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Concussion Care Pathway

Date of last update: September, 2024

About Concussion

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Overview: Concussion is a common condition caused from a blow, bump, or jolt to the head, or from a hit to the neck or body, which transmits force to the brain. It typically presents with symptoms such as headache, dizziness, confusion, or balance issues. While most cases resolve within 2 weeks (adults) or 4 weeks (children), some individuals may experience symptoms that persist longer. Diagnosis relies on a detailed history and physical examination, though it can be complicated by comorbid conditions such as anxiety, neck injury, or migraine. Clinicians must remain vigilant for signs and symptoms of more severe brain, head or neck injuries.

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Effective Management: 

  • Effective management of concussion is multifaceted, requiring a personalized approach tailored to the individual's specific symptoms and needs. Appropriate management strategies are ethical, evidence-driven, transparent, flexible, and responsive to the person's needs.

  • Initial essential interventions include: Short-term physical and cognitive rest immediately after the injury, followed by a gradual return to daily activities as tolerated; education about the condition; reassurance regarding the typical recovery process; addressing psychosocial factors, and promoting self-care practices.

  • For specific symptoms, interventions should be selected through shared decision-making to optimize function and participation. A multidisciplinary approach may be necessary depending on symptom complexity, involving coordination among healthcare professionals such as primary care physicians, chiropractors, physiotherapists, psychologists, and neurologists.

  • Continuous monitoring and assessment of symptoms and functional status are essential to adjust the management plan as needed, ensuring alignment with patient goals.

  • Effective management may be supported through in-person, virtual or hybrid care models to enhance accessibility and support recovery.

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About the Care Pathway

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  • Principles: Based on recommendations drawn from established clinical guidelines, integrating the best available evidence, clinical expertise, and patient preferences. Treatment considerations are aligned with current guideline-supported practices. Developed with input from professional leaders, clinicians, and researchers.

 

  • Target Audience: Supports clinicians who deliver conservative care and informs those who do not but may see people with these conditions for referral or co-management. Provides essential, concise guidance on key steps of a clinical encounter, with access to detailed information by clicking on specific sections. Includes a downloadable one-page quick guide for quick access to key information.

 

  • Updates: Regular updates are communicated through social media to ensure users have current information. The care pathways are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. They may be updated to ensure they remain current, and evidence driven.

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  • ​Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

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***CLICK HERE FOR A ONE-PAGE QUICK GUIDE: Concussion Management Quick Guide

1. Record Keeping 

  • Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).

  • Adhere to jurisdictional standards.

2. Informed Consent 

  • Document verbal consent for health history taking, physical examination, contact in sensitive areas.

  • Obtain written consent for treatment.

  • Adhere to jurisdictional standards.

3. Health History 

  • ​Apply cultural awareness and trauma-informed care principles.

  • Sociodemographic: Age, gender, sex.

  • Injury Characteristics:

    • Mechanism of injury: Blow to the head or sudden jolt of the head; context of injury (e.g., fall, sports, motor vehicle collision, struck by an object).

    • Symptoms and timing (immediate or developing over time):

      1. Physical: Loss of consciousness, dizziness, balance problems, headache, nausea/vomiting, visual disturbances, sensitivity to light/noise, inappropriate responses to stimuli.

      2. Cognitive: Confusion, memory problems, delayed responses, disorientation, difficulty concentrating.

      3. Emotional/Behavioral: Irritability, emotional instability, mood swings, anxiety.

      4. Sleep-Related: Trouble falling asleep, staying asleep, altered sleep patterns.

  • Symptom Inventory: Identify new or worsened symptoms. Use standardized symptom checklists (e.g., SCAT6) to capture headache, nausea, vomiting, balance problems, dizziness, fatigue, sleep problems, light/noise sensitivity, emotional issues, numbness, concentration/memory problems, visual disturbances, etc.

  • Symptom Characteristics: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors.

  • Body systems: Neurologic, cardiovascular (including hypertension), genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • Health, lifestyle, family, social, and occupational history: Previous or comorbid conditions (including headache, migraine, mental health conditions, learning disabilities, ADHD, developmental disorders, epilepsy/seizures, syncope), medications (including opioids), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

  • Previous treatments and responses: Effectiveness and any adverse events.

  • Beliefs and expectations: Understanding of their condition, treatment expectations.

  • Red, yellow, and orange flags (sections 4 – 6).

  • Concussion-Specific Tools: To facilitate appropriate health history and physical examination.

    • Sport Concussion Assessment Tool SCAT6, Office Assessment Tool SCOAT6: ages 13 years +

    • Sport Concussion Assessment Tool child SCAT6, Office Assessment Tool child SCOAT6: ages 8-12 years

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Meaningful Outcomes:

4. Serious Head or Neck Injuries (Red Flags) 

 

ACTION: Refer to emergency care immediately if any one of these red flags is present.

  • Canadian CT Head Rule: GCS <15 at 2 hours, suspected skull fracture, signs of basal fracture (leaking fluid from ears/nose, raccoon eyes, Battle’s sign), vomiting ≥2 episodes, age ≥65 years.

  • Canadian C-Spine Rule: Age ≥65 years, dangerous mechanism, weakness/tingling in extremities, inability to rotate neck 45° left/right, midline tenderness.

  • PECARN Minor Head Injury/Trauma Rule (Children <2 years): GCS score <15, altered mental status, palpable skull fracture, scalp hematoma (except frontal), loss of consciousness ≥5 seconds, severe mechanism of injury (e.g., fall >3 feet), not acting normally according to the parent.

  • Additional red flags: Seizure, double vision, severe/increasing headache, visible skull deformity, deteriorating conscious state, agitation.

5. Psychiatric Disorders (Orange Flags)

  • Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.

  • Screening tools: PHQ-9,  GAD-7.

  • Action: Refer to appropriate provider/psychiatric specialist.

6. Psychosocial Factors (Yellow Flags)

  • Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims, maladaptive coping mechanisms.

  • Screening tools: PHQ-9, GAD-7, FABQ, ORT, PCS.

  • Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination (Head and Neck) 

  • Observation: Abnormalities, asymmetries, posture, balance, coordination, gait, movements, facial expression.

  • Range of Motion: Cervical spine: active, passive, resisted (flexion, extension, lateral flexion, rotation).

  • Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.

  • Neurological and Functional Examination:

    • Cranial nerve tests

    • Motor strength/sensory/reflex testing: Upper and lower extremities.

    • Cerebellar, vestibular, and proprioceptive function: e.g., finger-to-nose, heel-to-shin, Romberg, tandem walking tests, VOMS (Vestibular Ocular Motor Screening), balance tests (e.g., Balance Error Scoring System [BESS]).

    • Memory and cognitive assessments: Immediate and delayed recall, orientation, concentration tasks.

    • Upper and lower motor neuron signs: Central nervous system involvement.

  • Vital Signs: Monitor blood pressure and heart rate in supine and standing positions.

  • Advanced Diagnostics: Apply CT Head and C-Spine Rules as indicated (section 4).

  • Concussion-Specific Tools: Integrate SCAT6, SCOAT6, child SCAT6, child SCOAT6 to guide examination and documentation.

8. Diagnosis 

Criteria: A blow to the head or sudden jolt of the head with at least one of the following:

  • ≥1 Clinical Signs: Altered mental status, loss of consciousness (<30 min), amnesia (<24 h), neurological signs (e.g., seizure, coordination problems).

  • ≥2 Symptoms: Dazed or confused feeling, physical symptoms (headache, nausea, dizzy, light/sound sensitivity), cognitive symptoms (feeling run down, fatigued, foggy), emotional symptoms (irritability, sadness).

  • Imaging: Clear evidence of neurotrauma.

9. Treatment Considerations for Concussion 

After providing a report of findings and obtaining written informed consent.

 

A. Initial Management:

  • Education and reassurance: Provide information on recovery process and the importance of gradually resuming activities.

  • Rest and gradual return: Emphasize short-term physical and cognitive rest (24-48 hours), followed by a gradual increase in activity levels as tolerated (e.g., work, school, driving, sports), incorporating early light physical activity (e.g., sub-symptom threshold aerobic exercise).

  • Return-to-Learn and Return-to-Sport: Follow SCOAT6, child SCOAT6 protocols. Prioritize learning before sport.

  • Address yellow flags: Identify and manage psychosocial factors that may delay recovery (e.g., anxiety, fear avoidance behaviours).
  • Promote self-care: Encourage exercise, proper nutrition, sleep hygiene, stress management, maintaining a healthy body weight, avoiding smoking/substance abuse.

 

B. Symptom Management:

Use SCAT6/SCOAT6 to guide symptom-specific interventions.

Multidisciplinary care may be required especially for persistent symptoms.

  • Headache and neck pain:

    • Exercise therapy: Cervicovestibular, strengthening, ROM, aerobic, mind-body (e.g., yoga).

    • Manual therapy: Spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage for neck and upper back.

    • Medications: Over-the-counter analgesics/prescription used sparingly to avoid medication overuse headaches. Discuss options/risks with medical provider.

    • Electrotherapies (e.g., TENS, low-level laser therapy).

  • Sleep problems or fatigue:

    • Behaviour modification: Sleep hygiene and activity-to-tolerance strategies.

    • Psychological support: e.g., cognitive behavioural therapy (CBT).

    • Supplements: e.g., melatonin, zinc, magnesium.

  • Mental health, emotional or behavioural problems:

    • Psychological support: CBT, psychoeducation.

    • Referral: e.g., primary care provider, psychologist, psychiatrist.

  • Cognitive/memory problems:

    • Behaviour modification: Work/school accommodations or modifications, sleep hygiene.

    • Psychological support: e.g., CBT.

    • Referral: e.g., primary care provider, neuropsychologist.

  • Vestibular (balance/dizziness) and vision problems:

    • Vestibular and oculomotor rehabilitation:

      • Sub-symptom threshold aerobic exercise: Low-intensity aerobic activities that do not exacerbate symptoms (e.g., walking, stationary cycling).

      • Cervicovestibular exercises: Include non-provocative ROM exercises, postural stability exercises, and craniovertebral flexion and extension exercises.

      • Vestibulo-oculomotor exercises: Exercises that target eye movements and coordination (e.g., gaze stabilization, saccades).

    • Behaviour modification:

      • Work/school accommodations: Reduce symptom provocation by allowing for breaks, reducing screen time, providing a quiet workspace, allowing more time for tasks.

      • Activity modifications:  Adjust daily activities to avoid symptom exacerbation while promoting gradual return to normal function.

    • Canalith repositioning maneuvers:

      • Epley Maneuver: Series of head and body movements to treat benign paroxysmal positional vertigo (BPPV).

      • Brandt-Daroff exercises:  Home exercises to reduce dizziness and improve vestibular function.

      • Referral: e.g., primary care provider, vestibular therapist.

10. Prognosis

  • Recovery: Most people recover within a few days to a few weeks, but symptoms can persist. Being a student or older adult is associated with prolonged symptoms.

  • Negative Prognostic Factors: High initial pain and disability levels; high initial number of symptoms; poor recovery expectations; history of concussions; pre-existing headache, mental health issues, developmental disorders, cognitive impairment, learning disorders, ADHD; post-injury stress, anxiety, depression.

11. Ongoing Follow-up 

  • Continuous Monitoring: Regularly reassess symptoms, cognitive function, balance, etc. using SCAT6/SCOAT6.  Adjust the treatment plan based on progress and emerging symptoms, ensuring it aligns with the patient’s evolving goals, feedback, and clinical judgement.

  • Referral: Consider referral/co-management if symptoms persist beyond recovery timelines (2 weeks for adults, 4 weeks for children) or if new red/yellow flags appear. If the patient is progressing well, continue management with close monitoring.

12. Criteria for Discharge 

  • Discharge when milestones are achieved (e.g., symptom resolution, cognitive and physical recovery, return to symptom-free normal activities), progress plateaus, or initial goals are met.

  • ​Referral: If symptoms persist beyond the expected timeline, consider referral, but use a case-by-case approach if the patient is progressing well.

  • Post-discharge Planning: Discuss self-management, follow-ups, and strategies to prevent recurrence.

References

 

 

  • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. CDC Heads Up [Internet]. CDC February 2022. Available from: https://www.cdc.gov/headsup/index.html.

 

  • David L. MacIntosh Sports Medicine Clinic, University of Toronto. Post-Concussion Return to Activity Guidelines. EMPWR Our Toolkit [Internet]. EMPWR Foundation 2019. Available from: https://empwr.ca/our-toolkit.

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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