New BC Guideline on concussion/mild traumatic brain injury (mTBI)

Authors

David Wilson, MD, CCFP (biography and disclosures) and Hilary Cullen (biography, no disclosures)

Dr. David Wilson’s disclosures: Has received payments from ICBC for providing input into their new concussion management strategy. Former member of the BC Guideline Protocol Advisory Committee (GPAC). Mitigating potential bias: Recommendations are consistent with current guidelines.

Acknowledgements: We would like to thank members of the BC Guidelines Concussion/Mild Traumatic Brain Injury (mTBI) Working Group for their valuable expertise and contributions to the development of this guideline. Special thanks to Dr. Doug McTaggart, who served as the official Medical Services Commission (MSC) medical consultant for the group, and to Dr. Sandra Lee, who also contributed in her capacity as a medical consultant to the MSC.

What care gaps we have noticed

Concussions were once mainly viewed as a sport-related issue, but they extend far beyond athletics. Other common scenarios, like bicycle or vehicle collisions, work-related incidents and interpersonal or intimate partner violence, can result in these mild traumatic brain injuries. Older adults also experience a high incidence of concussion related to falls.¹ Concussions are prevalent in BC and can cause significant physical and mental health, social and financial burdens for our patients.²

This broader understanding informed the new BC Guideline, Concussion/Mild Traumatic Brain Injury (mTBI), which prompts a rethinking of past practices and assumptions. A multidisciplinary working group contributed a range of expertise and perspectives, including senior and newer family clinicians, a physiatrist, an emergency medicine physician, a paediatrician, a neuropsychologist, an athletic therapist and an injury prevention researcher/specialist. The group noted common discrepancies in concussion recognition, diagnosis and management that can lead to delayed or inappropriate care. Past practice lacked clarity on diagnostic criteria, including whether loss of consciousness is a criterion for diagnosis (it is not), the role of routine imaging in the initial assessment and instruction for returning to regular activity. While the old guidance of prolonged rest in dark rooms has proven to be counterproductive to recovery,³ there were no clear recommendations about the specifics of relative rest and acceptable activities. There is now good evidence that aerobic exercise, if introduced early and gradually, enhances recovery and reduces the likelihood of persisting symptoms.^4–6 However, this is not yet widely adopted in practice.

Data that answers these gaps

The working group drew heavily on four main evidence-based sources to develop the guideline:

• American Congress of Rehabilitation Medicine (ACRM) 2023 Diagnostic Criteria for Mild Traumatic Brain Injury
• International Conference on Concussion in Sport 2022 Consensus Statement
• Ontario Neurotrauma Foundation 2023 Living Concussion Guidelines and Living Pediatric Guidelines
• Concussion Awareness Training Tool (CATT), an online education tool created in BC for clinicians, patients, families, coaches and others.

Most concussions are relatively benign and self-limiting, with individuals typically recovering within one month.⁶ However, certain risk factors increase the likelihood of a protracted recovery, including worrisome mental health sequelae. High initial symptom severity is the greatest predictor of persisting symptoms.⁷ Some other risk factors include age (risk increases with age), sex (female), having previous concussions with persisting symptoms, a personal or family history of migraines, mental health issues or learning difficulties.^7–9 Early assessment and active management are critical, even when concussion is only suspected.

New diagnostic criteria from the ACRM include references to investigations not readily available in BC.¹⁰ We worked with the lead author to simplify interpretation for rapid application in primary care. The more pragmatic criteria outlined in the BC Guideline require a plausible mechanism of injury plus either one clinical sign or two acute symptoms.

Current guidance recommends 24-48 hours of relative rest before gradually returning to regular activities.^6,10 Most recent research emphasizes that patients should continue to be active to improve their recovery trajectory, even in the presence of mild and transient symptoms.⁶ Mild and brief exacerbation of symptoms (i.e., <2 point increase in symptom severity score for <1 hour) is normal and is not associated with longer recovery.^4,6

Clinical management should also address headache, mood and sleep disturbances, which are common after concussion, often debilitating and amenable to intervention.¹¹ Patient education is an essential part of care, emphasizing the likelihood of a good prognosis while underscoring the risks of returning to activity too soon, which could result in subsequent head injury.¹²

What we recommend

The new BC Guideline is a concise, pragmatic and BC-focused resource. We recommend using the diagnostic and management algorithm (Figure 1) to guide care for patients in your office. It was developed with the best available evidence and considers the realities of time constraints in primary care clinics.

Download the interactive Concussion Diagnostic/Management Algorithm PDF, or access the algorithm at BCGuidelines.ca or PathwaysBC.

Figure 1. Concussion Diagnostic/Management Algorithm

The algorithm highlights the following process:

• Clinical Assessment:
  • History: Obtain a description of the injury, signs/symptoms, focused past medical history (including previous concussion(s), headaches, mental health and learning challenges).
  • Assessment: Conduct a focused exam of the head and neck, cranial nerves, cognition and balance.
  • Neuroimaging: Routine CT/MRI is not indicated unless there is a high index of suspicion and a need to rule out more serious head and neck pathology.¹² Tools like the CT Head Injury/Trauma Rule, PECARN Pediatric Head Injury/Trauma Algorithm or Canadian C-Spine Rule can assist in making determinations about injury severity.
• Diagnostic Criteria: Requires a plausible mechanism of injury and either one clinical sign or two acute symptoms. Loss of consciousness is not required for diagnosis. It is acceptable to treat “suspected” concussion according to the BC Guidelines algorithm.
• Initial Management:
  • Rest: Direct patients to observe 24-48 hours of relative rest, then start moving. Mild and transient symptoms are normal and are not associated with a longer recovery. However, patients should avoid any activities that could result in subsequent head injury.
  • Physical Activity: Prescribe aerobic exercise as treatment for concussion, after the relative rest period. Set an initial Target Heart Rate (THR) at 55% of a patient’s predicted maximum heart rate (calculated by 220 minus the patient’s age) and then progress to 70%, before considering readiness for greater exercise and activity.⁶
  • Return to School/Work/Play: Return to normal activities should be initiated early, but progress in a gradual fashion. There are defined protocols that outline steps for returning to general activity, plus specific directions for school, work and sport. Clinicians using PathwaysBC can access and email these and other resources directly to patients.
  • Symptom Management: Focus on headache, sleep and mood. Use the Patient Handout for self-care strategies. Similarly, the GF Strong Rehabilitation Centre’s My Guide: Adult Concussion and My Guide: Teen Concussion websites offer customizable self-management tools.
  • Patient Education: Use of the free, BC-specific, regularly updated Concussion Awareness Training Tool (CATT) is encouraged. Content is tailored for the reader, with specific modules for patients, parents, coaches, etc.
• Follow-Up: Assess tolerance of return to activity protocols and medical readiness to return to full normal activities, screen for persisting symptoms/other conditions, and consider indications for referral.
• Provider Education: Evidence in concussion care is rapidly evolving. We recommend awareness of the regularly updated CATT (the 2-hour health care provider module is eligible for CME credits) and Living Guidelines (Adult and Pediatric) resources in addition to the BC Guideline. Even since the BC Guidelines’ development, an additional resource for assessing concussion symptoms in children <8 years old (REACTIONS-48) was identified by one of our working group members. It isn’t in the guidelines, but we felt it would be useful to share here.

Resources for patients

• BC Guidelines: Patient Handout
• Vancouver Coastal Health (VCH): My Guide: Adult Concussion
• VCH: My Guide: Teen Concussion
• Concussion Awareness Training Tool (CATT)

Resources for health-care providers

• BC Guidelines: Concussion/Mild Traumatic Brain Injury (mTBI)
• BC Guidelines Concussion Diagnostic/Management Algorithm
  • or interactive PDF
  • or on PathwaysBC
• Concussion Awareness Training Tool (CATT)
• Living Concussion Guidelines for Adults
• Living Guidelines for Pediatric Concussion
• REACTIONS-48 for children aged 8 years and younger

Assessing Injury Severity

• CT Head Injury/Trauma Rule
• PECARN Pediatric Head Injury/Trauma Algorithm
• Canadian C-Spine Rule

Supporting Return to Activities

• CATT: Returning to general activity
• CATT: Returning to school
• CATT: Returning to work
• CATT: Returning to sport sport

References

1. Huang B, Babul S. Concussions and older adults. A report by the BC Injury Research and Prevention Unit. BC Injury Research and Prevention Unit; 2022. (Download PDF from Injury Research)
2. The burden of concussion in British Columbia. B.C. Injury Research and Prevention Unit; 2020. (Download PDF from Injury Research)
3. Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: Recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259. doi:10.1097/HTR.0b013e31825ad658 (View)
4. Leddy JJ, Burma JS, Toomey CM, et al. Rest and exercise early after sport-related concussion: A systematic review and meta-analysis. Br J Sports Med. 2023;57(12):762-770. doi:10.1136/bjsports-2022-106676 (View)
5. Carter KM, Pauhl AN, Christie AD. The role of active rehabilitation in concussion management: A systematic review and meta-analysis. Med Sci Sports Exerc. 2021;53(9):1835-1845. doi:10.1249/MSS.0000000000002663 (View)
6. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med. 2023;57(11):695-711. doi:10.1136/bjsports-2023-106898 (View)
7. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941-948. doi:10.1136/bjsports-2017-097729 (View)
8. Concussion recognition, initial medical assessment, return to school and activity. Living Guideline for Pediatric Concussion. Accessed March 31, 2025. (View)
9. Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED.JAMA. 2016;315(10):1014-1025. doi:10.1001/jama.2016.1203 (View)
10. Silverberg ND, Iverson GL; ACRM Brain Injury Special Interest Group Mild TBI Task Force members:, et al. The American Congress of Rehabilitation Medicine diagnostic criteria for mild traumatic brain injury. Arch Phys Med Rehabil. 2023;104(8):1343-1355. doi:10.1016/j.apmr.2023.03.036 (View)
11. Management of prolonged symptoms. Living Concussion Guidelines: Guideline for Concussion & Prolonged Symptoms for Adults 18 years of Age or Older. Accessed March 28, 2025. (View)
12. Silverberg ND, Iaccarino MA, Panenka WJ, et al. Management of concussion and mild traumatic brain injury: A synthesis of practice guidelines. Arch Phys Med Rehabil. 2020;101(2):382-393. doi:10.1016/j.apmr.2019.10.179 (View)

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