. Here, tests may include Functional Gait Assessment and the Bruininks-Oseretsky Test of Motor Proficiency (children and adults)

    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

  • Further guidance

    Demonstrations of the Dix-Hallpike test and Epley manoeuvre are provided by the RACGP. (See ‘Toolbox’ for resource)

  Balance disturbance

  • Vestibular rehabilitation therapy is recommended for people experiencing functionally limiting dizziness (children and adults)

    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. These can include earwax removal, white noise generators and hearing aids. Tinnitus is associated with psychological distress, depression and anxiety, management strategies that include psychological treatment including cognitive behavioural therapy can be beneficial.

  • There is no evidence to suggest for or against the use of any particular modality for the treatment of tinnitus after mTBI/concussion. If tinnitus is present, referral to a neuro-otolaryngologist (ENT specialist) may be considered if self-management strategies are not effective (children and adults)

    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

• Follow-up and referral

  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.

  • If vestibular, vision, balance and coordination symptoms remain functionally limiting, further assessment to identify potential causes of symptoms to direct treatment is required. Referral to a health professional with specialised training in the vision or vestibular system is recommended, where available (children and adults)

    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