Commotion cérébrale

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability, age, development and previous health care experiences (Public Health Agency of Canada 2018).
  
• Patient and contextual information: age; sex and gender when clinically relevant; preferred language and communication needs; school, work, caregiving and sport roles; developmental or learning needs; and the activities, identities, relationships and cultural or community connections important to the patient. Include parent, caregiver or other collateral information with consent when it improves accuracy or safety.
  

Primary concerns

• Injury event and onset: date and time; direct or indirect force; fall, collision, sport, workplace, motor vehicle, assault or other context; height or speed when relevant; immediate or delayed symptoms; and whether the person continued the activity or sustained another impact.
• Acute signs: loss or alteration of consciousness, confusion, amnesia, disorientation, seizure, vomiting, unusual behaviour, imbalance, speech or vision change, weakness or numbness, and available witness observations.
• Early care and safety: emergency or medical assessment; Glasgow Coma Scale when recorded; imaging or other tests; diagnosed injuries; discharge advice; current supervision; and new or worsening symptoms since the injury.
• Symptom pattern: headache, pressure, neck pain, dizziness, balance or motion sensitivity, nausea, light or noise sensitivity, visual or hearing change, fatigue, slowed thinking, concentration or memory difficulty, irritability, anxiety, low mood and sleep change. Record severity, variability, triggers and the response to physical and cognitive activity.
• Participation and safety: effects on self-care, mobility, school, work, driving, screen use, caregiving, recreation, social connection and sport; current accommodations; and activities with contact, collision or fall risk.

Previous brain and head injury: prior concussion or traumatic brain injury, number and circumstances, symptom pattern, time and supports needed for recovery, complications, and whether there were impacts before full recovery.

• Health, lifestyle and history: migraine or other headache disorder; neck, vestibular, vision or hearing conditions; seizure or syncope; mental health, sleep, learning, attention, developmental or neurological conditions; chronic pain; medications and supplements, including anticoagulant or antiplatelet treatment; alcohol or substance use; and other injuries or conditions that may affect assessment or recovery.
  
• Social determinants of health: relevant school or work demands and supports, caregiving, income, housing, transportation, food security, discrimination, safety, social support, access to care and culturally relevant or community resources. Ask only what is relevant and safe to discuss, and use the information to adapt care or connect the patient with support when possible (Public Health Agency of Canada 2026).
  
• Soins et interventions antérieurs : education, treatment, rehabilitation, medication or self-management tried; what helped or did not help; adverse effects; and reasons care was difficult to access, use or continue.
  
• Patient perspective: understanding of the problem, priorities, preferences, cultural context, concerns, recovery expectations, confidence, strengths and previous experiences of care.
  
• Flag review: check Red Flags and use the separate Orange Flags and Yellow Flags sections when relevant. Repeat relevant questions if symptoms or circumstances change.

Outcome measures: Use a small set of age-appropriate measures that are meaningful to the patient and practical to repeat. Record a baseline and reassess often enough to guide decisions.

• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Qualité de vie : a validated measure suited to age and setting, such as WHOQOL-BREF for adults or the Pediatric Quality of Life Inventory (PedsQL) for children and adolescents.
• Concussion symptoms: an age- and context-appropriate standardized measure, such as the Rivermead Post-Concussion Symptoms Questionnaire for adults or the Post-Concussion Symptom Inventory for children and adolescents. Sport tools can provide symptom data within their intended age and time window.
• Additional outcomes: headache, dizziness, sleep, mood, cognitive activity, exertion tolerance, school or work participation, return to activity and the patient’s own rating of change when the result will inform care.
• Objectifs individuels : agree on patient-defined goals and how progress will be recognized. SMART goal wording (Bovend’Eerdt et al. 2009) may be used when helpful but is not required.

Red flags after a head injury are prompts for urgent clinical reasoning, not a diagnosis of concussion. Interpret the injury mechanism, new change, combination and progression of findings.

ACTION: Arrange emergency assessment immediately:

• Reduced or deteriorating consciousness, difficulty staying awake, a Glasgow Coma Scale score below 15 unless this is the documented pre-injury baseline, rapidly worsening confusion, or a seizure without full recovery.
  
• A new or progressive focal neurological deficit, such as weakness, numbness, speech or language difficulty, marked loss of balance, inability to walk, new visual change, abnormal pupils or another rapidly evolving neurological finding.
  
• A suspected open, depressed or basal skull fracture or penetrating injury, including skull deformity, cerebrospinal fluid leaking from the ear or nose, blood behind the eardrum, bruising around both eyes without direct eye trauma, or bruising behind the ear.
  
• A high-energy head injury, unstable multisystem trauma, or suspected cervical spine injury with severe midline pain or tenderness, limb paresthesia or weakness, deformity, or an unsafe examination. Protect the cervical spine and do not test neck movement when instability remains possible.
  
• A severe or rapidly worsening headache, repeated vomiting, escalating agitation or behaviour change, or another pattern suggesting acute intracranial deterioration, especially when combined with altered consciousness or neurological change.

ACTION: Arrange prompt medical assessment:

• Any loss of consciousness, amnesia, persistent headache, vomiting, drug or alcohol intoxication, previous brain surgery, a bleeding or clotting disorder, or anticoagulant or antiplatelet treatment other than aspirin alone (National Institute for Health and Care Excellence 2023).
  
• Symptoms that are delayed, worsening or atypical; an uncertain diagnosis; a possible more severe brain injury, cervical injury, vestibular or neurological disorder, toxic or metabolic cause, or another condition that better explains the presentation.
  
• Possible non-accidental injury, intimate partner violence, abuse, neglect or another safeguarding concern. Follow the applicable safeguarding and emergency pathway.

ACTION: Arrange planned referral or shared care when:

• Symptoms or participation are not gradually improving by 2-4 weeks in a child or adolescent, persist beyond one month in an adult, or decline at any time. Refer earlier when symptom burden, medical history, examination findings or access barriers increase concern (Living Guideline for Pediatric Concussion Care 2026; Living Concussion Guidelines 2026).
  
• Headache, neck pain, dizziness, balance, vision, hearing, cognition, sleep, mood, fatigue, exertion intolerance or school/work difficulty requires assessment or care beyond the clinician’s competence or scope.
  
• Return-to-sport clearance, repeated concussion, complex medical or developmental history, diagnostic uncertainty, or decisions about contact or collision sport require medical or interdisciplinary input.
  
• Provide written safety-net advice about new or worsening symptoms that require earlier reassessment or emergency care. Document the findings, actions, advice, transport and follow-through.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change safety, the working diagnosis, care or referral. Adapt the pace, environment, communication and testing to age, development, disability, symptom irritability, comfort and consent.

• Ongoing consent and comfort: explain what you propose, provide choices about positioning, pace, lighting, breaks and support, and stop or modify testing when requested or when symptoms become more than mildly and briefly aggravated.
  
• Immediate safety: establish whether acute head or cervical injury has been medically assessed. Check mental status, orientation, behaviour and general appearance; use age-appropriate Glasgow Coma Scale components and vital signs when the acute setting or presentation makes them relevant.
  
• Examen neurologique : cranial nerves, motor function, sensation, reflexes, coordination, gait and balance as indicated. Compare sides and with the person’s known baseline, and document objective deficits and change over time.
  
• Cervical spine and regional examination: after fracture and instability have been excluded, assess neck symptoms, active movement, relevant neurological findings, palpation and functional tasks. Examine other injured regions when indicated. Do not test cervical range of motion when acute imaging or immobilization criteria remain possible (National Institute for Health and Care Excellence 2023).
  
• Symptoms and cognition: document symptoms with an age-appropriate standardized scale; assess orientation, attention, immediate and delayed memory and processing as relevant. Interpret cognitive tests with the broader clinical assessment and do not use one score in isolation.
  
• Standardized concussion assessment tools: the SCAT6 is for people aged 13 years and older and the Child SCAT6 for ages 8-12, with best utility in the first 72 hours and up to 7 days after sport-related injury. The SCOAT6 for people aged 13 years and older and the Child SCOAT6 for ages 8-12 provide a standardized, adaptable multidomain framework for office and serial assessment from 72 hours onward. Although developed in a sport-concussion framework, relevant components can inform office assessment after non-sport mechanisms when clinically appropriate. Use each tool within its intended age and time window; no tool establishes or excludes the diagnosis by itself (Patricios et al. 2023; Living Concussion Guidelines 2026).
  
• Vestibular, oculomotor and balance assessment: eye movements, near-point convergence, vestibulo-ocular reflex, visual motion sensitivity, static and dynamic balance and gait when relevant. The Vestibular/Ocular Motor Screening tool can help identify symptom provocation but is not a stand-alone diagnostic test.
  
• Positional vertigo: when brief vertigo is triggered by head-position change and the cervical spine is cleared, use appropriate positional testing within competence to assess benign paroxysmal positional vertigo. Refer when the pattern is atypical or testing is unsafe (Living Concussion Guidelines 2026).
  
• Exertion tolerance: when medically safe, assess the response to light then progressively greater physical activity with a validated or standardized approach suited to the setting. Record symptom change, heart rate and other findings needed to guide an individualized activity plan.
  
• Évaluation fonctionnelle : select tasks tied to goals and roles, such as reading, screen use, dual tasking, walking, stairs, school or work simulation, driving-related demands and sport-specific activity without head-impact risk.
  
• Imaging and decision rules: imaging is not routine to diagnose uncomplicated concussion. In acute medical assessment, use a validated decision rule in full and only in its intended population. The Règle canadienne de tomodensitométrie de la tête applies to patients aged 16 years or older with minor head injury who meet its inclusion criteria. The Règle canadienne sur la colonne cervicale applies to alert, stable patients aged 16 years or older after blunt trauma. The age-stratified PECARN pediatric head trauma prediction rules apply to children younger than 18 years with minor blunt head trauma and Glasgow Coma Scale scores of 14-15 in acute-care settings. These rules estimate risk of clinically important structural injury and guide imaging decisions; they do not diagnose or exclude concussion. Imaging decisions belong with the clinician responsible for acute medical assessment, and normal routine imaging does not rule out concussion (Stiell et al. 2001a; Stiell et al. 2001b; Kuppermann et al. 2009).
  
• Reassessment: repeat the smallest relevant set of symptoms, objective findings, exertion and functional tasks needed to review recovery, update the working presentation and decide whether further assessment or referral is appropriate.

Formal diagnostic framework

Use the 2023 American Congress of Rehabilitation Medicine criteria when diagnosing mild traumatic brain injury. After a biomechanically plausible mechanism, diagnosis requires at least one attributable clinical sign; or at least two acute symptoms plus an attributable clinical or laboratory finding; or neuroimaging evidence of traumatic brain injury. Confounding factors must not better explain the findings. The label concussion can be used interchangeably with mild traumatic brain injury when neuroimaging is normal or not clinically indicated (Silverberg et al. 2023).

Use suspected mild traumatic brain injury when the mechanism and acute symptoms or findings raise concern but the full criteria are not yet met or confounding remains unclear. Do not diagnose or grade concussion from a symptom count, SCAT/SCOAT result, loss of consciousness, routine imaging result or one examination finding alone.

Working clinical presentations

Add one or more working presentations when they help assessment, communication or care planning. They can overlap or change and do not replace the formal diagnosis or a differential diagnosis.

• Acute or subacute multimodal presentation: symptoms and findings across physical, cognitive, emotional, sleep, vestibular, oculomotor and cervical domains during the early period after injury.
  
• Headache and cervical presentation: post-traumatic headache, neck pain or both, with the headache pattern and cervical contribution assessed rather than assumed.
  
• Vestibular, oculomotor or balance presentation: dizziness, motion or visual sensitivity, impaired gaze stability, convergence or balance, or positional vertigo. Distinguish central, peripheral, cervical, migraine and other possible contributors.
  
• Exertional-intolerance presentation: symptoms are predictably aggravated by physical exertion, with examination used to distinguish deconditioning, autonomic, vestibular, cervical, cardiopulmonary and other contributors.
  
• Cognitive, fatigue or sleep presentation: slowed processing, attention or memory difficulty, fatigue or sleep-wake disturbance, interpreted with pain, mood, medication, school/work demands and the person’s pre-injury baseline.
  
• Emotional or behavioural presentation: anxiety, low mood, irritability, fear, trauma response or behavioural change that may be new, worsened or interacting with pre-existing concerns. Use Orange Flags and appropriate mental health or emergency care when risk is present.
  
• Persisting symptoms after concussion: one or more symptoms continue beyond 4 weeks. Use a multimodal reassessment because symptoms can reflect the concussion, coexisting injury, pre-existing conditions, contextual factors or another diagnosis (Patricios et al. 2023).
  
• Alternative or overlapping presentation: migraine, benign paroxysmal positional vertigo, whiplash-associated disorder, primary sleep or mental health disorder, medication or substance effect, visual or hearing disorder, syncope, systemic illness or another neurological condition may overlap or better explain part of the presentation. Arrange referral or shared care when needed.

Develop care with the patient and, when appropriate, family, school, workplace, sport and medical partners. Base choices on safety, the working presentation, goals, preferences, culture, age, development, other health conditions, access and response. Use adaptable options rather than a fixed sequence, and repeat meaningful outcomes to guide change.

Education, self-management and participation

• Education and communication: options include a clear explanation of the diagnosis and uncertainty, written and verbal safety-net information, reassurance that recovery is expected for most people, and a plan for follow-up. Involve a support person with consent when memory, age or safety makes this useful (Living Concussion Guidelines 2026; Living Guideline for Pediatric Concussion Care 2026).
  
• Early activity: options include relative rather than strict rest for the first 24-48 hours, activities of daily living and reduced screen exposure when it aggravates symptoms, followed by gradual cognitive and physical activity that causes no more than mild and brief symptom increase. Avoid contact, collision, fall and other repeat-head-injury risk until medically cleared (Leddy et al. 2023; Patricios et al. 2023).
  
• School, work and daily roles: a gradual return can include temporary changes to schedule, workload, breaks, screen exposure, lighting, noise, travel or task demands, with supports reduced as tolerance improves. Address driving directly; do not drive when symptoms, vision, cognition, reaction time or medication effects make it unsafe (Living Concussion Guidelines 2026; Parachute 2024).
  
• Sport: remove a person with suspected sport-related concussion from play and do not allow same-day return. Use the graduated Canadian return-to-sport process. Full return to learning comes before unrestricted return to sport, and medical clearance is required before stages with risk of contact, collision or falling (Parachute 2024).

Physical activity and exercise

• Options include early light, low-risk physical activity such as walking or stationary cycling, then gradual progression according to tolerance. Individualized subsymptom-threshold aerobic exercise based on appropriate exertion testing can form part of care when delivered by a clinician with the required competence and medical context (Leddy et al. 2023; Patricios et al. 2023).

Targeted rehabilitation and symptom-relieving care

• Cervical and vestibular care: options for a supported presentation include cervical exercise, balance and gaze-stability training, vestibular or cervicovestibular rehabilitation and graded exposure to movement or visual environments. Match the option to examination findings and response (Schneider et al. 2023; Living Concussion Guidelines 2026).
  
• Benign paroxysmal positional vertigo: for confirmed posterior-canal BPPV, options include an Epley/canalith repositioning manoeuvre selected for the involved side when appropriate positional testing is positive and the cervical spine is cleared. Brandt-Daroff exercises are habituation or home exercises, not canalith repositioning manoeuvres; their evidence is less certain than Epley, and they can be an alternative or adjunct when individualized instruction and safety review make them appropriate. Refer when the presentation is atypical, testing or treatment is unsafe, or symptoms do not respond as expected (Bhattacharyya et al. 2017; Alashram 2024; Living Concussion Guidelines 2026).
  
• Maux de tête et douleurs cervicales : options can include activity and sleep strategies, cervical exercise and, for a coexisting cervical presentation, soft-tissue care, mobilization or other manual care as an adjunct to active rehabilitation when safe. Treat these as care for the cervical presentation, not as treatment for the brain injury (Schneider et al. 2023; Living Concussion Guidelines 2026).
  
• Cognitive, sensory, fatigue and sleep concerns: options include pacing, task and environmental adaptation, graded exposure, sleep routines and targeted cognitive or occupational strategies. Adapt school, work and caregiving demands with the patient rather than requiring complete symptom resolution before participation (Living Concussion Guidelines 2026; Living Guideline for Pediatric Concussion Care 2026).

Psychological, social and interdisciplinary support

• Options include psychologically informed education, coping and behavioural strategies within competence, and coordination with mental health, medical, vision, vestibular, occupational, school, workplace, community, Indigenous or culturally specific supports. Interdisciplinary concussion care can form part of care for persisting symptoms, complex needs or participation barriers (Living Concussion Guidelines 2026; Living Guideline for Pediatric Concussion Care 2026).

Médicament

• Medication options for headache, nausea, sleep, mood or another symptom require coordination with an authorized prescriber or pharmacist. Review current medicines, contraindications, interactions, adverse effects, possible symptom masking and medication-overuse headache risk; keep prescribing and dosing outside the scope of this pathway (Living Concussion Guidelines 2026).

Monitoring and reassessment

• Set a reassessment point based on injury timing, presentation, safety, goals, care being tried, age, patient needs and access.
• Repeat the baseline outcome set and review symptoms, relevant neurological, cervical, vestibular and exertion findings, functioning, participation, benefits, harms, burden and goals.
• Continue, adapt or stop care according to response; revisit the diagnostic criteria, working presentation, differential diagnosis, safety and referral when progress differs from expectations or new concerns emerge.

• Expected course: prognosis is individual. Most adults and children improve over days to weeks; symptoms continuing beyond 4 weeks are described as persisting symptoms and warrant multimodal reassessment rather than a conclusion that recovery has stopped (Living Concussion Guidelines 2026; Living Guideline for Pediatric Concussion Care 2026; Patricios et al. 2023).
  
• Factors associated with a less favourable course: greater early symptom burden, loss of consciousness or amnesia, delayed access to care, previous prolonged concussion recovery, and pre-injury headache (particularly migraine), mental health or sleep disorders may be associated with longer recovery. ADHD, developmental and learning disorders may affect assessment and support needs, but their independent prognostic value is uncertain. Use these factors to guide follow-up, not predict an individual’s recovery (McIntosh et al. 2025; Living Guideline for Pediatric Concussion Care 2026; Cook et al. 2020).
  
• Potential supports for recovery: clear information, early low-risk activity, feasible school or work accommodations, sleep support, supportive relationships, access to care and targeted treatment of the symptoms or coexisting conditions most relevant to the patient may support recovery (Living Concussion Guidelines 2026; Living Guideline for Pediatric Concussion Care 2026).
  
• Discussing prognosis: explain uncertainty without alarm, ask what the patient and family want to know, and use repeated outcomes, return to meaningful roles and the observed course to update the plan. Do not use a prognostic factor, symptom score or expected timeline as a promise or a reason to blame the patient.