Table 2

Guideline recommendations: Appendices, tables, and figures referred to in the following table are located in the full Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms.²²

RECOMMENDATION	GRADE^*
1. Diagnosis and assessment of MTBI
Diagnosis and assessment of MTBI
1.1. MTBI in the setting of closed head injury should be diagnosed early, as early recognition will positively affect health outcomes for patients.¹³	A
1.2. Diagnosis of MTBI should be performed through a combined assessment of clinical factors and symptoms.¹³	A
1.3. Standardized measurement of posttraumatic amnesia should be routinely performed to assist with the monitoring, diagnosis, early management, and prognosis of patients who have experienced MTBI. The A-WPTAS (Appendix 1.1) is a standardized tool that can be used to monitor posttraumatic amnesia.¹³	A
1.4. Medical assessment should include screening for health and contextual factors (flags) to identify patients at increased risk of persistent symptoms and urgent complications, such as subdural hematoma. Table 7 outlines health factors and contextual risk factors (flags).¹³	B
Emergency department clinicians
1.5. Hourly clinical observation should occur until at least 4 hours after the injury. If the patient meets recommended discharge criteria at 4 hours after the injury, they should be considered for discharge.^†	C
1.6. At 4 hours after the injury, if the patient has a Glasgow Coma Scale score of 15, is clinically improving, and has normal CT scan findings or there is no indication for CT based on the Canadian CT Head Rules (Figure 3), but their A-WPTAS score is < 18, then clinical judgment is required to determine whether the patient should be discharged home before a normal score for this measure is obtained.¹³	C
1.7. If CT is not indicated on the basis of history and examination, the clinician may conclude that the risk to the patient is low enough to warrant discharge to own care or to home, as long as no other factors that would warrant a hospital admission are present (eg, drug or alcohol intoxication, other injuries, shock, suspected nonaccidental injury, meningism, cerebrospinal fluid leak) and there are appropriate support structures for safe discharge and for subsequent care (eg, competent supervision at home).^†	C
1.8. All patients with any degree of brain injury who are deemed safe for appropriate discharge from an emergency department or the observation ward should receive verbal advice and a written brain injury advice card (Appendix 1.2). The details of the card should be discussed with the patient and their care providers. When necessary, communication in languages other than English or by other means should be used to convey the information.¹⁸	C
1.9. If the patient returns to the emergency department with symptoms related to the initial injury, the following should be conducted¹³: full re-assessment; A-WPTAS assessment; and CT scan, if indicated. Also emphasize that the patient should visit his or her family physician for follow-up after discharge.	C
Health care providers
1.10. On presentation, the primary care provider should conduct a comprehensive review of any patient who has sustained MTBI. The assessment should include taking a history, physical examination, cognitive screening, postconcussive symptom assessment, and a review of mental health.¹³	A
1.11. An appraisal of the severity and effect of postconcussive symptoms should be made. A standardized tool such as the Rivermead Post-Concussion Symptoms Questionnaire (Appendix 1.3) can aid in this.¹⁵	C
1.12. Clinicians should consider that an individual who has sustained an MTBI is likely to experience reduced cognitive functioning after the injury, which might resolve in a few days or continue for months before resolving; this can include problems with recall of material, speed of information processing, or concentration and attention.¹³	A

2. Management of MTBI
Management of MTBI
2.1. Because a variety of factors, including biopsychosocial, contextual, and temporal preinjury, injury, and postinjury factors, can affect the outcomes of patients who have sustained MTBI, clinicians should consider these factors when planning and implementing management plans for patients.¹³	A
2.2. Minor problems should be managed symptomatically, and the person should be offered reassurance and information on symptom management strategies.¹⁵	C
2.3. All people who have sustained possible or definite MTBI should receive information about common symptoms and reassurance that recovery over a short period of time (days to a few weeks) is anticipated.¹⁵	B
2.4. A person who sustains an MTBI should not drive for at least 24 hours and might require medical re-assessment. An extension of the recommended 24-hour time period is advised if there are symptoms or complications that result in loss of good judgment, decreased intellectual capacity (including slowed thinking), posttraumatic seizures, visual impairment, or loss of motor skills. If there are complications, a medical assessment is required before an individual returns to driving.¹³	C
2.5. Symptomatic patients should be followed every 2 to 4 weeks from the time of initial contact until they are no longer symptomatic or until another re-assessment procedure has been put in place.¹⁴	C
2.6. A patient experiencing reduced cognitive functioning in the first few days following injury should be expected, with education and support, in most cases to have these symptoms resolve and preinjury cognitive functioning return within days or up to 3 months. However, patients who 1) have comorbidities or identified health or contextual risk factors (Table 7) and do not improve within 1 month or 2) have persistent symptoms at 3 months should be referred for more comprehensive evaluation in a specialized brain injury environment (see Appendix 2.1).¹³	A
2.7. Patients with preinjury psychiatric difficulties should be provided with multidisciplinary treatment.²³	A
Primary care providers
2.8. Management of MTBI patients by primary care providers should involve guidance on strategies to minimize the effects of symptoms and to gradually resume activity and participation in life roles.¹³	A
2.9. The primary care provider should consider referral of a patient who has had MTBI to specialist services when symptoms and concerns persist and fail to respond to standard treatments for any of the 3 spheres of physical, behavioural or emotional, and cognitive symptoms.^†	C
2.10. The primary care provider should consider the risk of depression or other mental health disorders in patients who have experienced MTBI and that the emergence and maintenance of symptoms might be influenced by maladaptive psychological responses to the injury.¹³	B
Providing education
2.11. Education about symptoms, including an advice card (Appendix 1.2), and reassurance should be provided to all patients who have experienced MTBI. Education should ideally be delivered at the time of the initial assessment or minimally within 1 week of the injury or first assessment.^13,15	A
2.12. Elements that can be included in the education session are as follows^14,17: information about common symptoms, reassurance that it is normal to experience some symptoms and that a positive outcome is expected, information about typical timelines (allowing for individual differences) and the course of recovery, advice about how to manage or cope with symptoms, advice about gradual reintegration of regular activities, information on how to access further support if needed, and advice on stress management.	C

3. Sport-related MTBI
Assessment and management
3.1. Patients with sport-related MTBI might present acutely or subacutely. If any one of the signs or symptoms outlined in Table 8 are observed at any point following a blow to or jarring of the head, MTBI should be suspected and appropriate management instituted.¹⁵	C
3.2. When a player shows any symptoms or signs of MTBI¹⁵ the player should not be allowed to return to play in the current game or practice; the player should not be left alone and should be regularly monitored for deterioration; the player should receive a medical evaluation, including evaluation of reported complaints (eg, somatic symptoms [Rivermead Post-Concussion Symptoms Questionnaire, Appendix 1.3], balance, and cognition); return to play must follow a medically supervised stepwise process; and a player should not be returned to play until he or she is asymptomatic at rest and with exertion.	C
Return-to-play decisions
3.3. A player should never return to play while he or she is symptomatic. “If in doubt, sit them out.”^13,19	C
3.4. Return to play after MTBI should follow a stepwise process, proceeding to the next level only if the player remains asymptomatic. If any symptoms recur, the person should revert to the previous asymptomatic level and try to progress again after 24 hours. No activity. When asymptomatic, proceed to level 2. Light aerobic exercise such as walking or stationary cycling; no resistance training. Sport-specific training (eg, skating in hockey, running in soccer). Non-contact training drills. Full-contact training after medical clearance. Game play. See the “Safe Steps to Return to Play After a Possible Traumatic Brain Injury”¹⁵ algorithm from the New Zealand Guidelines Group (Appendix 3.3).^15,19	C
3.5. An additional consideration for return to play is that athletes who have experienced MTBI should not only be symptom free but should also not be taking any pharmacologic agents or medications that might affect or modify the symptoms of concussion.¹⁹	C

4. General recommendations for diagnosis and assessment of persistent symptoms following MTBI
Diagnosis and assessment
4.1. Clinicians should assess and monitor persisting somatic, cognitive, and emotional or behavioural symptoms following MTBI.¹³	A
4.2. A standardized scale, such as the Rivermead Post-Concussion Symptoms Questionnaire (Appendix 1.3), should be used to monitor symptoms.¹³	C
4.3. Persistent symptoms following MTBI can be nonspecific. Therefore, careful and thorough differential diagnoses should be considered, as similar symptoms are common in chronic pain, depression, anxiety disorders, and other medical and psychiatric disorders (see Table 9 and Appendix 4.1).^†	C

5. General recommendations for management of persistent symptoms following MTBI
Management
5.1. Patients should be advised that they are likely to experience 1 or more persistent symptoms as a consequence of their MTBI for a short period and that this is expected and normal.¹³	A
5.2. The patient should be advised that a full recovery from symptoms is expected.¹³	A
5.3. Where there are prolonged and substantial complaints after MTBI, primary care providers should rule out other contributing or confounding factors (Table 7).¹³	A
5.4. Those with MTBI and preinjury mental health conditions, or any other health or contextual risk factors, should be considered for early referral to a multidisciplinary treatment clinic capable of managing postconcussive symptoms, because these factors have been associated with poorer outcomes.^†	C

6. Posttraumatic headache
Assessment
6.1. Take a focused headache history, identifying headache frequency, duration, location, intensity, and associated symptoms (eg, nausea or vomiting) to try to determine which primary headache type it most closely resembles (eg, episodic or chronic migraine, episodic or chronic tension-type headache, primary stabbing headache, occipital neuralgia). Unfortunately, some posttraumatic headaches cannot be classified. To aid in determining the specific phenotype of headache disorder present, refer to the ICHD II classification criteria in Appendix 6.3. Refer to the advice regarding assessment of posttraumatic headache provided in Appendix 6.6.^†	C
6.2. Perform a neurologic examination and musculoskeletal examination, including cervical spine examination (refer to Appendix 6.5).^†	C
Management
6.3. Management of posttraumatic headache should be tailored to the class of nontraumatic headache it most closely resembles (eg, chronic tension, migraine). Refer to the treatment algorithms specific to the appropriate class of headache taken from the ICSI guideline (Appendices 6.7 to 6.9) for treatment guidance. Refer to the advice regarding management of posttraumatic headache in Appendix 6.6.¹⁶	C

7. Persistent sleep disturbances
Diagnosis and assessment
7.1. Advise patients that the goal of treatment is to improve the continuity and restorative quality of sleep, not to make them “8-hour sleepers.” More often than not the total sleep time will be less than 8 hours per night.²⁴	C
7.2. Provide the sleep hygiene advice included in Appendix 7.1.²⁵	C
7.3. Relaxation training is effective and recommended therapy in the treatment of chronic insomnia.²⁶	C
7.4. Pharmacotherapy is generally recommended at the lowest effective dose as short-term treatment lasting less than 7 days. Although long-term use of hypnotic agents is discouraged owing to the potential for tolerance and dependence, there are specific situations and circumstances under which long-term use of hypnotics might be appropriate. Refer to the therapeutic options table taken from the Toward Optimized Practice guideline. See Appendix 7.2 for suggestions on useful medications.²⁴	C
7.5. Some insomnia patients spend excessive time in bed trying to attain more sleep. Sleep consolidation is accomplished by compressing the total time in bed to match the total sleep need of the patient. This improves sleep efficiency. See Appendix 7.3 for advice on achieving sleep consolidation.^24,25	C

8. Persistent mental health disorders
Assessment
8.1. Given their prevalence and potential effects, all patients with persistent symptoms following MTBI should be screened for mental health symptoms and disorders, including the following: depressive disorders; anxiety disorders, including PTSD; irritability or other personality changes; substance use disorders; and somatoform disorders. The use of self-report questionnaires can aid in the assessment and monitoring of common mental health disorders, such as the depression module of the PHQ-9 (Appendix 8.2) and the PTSD CheckList–Civilian Version (Appendix 8.3). Screen for other symptoms using the Rivermead Post-Concussion Symptoms Questionnaire (Appendix 1.3).^†	C
Management
8.2. Referral to a psychiatrist or mental health team (ideally with experience in treating individuals with persistent symptoms following MTBI, if available) should be obtained if¹⁵ the presentation is complex or severe, initial treatment is not effective within 2 months, psychosis or bipolar disorder are suspected, there is a failure of or contraindication to medication strategies that are familiar, the risk of suicide is judged to be considerable, or there are risk factors known to potentially affect the course of recovery (Table 7).	C
8.3. While awaiting specialist referral, the initial steps of treatment should not be delayed and symptoms should not be left unmanaged. General measures can be instituted, and common symptoms such as headache, sleep disturbance, dizziness, and pain can be addressed in an ongoing manner.^†	C
8.4. For medication trials, a “start low and go slow” approach is recommended. Nonetheless, dose optimization might be required before an antidepressant response is observed or a trial of medication is abandoned.¹⁵	C
8.5. A selective serotonin reuptake inhibitor is recommended as the first-line drug treatment for mood and anxiety syndromes after MTBI. However, in some cases the combination of sedative, analgesic, and antimigraine effects from a tricyclic antidepressant might be particularly desirable, although these agents are generally considered second-line options.¹⁵	C
8.6. Follow-up should occur at regular intervals: initially every 1 to 2 weeks, while increasing medication to monitor tolerability and efficacy; thereafter, every 2 to 4 weeks might be sufficient.¹⁵	C
8.7. CBT has well-established efficacy for treatment of primary depression; as such it is appropriate in the treatment of mood symptoms following MTBI.¹⁸	C
8.8. Individuals with PTSD following MTBI should be offered a trial of trauma-focused CBT. The need for concurrent pharmacotherapy should also be assessed, depending upon symptom severity and the nature of comorbid difficulties (eg, major depression, prominent somatic symptoms, severe hyperarousal, and sleeplessness, which all might limit psychological treatment).^†	C

9. Persistent cognitive difficulties
Assessment
9.1. When there are persistent cognitive complaints, the health care provider should make efforts to formally screen for cognitive deficits. Objective measures of those domains most commonly affected after MTBI (ie, attention and concentration, information processing speed, and memory) should be used. Although there currently is no screening measure specific to cognitive difficulties following MTBI, the Rivermead Post-Concussion Symptoms Questionnaire (Appendix 1.3) includes items assessing cognition.^†	C
9.2. Due consideration should be given to potential comorbid diagnoses that could be present and have the potential to influence cognition, such as anxiety, depression, PTSD, pain, fatigue, sleep disturbance, or acute stress disorder.^†	C
9.3. If screening reveals evidence of cognitive dysfunction that is likely attributable to the MTBI itself or if cognitive symptoms are reported to persist at 3 months, then more formal assessment should be considered and referral should be made. If available, refer such patients to a neuropsychologist (ideally with experience with TBI). When a local neuropsychologist is not available or known, referral to a TBI centre can be made (see Appendix 2.1 for a list of TBI centres in Ontario). For systems with long wait times, practitioners should consider referral earlier than 3 months.^†	C
Management
9.4. Following MTBI, acute cognitive deficits are common, and spontaneous cognitive improvement is expected in most injured individuals. Rehabilitation of cognitive impairments should be initiated if the individual exhibits persistent cognitive impairments on formal evaluation or the learning of compensatory strategies is necessary in order to facilitate the resumption of functional activities and work or there are safety issues in question (ie, possible harm to self or others).¹⁷	C
9.5. For cognitive sequelae following MTBI, the cognitive rehabilitation strategies that should be considered include compensatory strategies and restorative approaches.¹⁷	C
9.6. Electronic external memory devices such as computers, paging systems, or portable voice organizers have been shown to be effective aids for improving TBI patients’ everyday function.²⁷	B

10. Persistent balance disorders
Assessment
10.1. Clinicians should screen for balance deficits (Figure 4) for assessment of postural stability because clinical testing of balance offers additional information about the presence of ongoing symptoms and assists in the subsequent management of patients who have sustained MTBI.¹³	C
10.2. If symptoms of benign positional vertigo are present, the Dix-Hallpike maneuver (Appendix 10.1) should be used.²⁸	A
Management
10.3. For persons with functional balance impairments and a positive screening result on a balance measure, consideration of further balance assessment and treatment with physiotherapy might be warranted pending clinical course.^†	C
10.4. A canalith repositioning maneuver should be used to treat benign positional vertigo if the Dix-Hallpike maneuver result is positive.²⁸	A
10.5. Vestibular rehabilitation therapy is recommended for unilateral peripheral vestibular dysfunction.²⁹	A

11. Persistent vision disorders
Assessment
11.1. A) Take an appropriate history relevant to visual symptoms. B) Perform fundoscopic examination and examination of visual acuity, visual fields, and extraocular movements for symptoms of visual disturbance including visual field disturbance, blurring, diplopia, and photosensitivity.^†	C
11.2. If visual abnormalities are observed, refer the patient to an ophthalmologist, ideally a neuro-ophthalmologist or one specializing in brain injury.^†	C

12. Persistent fatigue
Assessment
12.1. Determine whether fatigue is an important symptom by taking a personal history, reviewing the relevant items from the Rivermead Post-Concussion Symptoms Questionnaire (Appendix 1.3), or by administering the FSS (Appendix 12.1).^†	C
12.2. Characterize the dimensions of fatigue and identify alternative, treatable causes that might not be directly related to the injury.³⁰ Take a complete medical history, review medications (see Appendix 12.2 for a list of medications associated with fatigue, asthenia, somnolence, and lethargy), and review systems, with particular attention to iatrogenic (medication) causes for comorbid medical conditions associated with fatigue (eg, metabolic disorders, thyroid dysfunction, anemia, low calcium, malnourishment). Obtain a sleep history to help identify primary or secondary sleep disorders (see optional self-report sleep questionnaire in Appendix 7.1). Evaluate for depression (loss of interest in activities; feelings of sadness, worthlessness, or guilt; changes in appetite or sleep; or suicidal thoughts), anxiety, stress, or other psychological distress. Conduct a general medical examination and a focused neurologic examination.	C
Management
12.3. If identified as an important symptom, key considerations that might aid in the management of persistent fatigue can include aiming for a gradual increase in activity levels that will parallel improvement in energy levels; reinforcing that pacing activities across the day will help patients to achieve more and to avoid exceeding tolerance levels; encouraging good sleep practices (especially regularity of sleep time and avoidance of stimulants and alcohol) and proper relaxation times; planning meaningful goals, using a notebook to record activity achievement and identify patterns of fatigue; and acknowledging that fatigue can be exacerbated by low mood. Provide patients with a pamphlet containing advice on coping strategies for fatigue (Appendix 12.3).¹⁵	C
12.4. If fatigue is persistent, refer the patient to a brain injury specialist for consideration of a medication trial.^†	C

13. Considerations for returning to work or school
Considerations for returning to work or school
13.1. When managing a patient’s return to work or study, the health care provider should consider patient-related and contextual variables. These include physical difficulties arising from the injury, psychosocial issues, cognitive impairment, and cultural or work-related contextual factors (eg, workload and responsibilities; workplace environment; transportation or driving issues; and hours, shifts, or rest breaks). Refer to Appendix 13.1 for guidance on considerations for return to work or study.¹³	C
13.2. For individuals who experience persistent deficits following MTBI, or who have difficulty once back at work, return-to-work programs should be implemented, which require carefully designed and managed plans. Specifically, referral to an occupational therapist to review the return-to-work process is recommended.¹⁶	C

A-WPTAS—Abbreviated Westmead Post-Traumatic Amnesia Scale, CBT—cognitive behavioural therapy, CT—computed tomography, FSS—Fatigue Severity Scale, ICHD—International Classification of Headache Disorders, ICSI—Institute for Clinical Systems Improvement, MTBI—mild traumatic brain injury, PHQ—Patient Health Questionnaire, PTSD—posttraumatic stress disorder, TBI—traumatic brain injury.
↵* Grade A evidence includes at least 1 randomized controlled trial, meta-analysis, or systematic review; grade B evidence includes at least 1 cohort comparison, case study, or other type of experimental study; grade C evidence includes expert opinion or the experience of a consensus panel.
↵† Recommendation based on consensus of the MTBI Expert Consensus Group.