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Concussion guidelines to help adults manage persistent symptoms, resume life

September 24, 2013 — A new set of guidelines, published today by the Ontario Neurotrauma Foundation (ONF), will help primary health-care providers treat and manage post-concussion symptoms that hang on months after an injury. Guidelines for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms (2nd Edition) uses significantly updated evidence to support health-care providers who are helping their adult patients return to normal daily life.

Every year in Ontario an estimated 80,000 people suffer a concussion, or mild traumatic brain injury (mTBI), according to numbers published in 2004. Of those, as many as 16,000 can experience lingering, troublesome symptoms for more than three months. Nearly a decade later, this incidence rate is widely thought to be considerably higher.

“Concussion is commonly thought of as a sports injury,” says Dr. Shawn Marshall, who is the lead author on the guidelines and a physician at The Ottawa Hospital Rehabilitation Centre. “But the reality is that many concussions, or mild traumatic brain injuries, come from mishaps of daily living, such as slipping on the ice while walking the dog, falling down the stairs at home, or being in a car crash.

“There are currently good sports guidelines about how to return to play. Our guidelines take a broader view. We want to help people return to their lives,” adds Marshall, who is also a clinical investigator at the Ottawa Hospital Research Institute and a professor of medicine at the University of Ottawa.

Dr. Marshall points out that resting the brain is certainly the first priority, and this helps the vast majority of concussion patients. But when symptoms last months, emerging research pulled together in the new guidelines shows that resting for too long can become detrimental to well-being. People lose physical fitness, and they can become isolated and depressed.

“Persistent symptoms need to be treated more actively in order to help people resume daily life,” says Marshall.

Just ask Leah Braithwaite, who was knocked down by a beginner skier in February 2011.

“It was an unremarkable fall, but the consequences on my work and family life have been anything but trivial,” says Leah Braithwaite, an Ottawa mother of two who is also Chief of Policy and Planning for the Canadian Ice Service of Environment Canada. “My physician diagnosed my concussion, but didn’t have a program for managing my lingering and debilitating symptoms.”

Braithwaite did her best to manage on her own. She used sick leave and spent a lot of time in her darkened bedroom. She tried to go back to work in March, but pressures and extended time working brought back her symptoms of fatigue, dizziness, headaches and vomiting. She was also having difficulty processing information, concentrating and even finding the right words in a conversation. She couldn’t take her son to basketball. She couldn’t bear the sound of dishes being unloaded from the washer. She asked to see a specialist.

“It was another four months before I saw someone familiar enough with concussions to actively address my symptoms and help me get back to work and my family. I hope these guidelines will help a lot of people start that journey sooner,” says Braithwaite, who, after several false starts, integrated slowly back to the office, working from home for several months and finally returning to full-time work nine months after her concussion. Although she still manages some symptoms two-and-a-half years later, such as fatigue and headaches, she feels lucky to have returned to her previous level of activity.

Talking about the need for these guidelines, Dr. Marshall says: “Not everyone is an expert on mild traumatic brain injury, or mTBI. There are many family doctors and other providers who want, or need, to become more knowledgeable about comprehensive management of concussion. These guidelines help them navigate the recent and overwhelming explosion of concussion research.”

Designed for health-care providers to manage concussion/mTBI in adults over 18 years of age, the guidelines include ways for physicians and other clinicians to objectively evaluate, monitor and manage symptoms. They also provide concrete strategies and tools for all types of health-care providers.

“These guidelines are important for changing the way concussions are managed, at the level of individual clinicians and health-care consumers, but also at a system level,” says Corinne Kagan of ONF. ONF will be working with its partners in the Concussion/mTBI Strategy to widely share and facilitate use of the guidelines, including a plan to implement the diagnosis and initial management components in some of the province’s emergency departments. ONF is also working on guidelines for managing persistent concussions symptoms in children and youth, expected sometime in 2014.

Dr. Marshall led a six-person team to develop the guidelines, including: Dr. Mark Bayley of UHN’s Toronto Rehabilitation Institute, Dr. Lindsay Berrigan of Dalhousie University, Dr. Scott McCullagh of Sunnybrook Health Sciences Centre, Dr. Donna Ouchterlony of St. Michael’s Hospital and Dr. Diana Velikonja of Hamilton Health Sciences.

In addition, the team drew upon 35 additional experts from Canada, the U.S. and Australia, including rehabilitation and medical professionals, people who had sustained mTBIs, as well as sports and military experts.

The guidelines are free and available at and

Media Contacts:

Paddy Moore
Ottawa Hospital Research Institute
613-737-8899 ext. 73687
613-323-5680 (cell)

Jennifer Kramer
Hamilton Health Sciences Centre

Leslie Shepherd
St. Michael’s Hospital

Nadia Norcia Radovini
Sunnybrook Health Sciences Centre

Melissa McDermott
Toronto Rehabilitation Institute, UHN
416-597-3422 ext. 3524

About Ontario Neurotrauma Foundation (ONF)
The Ontario Neurotrauma Foundation (ONF) is a not-for-profit research organization that works with partners across Ontario to create and sustain improvements in practice and policy related to the recognition, diagnosis and management of Concussion/mTBI.  ONF is a leader of strategic and applied research in acquired brain injury, spinal cord injury and prevention of injury.  Funded by the Ontario Ministry of Health and Long-Term Care, ONF capitalizes on its collaborative and networking strengths, and its focus on linking research and practice to work with provincial, national and international partners in neurotrauma.

About the Ottawa Hospital Research Institute (OHRI)
The Ottawa Hospital Research Institute (OHRI) is the research arm of The Ottawa Hospital and is an affiliated institute of the University of Ottawa, closely associated with the university’s Faculties of Medicine and Health Sciences. OHRI includes more than 1,700 scientists, clinical investigators, graduate students, postdoctoral fellows and staff conducting research to improve the understanding, prevention, diagnosis and treatment of human disease. Research at OHRI is supported by The Ottawa Hospital Foundation.