Medical Follow-up and Management of Prolonged Symptoms

Domain 3: Medical Follow-up and Management of Prolonged Symptoms

Recommendations

3.1

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

Tool 1.3: Manage Acute and Prolonged Symptoms Algorithm

Include a focused clinical history, focused physical examination, and consideration for the need for diagnostic tests including imaging. 

3.1a

Take a focused clinical history based on symptoms described.

Level of Evidence:   

 

Consider signs and symptoms in context with the child/adolescent’s normal performance, especially for those with pre-existing conditions (e.g., learning and communication deficits, ADHD, and/or physical disabilities) to identify the underlying causes of the prolonged symptoms or concerns and develop a management strategy.

3.1b

Examine the child/adolescent and perform a focused physical examination.

Level of Evidence:  

  • Vital signs (Resting heart rate and blood pressure).
  • A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait, balance testing) (Tool 2.1: Physical Examination).
  • A cervical spine examination (palpation, range of motion, provocative cervical spine tests) (Tool 2.1: Physical Examination.
  • Review mental health. Perform a post-concussive assessment and a cognitive screen, reassessing for existing and new mental health symptoms such as anxiety and mood. 
  • Screen the child/adolescent for medication/substances that may mask or modify the symptoms.
  • An examination of vestibular, visual, and oculomotor systems (e.g., Vestibular Ocular Motor Screening Tool (VOMS) or Visio-vestibular examination (VVE))
  • Consider a broad differential diagnosis for children/adolescents with prolonged symptoms.
  • Monitor the return-to-activity/sport and return-to-school status.

Further examination of the child/adolescent should be based on symptoms:

3.1c

Recommendation 2.1c:  Consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms. 

Level of Evidence:   MRI

Urgent conventional MRI should be considered in concussion patients who present with focal or worrisome symptoms (e.g., deteriorating vision, focal weakness or numbness, altered awareness, prominent behavioural changes, or worsening headaches that are not responding to treatment) and in whom a structural brain injury or abnormality is suspected. 

3.2

Provide patients with general education and guidance that outlines mental health considerations, non-pharmacological strategies to minimize symptoms including sleep hygiene, activity modifications, limiting triggers, information on screen time, the importance of social interaction, and how to work with the school team to facilitate school success. 

Level of Evidence:  

 

3.3

Encourage patients with post-concussion symptoms to engage in cognitive activity and low-risk physical activity as soon as tolerated  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: A Gradual Return to physical activity aerobic exercise treatment. B 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 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 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:

See the Living Guideline Post-Concussion Information Sheet for examples of low-risk activities. 

Links to exertion test resources:

 
Recommendation Updated: Sept 2023

3.4

Refer patients at elevated risk for delayed recovery to an interdisciplinary concussion team. 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.

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:  

3.5

For those who are not referred initially (See recommendation 3.4), refer to specialized care with an interdisciplinary concussion team if post-concussion symptoms do not resolve by 2-4 weeks. Medical follow-ups may be needed to guide appropriate referrals.

Level of Evidence:   

See Tool 1.3 Manage Acute and Prolonged Symptoms Algorithm.

Assessment by an interdisciplinary concussion team can assist in identifying the type of management that is required, along with the medical and health professions on the interdisciplinary concussion team or external to this team who can provide the required management. Not all children/adolescents will require care from all members of the interdisciplinary concussion team and care should be targeted based on identified symptoms and patient needs. Symptoms that persist beyond 4 weeks (persisting symptoms after a concussion (PSAC) or persistent post-concussion symptoms (PPCS) may be related to the concussion, due to pre-existing conditions, or both.

Recommendation updated: Sept 2023

3.6

Iniate treatment for specific symptoms or concerns while waiting for a referral to an interdisciplinary concussion team or sub-specialist. 

Level of Evidence:   

 

3.7

Recommend regular medical follow-up if a child/adolescent is still experiencing post-concussion symptoms or has not completed the return-to-school or return-to-sport/activity stages. Recommend an immediate medical follow-up in the presence of any deterioration.

Level of Evidence:  

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