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Concussion Care Pathway

Date of last update: September, 2024

8. Diagnosis

 

  • Prevalence: Nearly one in two people will experience a concussion in their lifetime.

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  • Considerations: While diagnosing concussion is straightforward in cases involving an obvious external force to the head, clinical reasoning is essential when symptoms overlap with other conditions (e.g. anxiety, migraine). A comprehensive diagnostic strategy should integrate clinical findings with the patient’s history and any relevant risk factors  to rule out more serious conditions or traumatic brain injuries.

 

Diagnostic Criteria:

  • One or more of the following conditions must be met for a concussion diagnosis, provided a plausible mechanism of injury has been established and other potential causes for the patient’s symptoms have been ruled out:

    • Presence of one or more of the following clinical signs: Altered mental status, loss of consciousness (<30 minutes), amnesia (<24 hours), neurological signs (e.g., seizure, coordination problems).

    • Presence of two or more new or worsened symptoms: Subjective alteration of mental status (i.e., feeling dazed or confused), physical symptoms (headache, nausea, dizzy or sensitive to light/sound), cognitive symptoms (feeling run down, fatigue or foggy/lower processing speed), emotional symptoms (irritability, sadness, lability, impulsivity).

    • Imaging: Clear evidence of neurotrauma.

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, loss of consciousness, deteriorating conscious state, agitation, GCS <15.

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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