Guidelines Quick Access
Persisting Symptoms
Assessment and Management of Persisting Symptoms
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.30 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.25, 26
EBR (Conditional) 194,200-209
The assessment and management of an individual with persisting mTBI/concussion-related symptoms should be directed towards specific symptoms identified and monitored with a symptom checklist. The person’s most prominent symptoms or impairments should be directly assessed, including (Children and adults):
- Headache (including neck pain), migraine
- Mood (i.e. depression), anxiety, post-traumatic stress disorder, somatisation and other trauma and stressor-related disorders
- Sleep
- Dizziness, balance and visual problems
- Cognitive symptoms (memory loss, attention)
- Fatigue
- Screening for medication/substances that may mask or modify the symptoms.
EBR (Conditional) 194,200-209
Physical examination should be conducted and include (Children and adults):
- Vital signs (resting heart rate and blood pressure)
- Complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait, balance testing)
- Cervical spine examination (palpation, range of motion, provocative cervical spine tests)
- Mental state examination including cognitive screening
- Further examination of the individual should be based on symptoms.
- In some settings, assessments may need to be conducted over a number of appointments.
CBR 195
The assessment of persisting symptoms should include a review of currently prescribed medications (and adherence), and non-prescribed medications/supplements and substance use, including but not limited to alcohol, cannabis and other drugs. (Children and adults)
EBR (Strong) 197,210
When neck pain is present, careful and thorough clinical examination is required. Investigation (i.e. imaging) should only be conducted according to established imaging guidelines (e.g. NEXUS, Canadian C-spine rule) (Children and adults)
Practice Points for Children and Adults
For people with persisting symptoms following mTBI/concussion, clinical assessment including identification of factors that may suggest an alternative diagnosis is recommended.
Further Guidance
Standardised tools for the assessment of mTBI/concussion-related symptoms include the SCOAT6, BIST, 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.
EBR (Strong) 197,200-204
Careful and thorough differential diagnoses should be considered as similar symptoms are common in chronic pain, depression, anxiety disorders, sleep disorders, functional neurological disorder, and other medical and psychiatric disorders (see Box B) (Children and adults)
Further Guidance
Further resources on functional neurological disorder are 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 when persisting symptoms extend beyond 3 months. Strategies for management include symptom reduction strategies, targeted treatments to the causes of the symptoms, psychological support, and strategies for graduated return to activities of daily living, learning, and work. Care should be taken to avoid medication overuse.
Early re-introduction of usual daily activities should occur within the first few days of injury. Gradual reintroduction to activity is recommended,212 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.213, 214.
EBR (Conditional) 125,217-224
Individuals with symptoms that persist after 4 weeks should be informed and reassured that a symptom-based approach will facilitate recovery and that symptom resolution is achieved by most people. (Children and adults)
This information should be provided in written, verbal and/or pictorial formats and should also outline mental health considerations, and non-pharmacological strategies to minimise symptoms including:
- Activity modifications
- Limiting triggers
- Managing fatigue
- Sleep hygiene
- The importance of social interaction
- Activities of daily living
- Graduated return to cognitive and physical activity
- Working with the school team/employer to facilitate school/work success.
EBR (Conditional) 166-168
For people with persisting symptoms, a slower progression in return to normal activity should be implemented if symptom worsening is more than mild or is prolonged. (Children and adults)
EBR (Strong) 225-233
The use of hyperbaric oxygen to treat symptoms post- mTBI/concussion is not recommended. (Children and adults)
CBR
The assessment of persisting symptoms should include a review of currently prescribed medications (and adherence), and non-prescribed medications/supplements and substance use, including but not limited to alcohol, cannabis and other drugs. (Children and adults)
CBR 159
Encourage people with persisting symptoms to engage in cognitive activity and low-risk physical activity while staying below their symptom-exacerbation threshold. Activities that pose no/low risk of sustaining a mTBI/concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity. (Children and adults)
An interdisciplinary concussion team (see Glossary) 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.234 Management by an interdisciplinary concussion team 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 GP is recommended.
CBR 177,219,235-237
Referral to interdisciplinary concussion team or subspecialist (where available) should be considered for people who have persisting symptoms. (Children and adults)