Physicians can take many actions to improve outcomes for patients with MTBI. The first step is to determine a plan of action for follow-up of symptomatic patients. Based on the findings of an evaluation, such as that provided by the ACE, the physician may decide to:

1. Monitor the Patient in the Office
   Office monitoring is particularly appropriate if the number and severity of symptoms are steadily decreasing over time and/or fully resolve within 3 to 5 days. However, if full abatement of symptoms does not occur in this time period or symptoms remain steady or worsen, referral to an MTBI specialist may be warranted.
2. Make a Referral to an MTBI Specialist
   Referral to a specialist who cares for patients with MTBI is appropriate if symptom reduction is not evident within 3 to 5 days post injury, or sooner, and if the type or severity of symptoms is of concern. Referral to a specialist can be particularly valuable to further evaluate the patient's complex presentation and help manage certain aspects of the patient's condition (e.g. return to sports, school, work). (Information about specific TBI specialists in a particular area is often available through state or national brain injury associations.)
3. Referral for Diagnostic Tests
   Diagnostic tests may include neuro-imaging (such as CT or MRI) or neuropsychological testing. As indicated above, any indication or suspicion of neurologic deterioration should prompt strong consideration of referral for emergency medical evaluation and/or neuro-imaging (e.g. CT Scan/ MRI to rule out intracranial bleed or other structural pathology).
   
   Referral for neuropsychological tests should also be considered as this focused evaluation can help to assess brain function and impairment, as well as the development of rehabilitation programs for cognitively impaired patients (ref). Neuropsychological testing is particularly helpful when cognitive and/or behavioral dysfunction affects school, home or work activities to assist treatment planning. Neuropsychological testing should also be considered when a patient may be returning to sports (see Concussion In Sport Group Return to Play guidelines) or other at-risk activities to ensure that the patient's neurocognitive function has returned to its normal baseline level.

Figure 3. ACE Management Plan

Management Approaches
It is critical for the physician to guide the patient in their recovery with an active management plan based on their current symptom presentation. Careful management can facilitate recovery and prevent further injury. The ACE Management Plan (see Figure 3) included in the tool kit was developed to assist physicians with active management of patients with known or suspected MTBI.

Rest and careful management of physical and cognitive exertion are the keys to recovery. Patients must not return to any risky activity (e.g., sports, physical education, high speed activity (riding a bicycle, riding carnival rides) if any of the post-concussion symptoms are present. If the veracity of the patient's self-report is of question or there are concerning aspects of the patient's case, referral for objective data via formal neuropsychogical evaluation may be helpful. When symptoms are no longer reported or experienced, a patient may slowly, gradually and carefully return to their daily activities. Children and adolescents will need the help of their parents, teachers, coaches, athletic trainers, etc. to assist their recovery. Management planning should involve all aspects of the patient's life including home life, school, work, and social-recreational activities.

Returning to Daily Home/Community Activities
Increased rest and limited exertion are important to assist in the patient's recovery. Patients should be advised to get adequate sleep at night and to take daytime naps or rest breaks when significant fatigue is experienced. Symptoms typically worsen or re-emerge with exertion. Let any return of a patient's symptoms be the guide to the level of exertion or activity that is safe for the patient. Patients should limit both physical and cognitive exertion accordingly.

• Physical activity includes physical education, sports practices, weight-training, running, exercising, heavy lifting, etc.
• Cognitive activity includes heavy concentration or focus, memory, reasoning, reading or writing (e.g., homework, classwork load, job-related mental activity).

As symptoms decrease, patients may return to their regular activities gradually. However, the patient's symptoms should continue to be monitored closely.

Returning to School
Symptomatic students may require active supports and accommodations in school, which may be gradually decreased as their functioning improves. Inform the student's teacher(s), the school nurse, school psychologist/counselor, and administrator of the student's injury and symptoms. Focused neuropsychological evaluation of attention/concentration, learning and memory, and speed of processing can be particularly useful in determining the student's cognitive status and academic needs.

School personnel should be advised to monitor the student for the following signs:

• Increased problems paying attention/concentrating
• Increased problems remembering/learning new information
• Longer time required to complete tasks
• Increase in symptoms (e.g., headache, fatigue) during schoolwork
• Greater irritability, less tolerance for stressors

Until a full recovery is achieved, students may need to the following supports:

• Time off from school
• Shortened day
• Shortened classes (i.e., rest breaks during classes)
• Allowances for extended time to complete coursework/assignments and tests
• Reduced homework/class work load
• No significant classroom or standardized testing at this time
• Rest breaks during the day

Physicians and school personnel should monitor the student's symptoms with cognitive exertion (mental effort such as concentration, studying) in order to evaluate the need and length of time supports should be provided to the student.

Returning to Play (Sports and Recreation)
An athlete should never return to play a competitive sporting activity while experiencing any lingering symptoms of concussion (this includes physical education (PE) class, as well as sports practices and games). The athlete should be completely symptom free at rest and with physical (e.g. sprints, non-contact aerobic activity) and cognitive exertion (e.g.studying, schoolwork) prior to return to sports. Given the potential of the athlete minimizing symptoms to facilitate return to play, objective data in the form of formal neuropsychological testing should also be considered as a criterion for safe return to play (ref Vienna Conference). It is important to inform the athlete's coach, PE teacher, and/or athletic trainer that the athlete should not return to play until they are symptom-free and their cognitive function has returned to normal - at rest and with exertion.

Return to play should occur gradually. Athletes should be monitored for symptoms and cognitive function carefully during each stage of exertion. Patients should only progress to the next level of exertion if they are asymptomatic at the current level. A specific return to play protocol outlining gradual increase in activity has been established by the Concussion in Sport Group as follows (Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell, McCrory, Meeuwise, Schasmasch, 2001. Clinical J. Sports Med.)

• Rest
• Aerobic exercise (.e.g., stationary bicycle)
• Sport Specific training (e.g., running, skating)
• Non-contact drills (includes cutting and other lateral movements)
• Full-contact controlled training
• Full-contact game play

Return to work
Return to work planning should be based upon careful evaluation of symptoms and neurocognitive status. To help expedite recovery from MTBI, initially patients may need to reduce of both physical and cognitive exertion. Rest is key. Restriction of work during initial stages of recovery may be indicated to help facilitate recovery. Focused neuropsychological evaluation of attention/concentration, learning and memory, and speed of processing can be particularly useful in assisting planning of return to work needs. Continual evaluation of both symptoms and cognitive status is recommended to help guide management considerations.

Until a full recovery is achieved, patients may need to the following supports:

Schedule Considerations:

• Shortened work day (e.g. 8am-12 noon)
• Allow for breaks when symptoms increase
• Reduced task assignments and responsibilities

Safety Considerations:

• No driving
• No heavy lifting/No working with machinery
• No heights due to dizziness, balance deficit