Monitoring

If symptoms return, activity should be reduced to a level that does not aggravate symptoms. Psychiatric symptoms, if they appear, should be treated immediately, referring to a neurologist, psychiatrist, or psychologist when necessary. Referral to individual medical specialists or to a specialized multidisciplinary mild traumatic brain injury (TBI) clinic is appropriate for patients with persistent symptoms (lasting more than 4-6 weeks) who do not respond to treatment in a primary care setting.​[69][93][98]​​​ Earlier referral may be helpful if:[98][122]​​​[123]​​​​ 

  • The patient has a high symptom burden or known risk factors for prolonged recovery, such as a preexisting mental health disorder

  • The patient is unable to progress with their return to activity or they are attempting to return to high-stakes roles soon after injury (e.g., those partaking in competitive sport or university exams)

  • Access to care is limited (e.g., long waitlist times)

Patients with one to two specific symptoms may only require individual disciplines rather than referral to a multidisciplinary clinic. For example, those with primarily vestibular symptoms should be referred to physical therapy or otolaryngology.​[69][98]​​​ ​​Cognitive symptoms usually resolve quickly after mild TBI; a minority of patients have memory and concentration problems within 3 months of injury.[55] Routine referral for cognitive (psychometric) assessment is not recommended after mild TBI; careful assessment of the nature of the injury and symptoms, including bedside cognitive tests, is more appropriate in the first instance.[55][68]​​​​[69] Most guidelines support the use of formal sidelines or office-based cognitive testing for sports-related concussion.[3][5]​​​​ Neuropsychological testing involves paper-and-pencil or computerized tests assessing attention, memory, and executive functions, as well as reaction times. Cognitive performance can be affected by stress, fatigue, effort, and drugs. Therefore, if testing is required, neuropsychological evaluations should be carried out by trained neuropsychologists who can disentangle the effects of these factors from the consequences of mild TBI. Neuropsychological testing can be used to delineate the effects of concussion as well as to monitor recovery. It is important to ensure that an appropriate amount of time has passed between testing sessions to guard against practice effects and uphold test validity. Although neuropsychological tests are an important component of mild TBI assessment, they should not be the only benchmark in making decisions about recovery from a mild TBI.

Patients taking anticoagulants (e.g., for coronary artery disease or previous stroke) should also be considered for outpatient referral following discharge to weigh up the risk/benefit of stopping or continuing anticoagulation, taking account of the risk of falls.[67]

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