Symptoms attributed to mTBI/concussion are non-specific, commonly also reported by healthy individuals and those with conditions other than mTBI/concussion, and can be exacerbated by biopsychosocial factors aside from mTBI/concussion.32 Other problems may exist prior to injury but can be exacerbated by a mTBI/concussion, co-occur with persisting symptoms or mimic persisting symptoms but may not arise from mTBI/concussion.32
The rate of recovery from a mTBI/concussion is influenced by a range of factors, including previous medical conditions, pre-injury mood and anxiety disturbances, learning difficulties, attention deficit disorders, and the mechanism and setting for the initial injury.29 While related symptoms usually resolve within a few weeks of the injury, they may continue for longer than 4 weeks. These are considered as ‘persisting symptoms’ and occur in 30–40% of children and as many as 20–50% of adults.24, 25
A coordinated approach to the assessment and management of persisting symptoms facilitates symptom
improvement and potential recovery.29 Validated assessment and monitoring tools may assist this approach.29 Common considerations in the context of persisting symptoms include headache disorders and migraine; sleep disturbance; mental health issues; learning or attention difficulties; visual, oculomotor, cervical and vestibular problems; dysautonomia, including orthostatic intolerance and postural orthostatic tachycardia syndrome; and pain.32
Referral to specialized services such as an interdisciplinary concussion service, especially where symptoms show no improvement or only slow improvement, can facilitate this coordinated approach.115
Symptoms that are considered the most debilitating and that are therefore prioritised for assessment and management are headache, mood and insomnia.157 These symptoms frequently impede the ability to administer active rehabilitation interventions.157
Review of a person’s current medication and substance use has the potential to identify the use of those that may exacerbate symptoms and those where lack of adherence to prescribed dosing can effect recovery.158 Another concern is the potential for commonly encountered complications such as medication-overuse headache with the use of simple analgesics.159
Pain can be a factor in maintaining persisting symptoms and/or can overlap with or exacerbate symptoms of mTBI/concussion.160 Neck injury and pain is a common comorbid condition following mTBI/concussion and can impede recovery.160 There is significant overlap in symptoms of a neck injury and concussion (e.g. headache, dizziness and visual disturbances) and the neck should be considered as a potential source of symptoms post mTBI/concussion.161, 162
EBR (conditional)157, 163-172 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.
157. Quinn DK, Mayer AR, Master CL, Fann JR. Prolonged postconcussive symptoms. Am J Psychiatry. 2018;175(2):103-11. doi: 10.1176/appi.ajp.2017.17020235.
158. Halstead ME. Pharmacologic therapies for pediatric
concussions. Sports Health. 2016;8(1):50-2. doi: 10.1177/1941738115622158.
159. Wakerley BR. Medication-overuse headache. Pract Neurol. 2019;19(5):399-403. doi: 10.1136/practneurol-2018-002048.
160. 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):1875-91. doi: 10.1007/s40279-021-01469-y.
161. Gil C, Decq P. How similar are whiplash and mild traumatic brain injury? A systematic review. Neurochirurgie. 2021;67(3):238-43. doi:
10.1016/j.neuchi.2021.01.016.
162. Rebbeck T, Evans K, Elliott JM. Concussion in combination with whiplash-associated disorder may be missed in primary care: key recommendations for assessment and management. J Orthop Sports Phys Ther. 2019;49(11):819-28. doi: 10.2519/jospt.2019.8946.
163. Buttner F, Howell DR, 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. J Orthop Sports Phys Ther. 2020;50(12):692-701. doi: 10.2519/jospt.2020.9485.
164. Hromas GA, Houck ZM, Asken BM, Svingos AM, Greif SM, Heaton SC, 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):186-95. doi: 10.1097/HTR.0000000000000618.
165. Ngwenya LB, Gardner RC, Yue JK, Burke JF, Ferguson AR, Huang MC, et al. Concordance of common data elements for assessment of subjective cognitive complaints after mild-traumatic brain injury: a TRACK-TBI Pilot Study. Brain Inj. 2018;32(9):1071-8. doi: 10.1080/02699052.2018.1481527.
166. Teymoori A, Gorbunova A, Haghish FE, Real R, Zeldovich M, Wu YJ, et al. Factorial Structure and Validity of Depression (PHQ-9) and Anxiety (GAD-7) Scales after Traumatic Brain Injury. J Clin Med. 2020;9(3). doi: 10.3390/jcm9030873.
167. 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):2514-9. doi: 10.1016/j.apmr.2017.05.019.
168. Langer LK, Comper P, Ruttan L, Saverino C, Alavinia SM, Inness EL, et al. 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. Front Sports Act Living. 2021;3:737402. doi: 10.3389/fspor.2021.737402.
169. Medvedev ON, Theadom A, Barker-Collo S, Feigin V, Group BR. Distinguishing between enduring and dynamic concussion symptoms: applying Generalisability Theory to the Rivermead Post Concussion Symptoms Questionnaire (RPQ). PeerJ. 2018;6:e5676. doi: 10.7717/peerj.5676.
170. 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):3256-61. doi: 10.1089/neu.2017.5234.
171. Parrington L, King LA, Hoppes CW, Klaiman MJ, Michielutti P, Fino PC, et al. Exploring vestibular ocular motor screening in adults with persistent complaints after mild traumatic brain injury. J Head Trauma Rehabil. 2022;37(5):E346-E54. doi: 10.1097/HTR.0000000000000762.
172. 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. BMC Neurol. 2021;21(1):376. doi: 10.1186/s12883-021-02410-6.Adapted29 EBR (conditional) 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 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 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 EBR (strong)160,173 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.
160. 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):1875-91. doi: 10.1007/s40279-021-01469-y.
173. Anderson JFI. 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. doi: 10.1037/neu0000585.Adapted29 EBR (strong)160,173 160. 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):1875-91. doi: 10.1007/s40279-021-01469-y.
173. Anderson JFI. 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. doi: 10.1037/neu0000585.New Standardised tools for the assessment of mTBI/concussion-related symptoms include the SCOAT6, PC-PTSD-5, PCL-5 and VOMS.
Prolonged physical, cognitive, and/or psychological symptoms following mTBI/concussion can be non-specific and may overlap.7, 174 The medical practitioner should continue to consider alternative diagnoses or factors which may be preventing or delaying symptom resolution and seek medical advice.
Functional neurological disorder should be considered early, especially where symptoms are progressive, atypical, fail to improve, last longer than three months, and/or follow biomechanically implausible injury, to ensure patients access more appropriate care pathways and avoid unnecessary investigations and incorrect treatments.
Post-traumatic stress symptoms or disorder (PTSD) can also overlap with persisting post-concussion symptoms. Here, memories revisiting the trauma trigger subconscious neurobiological responses and heightened emotional reactions. PTSD should be considered when minor provocations lead to exaggerated emotional reponses and/or minor challenges cause the patient to freeze or become helpless. Complex PTSD (cPTSD) can occur in adults and children who have experienced repeated or prolonged psychological trauma. PTSD and cPTSD requires specialized management by pschologists experienced in this area and not usually offered within interdisciplinary concussion services/clinics.
Differential diagnoses related to mTBI/concussion: Major depressive disorderGeneralised anxiety disorderPost-traumatic stress disorderChronic pain syndromeCervical strain/whiplash associated disorderSomatic syndrome disorder Functional neurological disorderMalingeringFibromyalgia syndrome (secondary)Primary sleep disorder (e.g. obstructive sleep apnoea) Source: 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. EBR (strong)160,163-167 7. McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-47. doi: 10.1136/bjsports-2017-097699.
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.
160. 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):1875-91. doi: 10.1007/s40279-021-01469-y.
163. Buttner F, Howell DR, 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. J Orthop Sports Phys Ther. 2020;50(12):692-701. doi: 10.2519/jospt.2020.9485.
164. Hromas GA, Houck ZM, Asken BM, Svingos AM, Greif SM, Heaton SC, 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):186-95. doi: 10.1097/HTR.0000000000000618.
165. Ngwenya LB, Gardner RC, Yue JK, Burke JF, Ferguson AR, Huang MC, et al. Concordance of common data elements for assessment of subjective cognitive complaints after mild-traumatic brain injury: a TRACK-TBI Pilot Study. Brain Inj. 2018;32(9):1071-8. doi: 10.1080/02699052.2018.1481527.
166. Teymoori A, Gorbunova A, Haghish FE, Real R, Zeldovich M, Wu YJ, et al. Factorial Structure and Validity of Depression (PHQ-9) and Anxiety (GAD-7) Scales after Traumatic Brain Injury. J Clin Med. 2020;9(3). doi: 10.3390/jcm9030873.
167. 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):2514-9. doi: 10.1016/j.apmr.2017.05.019.
174. Hsu HH, Lai WH, Yu HT, Xiao SH, Tsai YH, Wang KC, et al. Long-term presentation of postconcussion symptoms and associated factors: analysis of latent class modeling. Arch Clin Neuropsychol. 2021;36(1):62-73. doi: 10.1093/arclin/acaa063.Adapted29 Further resources on functional neurological disorder is available online.
Differential diagnoses related to mTBI/concussion are defined by ICD-10.
There are several potential causes of persisting symptoms post-concussion including vestibular, ocular, physiological and the cervical spine. Adjustment problems and new or pre-existing psychological disorders commonly play a role in when symptom persist beyond three months. Strategies for management include symptom reduction strategies, targeted treatments to the causes of the symptoms, psychological support, and strategies for graduated return to function, school, and work.
Early re-introduction of activities of daily living should occur within the first few days of injury. Gradual reintroduction to activity is recommended,175 as opposed to returning to full participation once individuals are symptom free at rest, as a recurrence of symptoms with exercise may indicate incomplete recovery from a concussion.176, 177
Targeted treatments combined with accessible and comprehensible education about mTBI/concussion aim to resolve symptoms, with the goal of return to baseline function.25, 115, 157, 178, 179 Since symptoms are often interrelated and impact one another, ideally the delivery of these treatments should be integrated, with communication amongst health professionals delivering them to optimise outcomes.
EBR (conditional)180-188 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.
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.
180. Beaton MD, Hadly G, Babul S. Stakeholder recommendations to increase the accessibility of online health information for adults experiencing concussion symptoms. Front Public Health. 2020;8:557814. doi: 10.3389/fpubh.2020.557814.
181. Belanger HG, Toyinbo P, Barrett B, King E, Sayer NA. Concussion coach for postconcussive symptoms: A randomized, controlled trial of a smartphone application with Afghanistan and Iraq war Veterans. Clin Neuropsychol. 2022;36(8):2093-119. doi: 10.1080/13854046.2021.1936188.
182. 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. Front Neurol. 2019;10:929. doi: 10.3389/fneur.2019.00929.
183. 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):2482-91. doi: 10.1080/09638288.2018.1563638.
184. Losoi H, Silverberg ND, Waljas M, Turunen S, Rosti-Otajarvi E, Helminen M, et al. Recovery from Mild Traumatic Brain Injury in Previously Healthy Adults. J Neurotrauma. 2016;33(8):766-76. doi: 10.1089/neu.2015.4070.
185. O’Neil ME, Carlson K, Storzbach D, Brenner L, Freeman M, Quinones A, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. VA Evidence-based Synthesis Program Reports. Washington (DC)2013.
186. Rakers SE, Timmerman ME, Scheenen ME, de Koning ME, van der Horn HJ, van der Naalt J, 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):1965-71 e2. doi: 10.1016/j.apmr.2021.06.004.
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.
188. McMahon P, Hricik A, Yue JK, Puccio AM, Inoue T, Lingsma HF, 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. doi: 10.1089/neu.2013.2984.Adapted29,30 EBR (conditional)136-138 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.
136. 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):273-8. doi: 10.1080/87565641.2015.1067706.
137. Remigio-Baker RA, Bailie JM, Gregory E, Cole WR, McCulloch KL, Cecchini A, et al. Activity level during acute concussion may predict symptom recovery within an active duty military population. J Head Trauma Rehabil. 2020;35(2):92-103. doi: 10.1097/HTR.0000000000000498.
138. Brett BL, Breedlove K, McAllister TW, Broglio SP, McCrea MA, Investigators CC, et al. Investigating the range of symptom endorsement at initiation of a graduated return-to-play protocol after concussion and duration of the protocol: A study from the National Collegiate Athletic Association-Department of Defense Concussion, Assessment, Research, and Education (CARE) Consortium. Am J Sports Med. 2020;48(6):1476-84. doi: 10.1177/0363546520913252.Adapted29 EBR (strong)189-197 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.
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. doi: 10.1097/HTR.0b013e3182a6aaf0.
190. Cifu DX, Walker WC, West SL, Hart BB, Franke LM, Sima A, et al. Hyperbaric oxygen for blast-related postconcussion syndrome: three-month outcomes. Ann Neurol. 2014;75(2):277-86. doi: 10.1002/ana.24067.
191. 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):420-32. doi: 10.1177/1545968313516869.
192. Dong Y, Hu X, Wu T, Wang T. Effect of hyperbaric oxygenation therapy on post-concussion syndrome. Exp Ther Med. 2018;16(3):2193-202. doi: 10.3892/etm.2018.6463.
193. Hart BB, Weaver LK, Gupta A, Wilson SH, Vijayarangan A, Deru K, 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):353-83. doi:
194. 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):205-19. doi: 10.3233/VES-180671.
195. 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. doi: 10.1016/j.sleep.2018.06.006.
196. Weaver LK, Wilson SH, Lindblad AS, Churchill S, Deru K, Price RC, et al. Hyperbaric oxygen for post-concussive symptoms in United States military service members: a randomized clinical trial. Undersea Hyperb Med. 2018;45(2):129-56. doi:
197. Harch PG, Andrews SR, Rowe CJ, Lischka JR, Townsend MH, Yu Q, 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. doi: 10.4103/2045-9912.279978.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
CBR128 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.
128. Leddy JJ, Burma JS, Toomey CM, Hayden A, Davis GA, Babl FE, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):762-70. doi: 10.1136/bjsports-2022-106676.Adapted30
An interdisciplinary concussion team/clinic is defined as a location or network where people with mTBI/concussion are assessed by a physician with experience in concussion management and an allied team of interdisciplinary practitioners. Management at an interdisciplinary concussion clinic includes specific assessment and treatment recommendations, and may include a period of follow-up. As the individual’s regular doctor is an important part of this team, communication and ongoing follow-up with the general practitioner is recommended. In rural and remote areas access to such services can be difficult, here GP monitoring together with telehealth services can be used to organise assessments, optimise local services, and plan more specialised services where needed.
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