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QME Mild Traumatic Brain Injury: A Comprehensive Review

by Marshall et al. and Ontario Neurotrauma Foundation.

12 Credit Hours - $299
Last revised: 07/24/2020

Course content © Copyright 2020 - 2024 by Marshall et al. and Ontario Neurotrauma Foundation. All rights reserved.


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TBI Image

Overview of the Course


The course involves reading the following introductory materials adapted from (1) the CDC website regarding Traumatic Brain Injury and Concussion and (2) Guideline for Concussion/Mild Traumatic Brain Injury and Prolonged Symptoms (3rd Edition for adults over 18 years of age). After reviewing the following introductory materials, the remainder of the course involves reading the pdf version of: Guideline for Concussion/Mild Traumatic Brain Injury and Prolonged Symptoms (3rd Edition for adults over 18 years of age). (or click here if you have trouble with the above pdf link). Please note that the test help prompts will not be available for information in the Guideline. However, the source of the question information is documented after each question.


Reference for Guideline


Marshall S, Bayley M, McCullagh S, Berrigan L, Fischer L, Ouchterlony D, Rockwell C, Velikonja D, et al. Guideline for Concussion/Mild Traumatic Brain Injury and Prolonged Symptoms: 3rd Edition (for Adults 18 years of age). Ontario Neurotrauma Foundation, 2018. 






Discuss the Diagnosis and Assessment of mTBI


List 3 common symptoms of mTBI from each domain of physical, behavioral, and cognitive


Explain the primary and secondary targets of treatment


Explain how the symptoms of PCS overlap with those of depression and chronic pain.


List 5 self-report or interviewer tests commonly used to assess mTBI and PCS



Course Outline


Overview from the CDC website

Overview from the brain injury Guidelines (Neurotrauma Foundation)

MTBI and the QME Evaluation

Removal of Neuropsychology as a QME designation



Diagnosis/Assessment of Concussion/mTBI

Initial Management of Concussion/mTBI

Sport-Related Concussion/mTBI

General Recommendations Regarding Diagnosis/Assessment of Persistent Symptoms

General Recommendations Regarding Management of Persistent Symptoms

Post-Traumatic Headache

Persistent Sleep-Wake Disturbances

Persistent Mental Health Disorders

Persistent Cognitive Difficulties

Persistent Vestibular (Balance/Dizziness) and Vision Dysfunction

Persistent Fatigue

Return-To-Activity/Work/School Considerations


1.1: Initial Diagnosis/Assessment of Adult mTBI

2.1: Initial Management of Symptoms Following mTBI

5.1: Management of Persistent Symptoms Following mTBI

6.1: Assessment and Management of Post-Traumatic Headache Following mTBI

7.1: Assessment and Management of Persistent Sleep-Wake Disturbances Following mTBI

8.1: Assessment and Management of Persistent Mental Health Disorders Following mTBI

12.1: Return-to-Work Considerations

12.2: Return-to-School (Post-Secondary) Considerations


Section 1: Diagnosis/Assessment of Concussion/mTBI

Section 2: Management of Concussion/mTBI

Section 3: Sport-Related Concussion/mTBI

Section 4: General Recommendations Regarding Diagnosis/Assessment and Persistent Symptoms

Section 6: Post-Traumatic Headache

Section 7: Sleep-Wake Disturbances

Section 8: Mental Health Disorders

Section 10: Vestibular (Balance/Dizziness) and Vision Dysfunction

Section 11: Fatigue

Section 12: Return-to-Activity/Work/School Considerations



Overview from the CDC website


Traumatic brain injury (TBI) is a major cause of death and disability in the United States. From 2006 to 2014, the number of TBI-related emergency department visits, hospitalizations, and deaths increased by 53%. In 2014, an average of 155 people in the United States died each day from injuries that include a TBI.  Those who survive a TBI can face effects that last a few days, or the rest of their lives. Effects of TBI can include impairments related to thinking or memory, movement, sensation (e.g., vision or hearing), or emotional functioning (e.g., personality changes, depression). These issues not only affect individuals but also can have lasting effects on families and communities.


What is a TBI?


A TBI is caused by a bump, blow, or jolt to the head that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from “mild” (i.e., a brief change in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or memory loss after the injury).  Most TBIs that occur each year are mild, commonly called concussions.


How big is the problem?


In 2014,1 about 2.87 million TBI-related emergency department (ED) visits, hospitalizations, and deaths occurred in the United States, including over 837,000 of these health events among children. TBI contributed to the deaths of 56,800 people, including 2,529 deaths among children. TBI was diagnosed in approximately 288,000 hospitalizations, including over 23,000 among children.  These consisted of TBI alone or TBI in combination with other injuries. In 2014, an estimated 812,000 children (age 17 or younger) were treated in U.S. EDs for concussion or TBI, alone or in combination with other injuries. Over the span of eight years (2006–2014), while age-adjusted rates of TBI-related ED visits increased by 54%, hospitalization rates decreased by 8% and death rates decreased by 6%.


What are the leading causes of TBI?


In 2014, falls were the leading cause of TBI. Falls accounted for almost half (48%) of all TBI-related emergency department visits. Falls disproportionately affect children and older adults: Almost half (49%) of TBI-related ED visits among children 0 to 17 years were caused by falls. Four in five (81%) TBI-related ED visits in older adults aged 65 years and older were caused by falls. Being struck by or against an object was the second leading cause of TBI-related ED visits, accounting for about 17% of all TBI-related ED visits in the United States in 2014. Over 1 in 4 (28%) TBI-related ED visits in children less than 17 years of age or less were caused by being struck by or against an object. Falls and motor vehicle crashes were the first and second leading causes of all TBI-related hospitalizations (52% and 20%, respectively). Intentional self-harm was the first leading cause of TBI-related deaths (33%) in 2014.


What are the Symptoms of TBI?


Most people with a TBI recover well from symptoms experienced at the time of the injury. Most TBIs that occur each year are mild, commonly called concussions, which is a mild TBI.1  But for some people, symptoms can last for days, weeks, or longer. In general, recovery may be slower among older adults, young children, and teens. Those who have had a TBI in the past are also at risk of having another one. Some people may also find that it takes longer to recover if they have another TBI.










Difficulty thinking clearly



Fuzzy or blurry vision





Sleeping more than usual



Feeling slowed down   


Nausea or vomiting

(early on)







Sleep less than usual



Difficulty concentrating


Sensitivity to noise or light


Balance problems



More emotional


Trouble falling asleep



Difficulty remembering new information



Feeling tired, having no energy


Nervousness or anxiety     




Some of these symptoms may appear right away. Others may not be noticed for days or months after the injury, or until the person resumes their everyday life. Sometimes, people do not recognize or admit that they are having problems. Others may not understand their problems and how the symptoms they are experiencing impact their daily activities. The signs and symptoms of a concussion can be difficult to sort out. Early on, problems may be overlooked by the person with the concussion, family members, or doctors. People may look fine even though they are acting or feeling differently.


Overview from the Guidelines


Concussion/Mild Traumatic Brain Injury


Concussion/Mild traumatic brain injury (mTBI) is a significant cause of morbidity and mortality, with many survivors of concussion/mTBI dealing with persisting difficulties for years post-injury. Over the years, various terms have been used synonymously with mild traumatic brain injury, such as mild head injury and concussion. It is important to note that all concussions are considered to be a mTBI however mTBI is distinguished from concussion when there is evidence of intracranial injury on conventional neuroimaging or there is persistent neurologic deficit.


Definition of Concussion/mTBI


Concussion/mTBI denotes the acute neurophysiological event related to blunt impact or other mechanical energy applied to the head, neck, or body (with transmitting forces to the brain), such as from sudden acceleration, deceleration, or rotational forces. Concussion can be sustained from a motor vehicle crash, sport, or recreational injury, falls, workplace injury, assault, or incident in the community. Clinical signs of concussion immediately following the injury include any of the following:


1. Any period of loss of or a decreased level of consciousness less than 30 min.

2. Any lack of memory for events immediately before or after the injury (post-traumatic amnesia) less than 24 hours.

3. Any alteration in mental state at the time of the injury (e.g., confusion, disorientation, slowed thinking, alteration of consciousness/mental state).

4. Physical Symptoms (e.g., vestibular, headache, weakness, loss of balance, change in vision, auditory sensitivity, dizziness).

5. No evidence of Intracranial lesion on standard imaging (if present, suggestive of more severe brain injury)


Concussion is a traumatic brain injury at the beginning of the brain injury spectrum ranging from mild to severe brain injury. Mild TBI is among the most common neurological conditions with an estimated annual incidence of 500/100,000 in the United States. One Canadian study examining both hospital-treated cases as well as those presenting to a family physician calculated the incidence of mTBI in Ontario to lie between 493/100,000 and 653/100,000, depending on whether diagnosis was made by primary care physicians or a secondary reviewer. There has been much research in the role of structural imaging in diagnosing concussion/mTBI and persistent symptoms, however studies have yet to find a consistent pattern in structural brain changes to diagnose concussion/mTBI and further research is needed. Computed Tomography (CT) and conventional Magnetic Resonance Imaging (MRI) usually fail to detect evidence of structural brain abnormalities in mTBI. Research in Diffusion Tensor Imaging (DTI) to detect white matter changes post-concussion/mTBI has detected structural changes acutely following, but results have not been shown to be consistent across groups, the resolution does not get at the submillimeter level and is only detecting macroscopic changes, therefore these tests are unable to accurately diagnose concussion/mTBI. DTI has also been researched in people with chronic persistent symptoms however more research is needed as the association with persistent symptoms has not been established. Reviews of recent advances in the biomechanical modeling of mTBI in humans and animals conclude that mTBI leads to functional neuronal disruption, and at times structural damage. There are several criteria commonly used to index severity of traumatic brain injuries. One of the most commonly used is the Glasgow Coma Scale (GCS), which assesses a patient’s level of consciousness. GCS scores can range from 3 to 15; mTBI is defined as a GCS score of 13-15, typically measured at 30 minutes post-injury or “on admission.” Post-traumatic amnesia (PTA), measured as the time from when the trauma occurred until the patient regains continuous memory, is another criterion used to define injury severity, and the cut-off for mild injuries is usually placed at 24 hours or less. Finally, a loss of consciousness of less than 30 minutes has also served as an index of mTBI. However, it should be noted that mTBI can occur in the absence of any loss of consciousness.


Acute symptoms


The acute symptoms that may follow mTBI are often categorized according to the following domains: 1) physical, 2) behavioral/emotional and 3) cognitive. Disparities exist in the definitions used for mTBI, and several organizations have created formal diagnostic criteria in order to try to overcome inconsistencies. Due to this fact the Expert Consensus Group (see Methodology) established a sub-committee to review the diagnostic criteria of concussion/mTBI. Experts reviewed recent definitions of concussion/mTBI as published by established mTBI consensus groups (sport, military) and from clinical practice guidelines. Depending on the population studied the literature would suggest that minimally 15% of persons with concussion may experience persisting symptoms beyond the typical 3-month time frame. The consequences for these individuals may include reduced functional ability, heightened emotional distress, and delayed return to work or school. In a Canadian longitudinal study, they found that only 27% of patients diagnosed with concussion and with symptoms lasting greater than 3 months at clinic presentation eventually recovered and 67% of those who recovered did so within the first year. They also found that no patient recovered who had post-concussion syndrome lasting 3 years or longer. When symptoms persist beyond the typical recovery period of three months, the term post-concussion syndrome or disorder may be applied.


Persistent symptoms


Just as there is confusion surrounding the definition of mTBI, this is also the case with the definition of post-concussion syndrome. There has been debate as to whether persistent symptoms are best attributed to biological or psychological factors. It now appears that a variety of interacting neuropathological and psychological contributors both underlie and maintain post-concussive symptoms. One source of controversy has been the observation that the symptoms found to persist following mTBI are not specific to this condition. They may also occur in other diagnostic groups, including those with chronic pain, depression, and post-traumatic stress disorder, and are observed to varying extent among healthy individuals. For the purposes of this guideline persistent symptoms refer to: A variety of physical, cognitive, emotional, and behavioral symptoms that may endure for weeks or months following a concussion.


Overall approach to treatment:


Phase of recovery should be considered in regard to treatment approaches:


  • Acute: (0-4 weeks): Emphasis should be placed on facilitation of recovery including education, reassurance, subsymptom threshold training and non-pharmacological interventions.
  • Post-Acute: (4-12 weeks): If patient not improving or symptoms worsening, then referral to an interdisciplinary clinic should be made. Focus should be placed on managing symptoms of sleep impairment, headache, mood, fatigue, and memory/attention. The focus is on a graduated return to activity which may include work and school.
  • Persistent: (3 mo. ): If symptoms persist for more than 3 months, patients require an interdisciplinary team for symptom management using an individualized management approach with focus on returning to pre-injury activities.


Another area of controversy is the potential influence of related litigation and financial compensation on the presentation and outcome for persons who have sustained mTBI. While there is consistent evidence of an association between seeking/receiving financial compensation (i.e., via disability benefits or litigation) and the persistence of post-concussive symptoms, this relationship is complex and the mechanisms through which litigation/financial compensation issues affect rate of recovery are not well studied. Further, it must not be assumed that the initiation of a compensation claim arises solely from the pursuit of secondary gain. The intentional exaggeration or manufacturing of symptoms (i.e., malingering) is relatively rare, whereas there are many potential factors which can contribute to symptom expression and accentuation, including levels of emotional distress, fatigue, and pain, as well as pre- and post-injury coping/adaptation. The focus within the healthcare provider-patient interaction must be upon the development of a collaborative therapeutic alliance, as it is from this vantage point that an accurate understanding of the patient’s beliefs and experience of symptoms can arise and, in turn, form the basis for an appropriate treatment plan.


MTBI and the QME Evaluation


When an individual presents with brain disease or damage, there may be impairments involving several parts of the body as well as several parts of the nervous system (e.g. brain, spinal cord, cranial nerves, and/or peripheral nerves). Associated impairments to the ear, nose, and throat (AMA Guides, Chapter 11) or visual (AMA Guides, Chapter 12) systems may also be involved. These impairments are assessed using Chapter 13, The Central and Peripheral Nervous System. The AMA Guides Fifth Edition revisions include the addition of an impairment evaluation summary (Table 13-25 of the Guides) at the end of Chapter 13 to allow easy access to the neurologic impairment in question, as well as, brief discussion of ancillary tests with some of their indications, greater guidance in the assessment of several impairment categories, and additional illustrative cases. There are numerous relevant sections in Chapter 13 that all clinicians must be familiar with in order to rate impairment associated with central nervous system dysfunction as is seen with TBI. 


Individual impairments should be separately calculated and their whole person values combined using the “combined values chart” in the Guides (5th ed, 604-606). In general, only the medical condition causing the greatest impairment should be evaluated. The Guides also divides the assessment of the most severe central nervous system (CNS) impairments, based on neurologic evaluation and relevant clinical investigations, into 4 categories: 


State of consciousness and level of awareness (whether permanent or episodic) 

Mental status evaluation and integrative functioning 

Use and understanding of language 

Influence of behavior and mood 


“The most severe of these four categories should be used to determine a cerebral impairment rating” (5th ed, 308). Sensorimotor systems, gait and coordination, cranial nerve function, spinal cord impairments, peripheral nervous system problems, and chronic pain are then combined with the most severe impairment.   


Evaluation of impairment following TBI often presents a significant differential diagnostic challenge. The Guides rating system has limitations for rating most of the deficits associated with these disorders. Further, the accurate determination of diagnosis and neurologic sequelae and symptom source relies on the assessment of important potential confounds and obstacles. Examiners should be familiar with the full range of potential confounds. The presenting symptoms of brain injury or disease must be differentiated from other conditions including, but not limited to, concurrent unrelated and related psychiatric and neuropsychiatric diagnoses. Clinical psychological and psychiatric conditions such as depression (reactive and/or organic), pain disorders, and/or post-traumatic stress disorder need to be appropriately considered in both litigating, as well as non-litigating, individuals. Less commonly, clinicians may encounter examinees with somatoform disorders, factitious disorders, as well as other response biases and malingering. These must be considered in the differential diagnosis of the individual, particularly when there is readily apparent secondary gain as with litigation, avoidance of work, identification with sick roles, access to insurance benefits, financial gain, desire to gain or fear of losing access to privileges, etc. 


An important obstacle to valid impairment assessment is response bias. The frequently significant consequences of impairment determinations undoubtedly explain the sometimes-high estimates of response bias in this population. Although most commonly conceptualized as deliberate exaggeration of difficulty, response bias exists on a continuum that extends from (1) denial or unawareness of impairments through (2) symptom minimization, (3) normal or average symptom presentation, (4) sensitization to subtle or benign symptoms or problems, (5) exaggeration or symptom magnification, and up to (6) frank malingering. Especially in medicolegal evaluations, assessment of response bias is critical to ensure accurate determination of diagnosis; symptom severity and source; and appropriate treatment and compensation decisions as well as prevention of iatrogenic complications. As much as possible, reports of interference in activities of daily living should be collaborated and assessment of motivational issues should integrate information from a variety of sources rather than relying on individual indicators.   


Brief Annotated Research Review – PCS Symptom Overlap


Just as there is confusion surrounding the definition of mTBI, this is also the case with the definition of post-concussion syndrome. There has been debate as to whether persistent symptoms are best attributed to biological or psychological factors. It now appears that a variety of interacting neuropathological and psychological contributors both underlie and maintain post-concussive symptoms. One source of controversy has been the observation that the symptoms found to persist following mTBI are not specific to this condition. They may also occur in other diagnostic groups, including those with chronic pain, depression, and post-traumatic stress disorder, and are observed to varying extent among healthy individuals. The following brief, annotated review shows how frequently these symptoms can overlap.


Carroll et al. (2004). Prognosis for mild traumatic brain injury: Results of the WHO collaborative center task force in mild traumatic brain injury. J. of Rehabilitation Medicine, 43, 84-105.


This was a review of 428 evidenced-based studies accepted after critical review for methodology.  The results concluded, for adults, cognitive deficits and symptoms are common in the acute stage [of MTBI], and the majority of studies report recovery for most within 3-12 months. (p. 84). The accepted studies provide consistent and methodologically sound evidence of cognitive deficits within the first few days after the injury, including problems of recall of material, speed of information processing and attention (p. 88). There are consistent findings that early cognitive deficits in MTBI are largely resolved a few months post-injury, with most studies suggesting resolution within 3 months (p. 88). Predictors of cognitive functioning after MTBI include brain lesions and/or depressed skull fracture (limited evidence and suggesting more of a moderate TBI rather than a mild TBI; p. 88). Many symptoms of MTBI are not unique and occur in other disorders including depression and chronic pain (p. 89). There is consistent evidence that individuals experience symptoms, especially headache, in the acute stage and during the first month of MTBI. Although symptoms are common after MTBI, they are not unique to this type of injury since they are evident in chronic pain, other injuries, and healthy controls (p. 89). Therefore, MTBI and post-concussive symptoms must be  assessed in light of the background prevalence of these symptoms and with attention to other possible contributing factors such as psychological distress, depression, and/or pain (p. 89). The most serious problem in the diagnosis of post-concussion syndrome (PCS) is linking the residual symptoms to the MTBI. 


Stalnacke, B.M. (2012). Postconcussion symptoms in patients with injury-related chronic pain. Rehabilitation Research and Practice. Doi:10.1155/2012/528265.


After MTBI, post-concussion symptoms (PCS) include headache, fatigue, dizziness, and impaired memory. The natural course of PCS is resolution of most symptoms within three months.  Whether PCS symptoms are specific to MTBI is unclear since symptoms commonly reported after MTBI have been reported in the general population and by patients with chronic pain. Some of the factors that have been found to be associated with persistence of symptoms include depression and PTSD. The research studied postconcussion symptoms in patients with chronic pain not related to a head injury. The study demonstrated that patients with injury-related pain (without any head injury) often reported postconcussion symptoms several years after injury. This shows the overlap of symptoms between chronic pain patient (non-head injury) and those with MTBI.


Smith-Seemiller et al. (2009). Presence of post-concussion syndrome symptoms in patients with chronic pain vs mild traumatic brain injury. Brain Injury, vol 17.


The findings were similar to what was found by Stalnacke in terms of overlap of symptoms between MTBI and chronic pain.


Iverson, G.L. (2005). Misdiagnosis of the persistent postconcussion syndrome in patients with depression. Archives of Clinical Neuropsychology, 21, 303-310.


Many specific symptoms of depression and other problems associated with this condition are similar to the postconcussion syndrome. The purpose of the study was to examine the prevalence of postconcussion-like symptoms in patients with depression. The results demonstrated that 9 out of 10 patients with depression met liberal self-report criteria for post-concussion syndrome (with 5 out of 10 meeting conservative criteria).


Greenberg et al. (2015). Pilot study of neurological soft signs and depressive and postconcussive symptoms during recovery from mild traumatic brain injury(mTBI). J Neuropsychiatry and Clin Neuroscience, 27, 199-205.


The study found that, “In contrast to neurological measures, the presence of self-reported depressive symptoms following mTBI was significantly associated with postconcussive symptoms and functional impairment across visits. This finding comports well with existing literature on the role of mood dysfunction in mTBI” (p. 203).


The Iverson (2005) and Stalnacke (2012) data can be combined to estimate the proportion of patients with depression and those with chronic pain (with any head injury) will show PCS symptoms. This is summarized in the following Table for the most frequent symptoms.


As can be seen in the Table, the overlap of PCS symptoms with those of chronic pain and depression can be significant.






PCS Symptom

Depressed (%)  

Chronic Pain (%)




Disrupted Sleep






Decreased Concentration









Poor Memory





Removal of Neuropsychology as a QME designation


A revision of the QME regulations was approved by the Office of Administrative Law in August 2015. One controversial part of these new regulations was the removal of neuropsychology as a designated QME specialty. Labor Code Section 139.2 provides the statutory basis for identification of QME specialties. After more than 22 years of recognition, the Division decided that based on the lack of recognition of that specialty by the statutorily identified entity, the Administrative Director felt required to remove the classification. A legislative solution to enable the Administrative Director to reinstate the specialty panels for neuropsychology was set forth in AB 1542. However, the Governor vetoed the bill.


Currently, aside from getting an AME, there is no direct method to get a neuropsychological QME evaluation for a TBI case. When a panel is requested for a psychology or psychiatry QME, the subspecialty for evaluating brain injury does not exist. Faced with the prospect of accommodating evaluations for brain injured workers, but having no direct method to do so, the DWC  has offered alternatives for obtaining the requisite neuropsychological evaluations. The two alternatives offered by the DWC included:


  • The injured worker obtaining a lawyer who, based on an unlikely agreement from the defense attorney, might decide on a neuropsychologist as an Agreed Medical Evaluator (AME).


  • The injured worker requesting a QME who is a general psychologist/psychiatrist, and who, upon discovering the nature and extent of the injuries, could obtain a consultation from a neuropsychologist. The DWC made this suggestion despite the fact that earlier changes by the Division to its regulations (8 CCR, Sections 31.7 & 32) now prohibit such consultations.


The DWC’s second alternative, expecting a general psychologist as the QME to obtain a consultation, may actually violate DWC rules. The Division changed 8 CCR Section 32 to exclude consultations by any QME except an Acupuncturist. In fact, QMEs, when faced with a body system they are not qualified to directly evaluate, are currently instructed to state the situation in their report and recommend that the parties obtain a QME with the proper background and training to address the issue(s). Unfortunately, the QME in this situation cannot recommend obtaining a panel of three neuropsychologists because the DWC no longer recognizes them and has no way of identifying them within the QME pool.


Regulation 32(b) provides that, “Except as provided in subdivision 32(a) above [concerning evaluations by acupuncturists], no QME may obtain a consultation for the purpose of obtaining an opinion regarding permanent impairment disability and apportionment consistent with Labor Code sections 4660 through 4664 and the AMA Guides.” Regular clinical psychologists use the GAF to measure impairment but many traumatic brain injuries require evaluation by a neuropsychologist using Chapter 13 of the Guides. General clinical psychologists do not typically use Chapter 13 and Labor Code Section 4663 does not cure this defect since it only applies to apportionment and permanent disability issues.


This situation has created a Catch-22 for the general psychologist or psychiatric (and presumably neurologist), who gets a Panel QME for a brain injury and then wants a neuropsychological evaluation, including testing, to provide an opinion about impairment and apportionment under Chapter 13.


The remainder of the course


For the remainder of the course please review the following document: It can be reviewed directly from the website at this link:  Guideline for Concussion/Mild Traumatic Brain Injury and Prolonged Symptoms (3rd Edition for adults over 18 years of age).


You can review a pdf version of the document at the following link: Guideline for Concussion/Mild Traumatic Brain Injury and Prolonged Symptoms (3rd Edition for adults over 18 years of age). (or click here if you have trouble with the above pdf link).


Please note that the test-help prompts will not be available for information in the Guideline. However, the source of the questions' information is documented after each question. You can take the test at any time by clicking the Take Test button. It is visible only if you are logged in. Enjoy the course!




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