Management of Persistent Concussion Symptoms

Core Initial Interventions

The American Physical Therapy Association recommends providing systematic, individualized information about symptom management, expected recovery course, and self-care strategies delivered over an extended period, which has demonstrated positive effects on reducing overall symptom burden and preventing memory problems, with strong (Grade A) recommendations 1, 2
Tailor information to individual patient needs rather than generic handouts, as recommended by the American Physical Therapy Association 2
Implement sub-symptom threshold aerobic exercise with gradual increases in intensity and complexity, which shows positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life, as recommended by the American College of Sports Medicine 2, 3

If vestibular dysfunction is present, initiate vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training at least once weekly for minimum 4 weeks, which demonstrates positive effects on physical functioning and readiness to return to activities, as recommended by the American Physical Therapy Association 2, 3
Implement spinal manual therapy (mobilization/manipulation) for patients with concurrent neck pain and headache, which shows positive effects on pain reduction and readiness to return to sport/activities, as recommended by the American Physical Therapy Association 3
Consider oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises for persistent visual symptoms, as recommended by the American Academy of Optometry 1, 4
Offer psychological treatment as individual or group therapy administered at least 1 hour weekly for minimum 4 weeks, which shows positive effects on overall symptom burden, emotional symptoms, and quality of life, as recommended by the American Psychological Association 2, 3

The American Congress of Rehabilitation Medicine recommends avoiding complete rest beyond the first 24-48 hours, as prolonged rest may have negative implications for recovery and mental/physical wellbeing 5
Do not wait for spontaneous recovery—active management at 2 weeks can prevent progression to persistent post-concussion syndrome, as recommended by the Ontario Neurotrauma Foundation 1, 2
Do not rely solely on patient self-report without objective assessment—evaluate specific domains (vestibular, visual, cervical, cognitive) systematically, as recommended by the American Congress of Rehabilitation Medicine 5

The American Academy of Emergency Medicine recommends systematically evaluating post-concussive symptoms, including fatigue (17.2% prevalence) and forgetfulness (14.6% prevalence), in patients at two weeks post-injury 6
Patients with previous psychiatric history (depression, anxiety, PTSD symptoms) are at higher risk for persistent symptoms, according to the American Academy of Emergency Medicine 6
Female gender is a high-risk feature that predicts prolonged recovery, as reported by the American Academy of Emergency Medicine 6
No recall of receiving brain injury information initially is a risk factor for persistent symptoms, as noted by the American Academy of Emergency Medicine 6
Problems may persist for at least 6 months and may require not only continued medical care but also social assistance with driving support, employment issues, and financial assistance during recovery, as stated by the American Academy of Emergency Medicine 6

The American Academy of Pediatrics recommends exercise should be performed below the threshold that exacerbates symptoms, with a goal of increasing participation without significantly exacerbating symptoms 7
Gradually increase duration and intensity of cognitive activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms, as suggested by the American Academy of Pediatrics 7
Continue monitoring collaboratively with patient and family to determine what modifications are needed to maintain activities without significantly exacerbating symptoms, as recommended by the American Academy of Pediatrics 7