What is the recommended follow-up approach for a patient with a reported concussion (mild traumatic brain injury) two weeks post-injury?

Follow-Up Approach for Concussion at Two Weeks Post-Injury

At two weeks post-concussion, you should immediately initiate active rehabilitation with sub-symptom threshold aerobic exercise and refer to a concussion specialist, as this patient is now at risk for developing persistent post-concussion syndrome and delayed evaluation beyond 30 days significantly worsens outcomes. 1, 2

Immediate Assessment at Two-Week Follow-Up

Symptom Evaluation

• Systematically assess postconcussive symptoms using a validated tool like the Post-Concussion Symptom Scale (PCSS), which has demonstrated high responsiveness (effect size >1.3) for monitoring recovery 3
• Specifically evaluate for the most common persistent symptoms: fatigue (17.2% prevalence) and forgetfulness (14.6% prevalence) 4
• Document symptom number, severity, and whether symptoms worsen with physical or cognitive activity 2

Domain-Specific Screening

Do not rely on patient self-report alone—systematically evaluate these specific domains: 1

• Vestibular dysfunction: Assess for dizziness, balance problems, motion sensitivity 1
• Visual/oculomotor symptoms: Screen for convergence insufficiency, accommodation problems, eye movement abnormalities 1
• Cervical spine: Evaluate for concurrent neck pain and headache 1
• Psychological factors: Screen for anxiety (GAD-7), depression (PHQ-8), as these strongly predict persistent symptoms 4, 2

Risk Stratification for Persistent Symptoms

Identify high-risk features that predict prolonged recovery: 4

• Female gender
• Previous psychiatric history (depression, anxiety, PTSD symptoms)
• Age >40 years 5
• High initial symptom burden
• Loss of consciousness at time of injury
• No recall of receiving brain injury information initially

Active Management Protocol

Aerobic Exercise Prescription (Start Immediately)

Begin sub-symptom threshold aerobic exercise at 60-70% maximum heart rate for 15-20 minutes daily, gradually increasing as tolerated. 1, 5

• This intervention shows positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 1
• Exercise should be performed below the threshold that exacerbates symptoms 4
• Gradually increase intensity and complexity over time 1

Critical pitfall to avoid: Do not prescribe complete rest beyond the first 48-72 hours, as prolonged rest may have negative implications for recovery and mental/physical wellbeing 1, 5

Cognitive Activity Management

• Implement partial cognitive rest with screen time limited to 30-minute intervals with breaks 5
• Gradually increase duration and intensity of cognitive activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms 4
• For working patients, consider shortened work days with reduced workload 5

Patient Education (Essential Component)

Provide systematic, individualized information about symptom management, expected recovery course, and self-care strategies delivered over an extended period. 1

• Tailor information to individual patient needs rather than generic handouts 1
• Discuss expected prognosis: 80-85% recover completely within 3 months, but 15-20% develop post-concussion syndrome with symptoms beyond 3 months 5
• Emphasize that active management prevents progression to persistent symptoms 1

Specialist Referral (Mandatory at This Stage)

Refer to a concussion specialist or sports medicine physician because symptoms persisting beyond the acute injury period require specialized management. 5

This referral is particularly important because: 5

• Delayed evaluation beyond 30 days is associated with greater symptom number, severity, and aggravation from activity at 3-month follow-up 2
• Specialized interventions may include vestibular rehabilitation, psychological treatment, or interdisciplinary coordinated care 5
• Early specialty evaluation represents an important opportunity in promoting better recovery and reducing persistent symptoms 2

Domain-Specific Interventions (If Applicable)

If Vestibular Dysfunction Present

• Initiate vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training at least once weekly for minimum 4 weeks 1
• This demonstrates positive effects on physical functioning and readiness to return to activities 1

If Concurrent Neck Pain and Headache

• Implement spinal manual therapy (mobilization/manipulation), which shows positive effects on pain reduction and readiness to return to activities 1

If Visual Symptoms Persist

• Consider oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises 1

If Psychological Symptoms Present

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

Red Flag Symptoms Requiring Emergency Evaluation

Provide written and verbal instructions to return immediately for: 5

• Repeated vomiting
• Worsening or severe headache
• Increasing confusion or memory problems
• Focal neurologic deficits
• Abnormal behavior
• Increased sleepiness or loss of consciousness
• Seizures

Follow-Up Schedule

• Schedule reassessment in 2-4 weeks to monitor symptom progression and exercise tolerance 1
• Continue monitoring collaboratively with patient and family to determine what modifications are needed to maintain activities without significantly exacerbating symptoms 4
• If symptoms persist beyond 4 weeks, intensify multidisciplinary approach with domain-specific interventions 1
• 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 4