What is the recommended management for a patient 2 weeks post-concussion (mild traumatic brain injury) with persistent symptoms?

Management of Persistent Concussion Symptoms at 2 Weeks Post-Injury

At 2 weeks post-concussion with persistent symptoms, initiate active management with graded physical exercise below symptom threshold, provide tailored patient education about expected recovery, and assess for specific symptom domains (vestibular, visual, cervical, psychological) to guide targeted interventions. 1

Shift from Passive to Active Management

The paradigm has shifted from passively awaiting symptom remission to recommending active management when symptoms persist beyond the acute phase. 1 At 2 weeks, you are in a critical window where 15-20% of patients may develop persistent post-concussion syndrome, making early intervention essential. 2, 3

Core Initial Interventions

Patient Education and Information

• Provide systematic, individualized information about symptom management, expected recovery course, and self-care strategies delivered over an extended period (not just a single session). 1
• This intervention has demonstrated positive effects on reducing overall symptom burden and preventing memory problems, with strong (Grade A) recommendations from the Ontario Neurotrauma Foundation and American Physical Therapy Association guidelines. 1
• Tailor information to individual patient needs rather than generic handouts. 1

Graded Physical Exercise

• Implement sub-symptom threshold aerobic exercise with gradual increases in intensity and complexity. 1
• This intervention shows positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life. 1
• The exercise should not exacerbate symptoms beyond mild, temporary increases—if symptoms worsen significantly or persist, reduce intensity. 1

Domain-Specific Assessment and Treatment

Vestibular Symptoms (Dizziness, Balance Problems)

• If vestibular dysfunction is present, initiate vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training at least once weekly for minimum 4 weeks. 1, 2
• This often includes concurrent exercise and manual treatment of cervical/thoracic spine. 1
• Demonstrates positive effects on physical functioning and readiness to return to activities. 1, 3

Cervical/Neck Pain and Headache

• Implement spinal manual therapy (mobilization/manipulation) for patients with concurrent neck pain and headache. 1, 2
• This intervention shows positive effects on pain reduction and readiness to return to sport/activities. 1

Visual Symptoms (Eye strain, difficulty focusing, visual disturbances)

• Consider oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises. 1, 2
• While controlled trial evidence is limited, clinical experience and uncontrolled studies support its use for persistent visual symptoms. 1
• Administer as optometric sessions minimally once weekly for 4 weeks. 1

Emotional Symptoms (Anxiety, Depression, Irritability)

• Offer psychological treatment as individual or group therapy administered at least 1 hour weekly for minimum 4 weeks. 1, 3
• This shows positive effects on overall symptom burden, emotional symptoms, and quality of life at longest follow-up. 1

When to Escalate to Interdisciplinary Care

If symptoms persist beyond 4 weeks or involve multiple domains, coordinate treatment from at least two healthcare disciplines (e.g., physical therapy, psychology, occupational therapy). 1, 2, 3

• Interdisciplinary coordinated rehabilitation demonstrates positive effects on overall symptom burden, physical functioning, emotional symptoms, quality of life, and work satisfaction. 1, 3
• This comprehensive approach should include at least 2 interventions administered minimally once weekly for 4 weeks. 1, 3

Critical Pitfalls to Avoid

• Do not prescribe complete rest beyond the first 24-48 hours—prolonged rest may have negative implications for recovery and mental/physical wellbeing. 1
• Do not wait for spontaneous recovery—active management at 2 weeks can prevent progression to persistent post-concussion syndrome. 1
• Do not rely solely on patient self-report without objective assessment—evaluate specific domains (vestibular, visual, cervical, cognitive) systematically. 1, 2
• Do not allow premature return to full activity—ensure graded progression below symptom threshold to avoid symptom exacerbation. 1

Evidence Quality Context

The certainty of evidence for these interventions ranges from very low to low due to risk of bias and indirectness in available studies. 1 However, the recommendations are consistent across multiple guideline organizations including the American Congress of Rehabilitation Medicine, American Physical Therapy Association, and Ontario Neurotrauma Foundation. 1 The weak strength of recommendations reflects evidence quality, not lack of clinical benefit—these interventions show consistent positive effects without serious adverse events. 1