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Concussion Care Pathway

Date of last update: May, 2024

Clinical Examination

Clinical Cornerstone:

  • It’s important to view the patient holistically, considering the biopsychosocial aspects of the patient’s condition. When re-evaluating existing patients, a thorough assessment is just as important.

Useful for arriving at a diagnosis:

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

  • Red Flags: Examination of complaints that might indicate a more serious underlying condition (see 'Red Flags' Section).

  • Neurological Examination:
    • Motor Strength: Test the strength of the upper and lower extremities.

    • Sensory Examination: Check for any sensory deficits in the upper and lower extremities.

    • Reflexes: Test the biceps, triceps, brachioradialis reflexes and the patellar and Achilles reflexes.

    • Cranial Nerves: Test CN sensation (e.g. facial numbness), CN motor (e.g. smile, tongue deviation, H-pattern, saccades, shoulder shrug), and CN reflexes (e.g. pupillary light, corneal, gag) as indicated.

    • UMN (upper motor neuron) Testing: If cervical myelopathy is a clinical consideration, tests such as Hoffman’s, Inverted Supinator Sign, and Romberg’s can be informative.

    • Balance: Romberg’s (static balance), Tandem gait (dynamic balance)

    • Cerebellum: e.g. Heel-shin, Finger-nose, Diadokinesia

    • Cognitive: 10 word immediate recall, Digit string backwards test, Delayed word recall

  • Vitals: Blood pressure and heart rate (taken in two positions: supine, standing).

  • Special/Orthopedic Tests: In the absence of red flags, select tests to use alongside a fulsome clinical examination, since the specificity and sensitivity of these tests vary. Tests selection should consider the presenting condition. Examples include: Rotary-chair test, Head Impulse test, Vestibulo-occular Reflex (VOR) test, additional Vestibular Occulomotor screening (VOMS) (e.g. Smooth pursuit, Saccades, Vestibulo-occular Cancellation test, Accomodation, Convergence), and Dynamic Visual Acuity (DVA) test.

  • Imaging/laboratory tests: As indicated (e.g., red flags are present, progressive neurological deficits, non-response to care).

May help guide treatment:

  • Palpation: Palpate bony and muscular areas of the cervical spine.

  • Movement: Active ROM in all planes (flexion, extension, lateral flexion, and rotation). Passive ROM. Consider regional and segmental hypomobility, hypermobility and aberrant movement patterns.

  • Associated Special/Orthopedic Tests: In the absence of red flags, select tests to use alongside a fulsome clinical examination, since the specificity and sensitivity of these tests vary. Tests selection should consider associated conditions and the differential diagnoses from the History. Examples include: Spurling’s test, Neck Distraction test, Cervical Kemps, Spinous Percussion, and Bakody’s sign.

Documentation: Record all findings in the patient record.

Conduct patient assessment

Red flags or Orange flags present

Red flags or Orange flags present

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Refer to appropriate emergency or healthcare provider

No

Yes

Acute mTBI

  • Structured patient education

  • Self Care

  • Return to work / school

  • Return to driving

  • Return to sport / activity

Persistent mTBI

  • Monitoring and Reassessment

  • Tailored clinical management of symptoms:

    • Headache
    • Neck Pain
    • Sleep Disturbance
    • Fatigue
    • Emotional / Behavioural
    • Cognitive Disorders
    • Vestibular Disorders

Differential Diagnosis

Diagnosis

 

Diagnosis

Follow-up

Follow-up

(Align with patient goals, Criteria for discharge)

Major symptom/sign change

Goals not achieved

Discharge

No

Yes

Re-evaluate

Adjust treatment and management plan or refer

References or links to primary sources

  • 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.

 

Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

Disclaimer:

These care pathways are intended to provide information to practitioners who provide care to people with musculoskeletal conditions. The care pathways on this website are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. As knowledge and healthcare practices evolve, these pathways may be updated to ensure they remain current and evidence driven. These pathways are not intended to replace advice from a qualified healthcare provider.

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