11.1

Perform a repeat medical assessment on all patients presenting with post-concussion fatigue 1-2 weeks following acute injury. 

Level of Evidence:  

The medical assessment should include a clinical history of symptoms, physical examination, and screen for other causes of fatigue (e.g., mononucleosis, anemia, thyroid dysfunction, mood disorders, pregnancy, etc.).

11.2

Provide patients with post-concussion fatigue with general education and guidance that outlines non-pharmacological strategies to help cope with fatigue symptoms and set expectations. 

Level of Evidence:  

Strategies and post-concussion education guidance related to fatigue:

• Emphasize that spreading activities throughout the day helps patients achieve more and that they should avoid doing too much at once.
  • Tool 2.5 “Four P’s” – Prioritize, Plan, Pace and Position.
• Encourage good diet and hydration.
• Encourage good sleep hygiene.
  • Tool 2.7: Strategies to Promote Good Sleep and Alertness.
• Avoid daytime napping.
• Identify the triggers of fatigue.
• Encourage the child/adolescent to plan meaningful goals, record activity achievement, and identify patterns of fatigue by using a notebook or diary.
• Link: Sleep for Youth. CHEO Sleep Hygiene handout
• Inform that fatigue can be worsened by low mood or stress. 
• Inform that deconditioning can compound fatigue.
• Encourage a gradual return to school with accommodation (Domain 12: Return-to-School and Work).

11.3

Encourage patients with post-concussion fatigue to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation thresholds. Activities that pose no/low risk of sustaining a 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.

Level of Evidence: Gradual return to physical activity. Gradual return to cognitive activity. 

See Recommendation 2.3.

• Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:
• Patients who are active may benefit from referral to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:

Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

11.4

Consider referral to an interdisciplinary concussion team for patients with prolonged post-concussion fatigue (more than 4 weeks following the acute injury) to learn pacing techniques.

Level of Evidence:  

11.5

Recommend a medical follow-up to re-assess clinical status if fatigue symptoms persist.  Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (before 4 weeks) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence: Medical follow-up. Early referral in the presence of modifiers that may delay recovery.

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. 

Level of Evidence:  

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.