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Concussion

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About Concussion

Concussion is a common condition caused by a blow, bump, or jolt to the head, or from a hit to the neck or body, which transmits force to the brain. It typically presents with symptoms such as headache, dizziness, confusion, or balance issues. While most cases resolve within 2 weeks (adults) or 4 weeks (children), some individuals may experience symptoms that persist longer. Clinicians must remain vigilant for signs and symptoms of more severe brain, head or neck injuries. 

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Concussion Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic information: Age, gender, sex, race/ethnicity.
  • Injury Characteristics:
    • Mechanism of injury: Blow to the head or sudden jolt of the head; context of injury (e.g., fall, sports, motor vehicle collision, struck by an object).
    • Symptoms and timing (immediate or developing over time):
      • Physical: Loss of consciousness, dizziness, balance problems, headache, nausea/vomiting, visual disturbances, sensitivity to light/noise, inappropriate responses to stimuli.
      • Cognitive: Confusion, memory problems, delayed responses, disorientation, difficulty concentrating.
      • Emotional/Behavioral: Irritability, emotional instability, mood swings, anxiety.
      • Sleep-Related: Trouble falling asleep, staying asleep, altered sleep patterns.
  • Symptom Inventory: Identify new or worsened symptoms. Use standardized symptom checklists (e.g., SCAT6) to capture headache, nausea, vomiting, balance problems, dizziness, fatigue, sleep problems, light/noise sensitivity, emotional issues, numbness, concentration/memory problems, visual disturbances, etc.
  • Symptom Characteristics: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors.
  • Body systems review: Neurologic, cardiovascular (including hypertension), genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
  • Health, lifestyle, and history: Previous or comorbid conditions (including headache, migraine, mental health conditions, learning disabilities, ADHD, developmental disorders, epilepsy/seizures, syncope), medications (including opioids), supplements, injuries, hospitalizations, surgeries, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
  • Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects.
  • Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
  • Flag considerations: Identify red, orange, and yellow flags for potential referrals.
  • Concussion-Specific Tools: To facilitate appropriate health history and physical examination.
    • Sport Concussion Assessment Tool SCAT6, Office Assessment Tool SCOAT6: ages 13 years +
    • Sport Concussion Assessment Tool child SCAT6, Office Assessment Tool child SCOAT6: ages 8-12 years

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

  • Symptom Inventory: Use RPQ, PCSS.
  • Pain: Use pain scales (e.g., NRS), pain diagram.
  • Function and Participation: Evaluate impact of concussion on daily activities (PSFS, WHODAS, HIT-6).
  • Recovery: Use Self-rated recovery scales.
  • Quality of Life: Assess using tools such as SF-12.
  • Work/School Status: Monitor return to activities.
  • Sleep quality: Assess using tools such as PSQI.
  • Individual Goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
  • Patient Feedback: Gather and integrate patient experience and satisfaction.

4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

  • Canadian CT Head Rule: GCS <15 at 2 hours, suspected skull fracture, signs of basal fracture (leaking fluid from ears/nose, raccoon eyes, Battle’s sign), vomiting ≥2 episodes, age ≥65 years. 
  • Canadian C-Spine Rule: Age ≥65 years, dangerous mechanism, weakness/tingling in extremities, inability to rotate neck 45° left/right, midline tenderness.
  • PECARN Minor Head Injury/Trauma Rule (Children <2 years): GCS score <15, altered mental status, palpable skull fracture, scalp hematoma (except frontal), loss of consciousness ≥5 seconds, severe mechanism of injury (e.g., fall >3 feet), not acting normally according to the parent.
  • Additional red flags: Seizure, double vision, severe/increasing headache, visible skull deformity, deteriorating conscious state, agitation.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination
  • Observation: Abnormalities, asymmetries, posture, balance, coordination, gait, movements, facial expression.
  • Range of Motion: Assess active, passive, and resisted cervical spine ROM in flexion, extension, lateral flexion, and rotation. Note regional or segmental hypo-/hypermobility and aberrant movements.
  • Palpation: Examine for tenderness, swelling, tightness, or temperature changes in bones, joints, and soft tissues of the cervical region.
  • Neurological examination:
    • Cranial nerve tests
    • Motor strength testing: Assess for asymmetry or weakness in key muscle groups:
      • C5: Shoulder abduction
      • C6: Wrist extension
      • C7: Wrist flexion and finger extension
      • C8: Finger flexion
      • T1: Finger abduction/adduction
      • L2: Hip flexion
      • L3: Knee extension
      • L4: Foot dorsiflexion and some contribution to foot inversion
      • L5: Foot dorsiflexion, big toe extension, and foot inversion 
      • L5/S1: Knee flexion 
      • S1: Plantarflexion and foot eversion 
      • S2: Big Toe flexion
    • Sensory testing: Assess for sensory deficits in dermatomal distributions:
      • C5: Lateral arm (over the deltoid)
      • C6: Lateral forearm, thumb, index finger
      • C7: Middle finger
      • C8: Ring finger, small finger, medial forearm
      • T1: Medial arm (just above the elbow)
      • T2: Axilla and upper medial arm
      • L3: Medial thigh at the knee
      • L4: Medial side of the calf
      • L5: Top of the foot and toes
      • S1: Lateral side of the foot and little toe
    • Reflex testing: Assess for asymmetry, diminished/absent reflexes:
      • C5: Biceps reflex
      • C6: Brachioradialis reflex
      • C7: Triceps reflex
      • L4: Patellar reflex
      • L5: Medial hamstring reflex
      • S1: Achilles reflex
    • Cerebellar, vestibular, and proprioceptive function:
      • Coordination and Cerebellar Function: finger-to-nose, heel-to-shin, rapid alternating movements, rebound test
      • Balance, Vestibular, and Proprioceptive Function: Romberg, tandem walking tests, VOMS (Vestibular Ocular Motor Screening), balance tests (e.g., Balance Error Scoring System [BESS]).
    • Memory and cognitive assessments: Immediate and delayed recall, orientation, concentration tasks.
    • Upper motor neuron signs: Asses for increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries).
    • Lower motor neuron signs: Assess muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate a systemic neurological condition (e.g., radiculopathy, peripheral neuropathy, ALS, spinal muscular atrophy).
  • Vital Signs: Monitor blood pressure and heart rate in supine and standing positions.
  • Advanced Diagnostics: Apply CT Head and C-Spine Rules as indicated (section 4).
  • Concussion-Specific Tools: Integrate SCAT6, SCOAT6, child SCAT6, child SCOAT6 to guide examination and documentation.

8. Diagnosis

Criteria: A blow to the head or sudden jolt of the head with at least one of the following:

  • Imaging: Clear evidence of neurotrauma.
  • ≥1 Clinical Signs: Altered mental status, loss of consciousness (<30 min), amnesia (<24 h), neurological signs (e.g., seizure, coordination problems).
  • ≥2 Symptoms: Dazed or confused feeling, physical symptoms (headache, nausea, dizzy, light/sound sensitivity), cognitive symptoms (feeling run down, fatigued, foggy), emotional symptoms (irritability, sadness).

9. Treatment Considerations for Concussion

A. Initial Management (CDC 2022, David 2019, Marshall et al., 2023, Patricios et al., 2023, Reed et al., 2021)

  • Education and reassurance: Provide clear information on the typical recovery process, emphasizing the gradual resumption of activities. Address any misconceptions and encourage questions to ensure understanding.
  • Rest and gradual return: Emphasize short-term physical and cognitive rest (24-48 hours), followed by a gradual increase in activity levels as tolerated (e.g., work, school, driving, sports), incorporating early light physical activity (e.g., sub-symptom threshold aerobic exercise).
  • Return-to-Learn and Return-to-Sport: Follow SCOAT6, child SCOAT6 protocols. Prioritize learning before sport. 
  • Promote self-care: Encourage exercise, proper nutrition, sleep hygiene, stress management, maintaining a healthy body weight, avoiding smoking/substance abuse.

B. Symptom Management (CDC 2022, David 2019, Marshall et al., 2023, Patricios et al., 2023, Reed et al., 2021)

Use SCAT6/SCOAT6 to guide symptom-specific interventions.
Multidisciplinary care may be required especially for persistent symptoms.

  • Headache and neck pain:
    • Exercise therapy: Cervicovestibular, strengthening, ROM, aerobic, mind-body (e.g., yoga). 
    • Manual therapy: Spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage for neck and upper back.
    • Medications: Over-the-counter analgesics/prescription used sparingly to avoid medication overuse headaches. Discuss options/risks with medical provider.
  • Sleep problems or fatigue: 
    • Behaviour modification: Sleep hygiene and activity-to-tolerance strategies.
    • Psychological support: e.g., cognitive behavioural therapy (CBT).
    • Supplements: e.g., melatonin, zinc, magnesium.
  • Mental health, emotional or behavioural problems:
    • Psychological support: CBT, psychoeducation.
    • Referral: e.g., primary care provider, psychologist, psychiatrist.
  • Cognitive/memory problems: 
    • Behaviour modification: Work/school accommodations or modifications, sleep hygiene.
    • Psychological support: e.g., CBT.
    • Referral: e.g., primary care provider, neuropsychologist.
  • Vestibular (balance/dizziness) and vision problems:
    • Vestibular and oculomotor rehabilitation:
      • Sub-symptom threshold aerobic exercise: Low-intensity aerobic activities that do not exacerbate symptoms (e.g., walking, stationary cycling).
      • Cervicovestibular exercises: Include non-provocative ROM exercises, postural stability exercises, and craniovertebral flexion and extension exercises.
      • Vestibulo-oculomotor exercises: Exercises that target eye movements and coordination (e.g., gaze stabilization, saccades).
    • Behaviour modification:
      • Work/school accommodations: Reduce symptom provocation by allowing for breaks, reducing screen time, providing a quiet workspace, allowing more time for tasks.
      • Activity modifications: Adjust daily activities to avoid symptom exacerbation while promoting gradual return to normal function.
    • Canalith repositioning maneuvers:
      • Epley Maneuver: Series of head and body movements to treat benign paroxysmal positional vertigo (BPPV).
      • Brandt-Daroff exercises: Home exercises to reduce dizziness and improve vestibular function.
      • Referral: e.g., primary care provider, vestibular therapist.
10. Risk and Prognostic Factors
  • Common Risk Factors: (Public Health Ontario 2021, CDC 2022, Eliason et al., 2023, Abrahams et al., 2014)
    • Previous concussion, older age, female sex, participation in contact sports, specific playing positions, inadequate protective equipment, aggressive play, mental health or neurological conditions, fatigue, and unsafe environments
  • Prognosis: (Carol et al., 2020, Carol et al., 2023, Marshall et al., 2023)
    • Most people recover within a few days to a few weeks, but symptoms can persist. Being a student or older adult is associated with prolonged symptoms.
    • Common negative Prognostic Factors: High initial pain and disability levels; high initial number of symptoms; poor recovery expectations; history of concussions; pre-existing headache, mental health issues, developmental disorders, cognitive impairment, learning disorders, ADHD; post-injury stress, anxiety, depression.
11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References