Living Guideline Updates

The Ontario Neurotrauma Foundation has committed to supporting the real-time update of this guideline and any derivative products. Living Guideline Scoping Reviews:

Last updated October 2020 Recommendations: 

Last update: March 1, 2021

Please see the Living Guideline Methodology section for information about how the updates are performed and how the website is kept up to date.

Summary of New Evidence:

The information below highlights several recommendations related to diagnosis and management of pediatric concussion that have changed since the 2014 Guideline on the Diagnosis and Management of Pediatric Concussion.

Considerations for telemedicine and virtual concussion care

Diagnosing Concussion:

Children and adolescents with a suspected concussion should be referred to a physician or nurse practitioner to perform a comprehensive medical assessment to exclude more severe injuries, consider a full differential diagnosis, and confirm the diagnosis of concussion.    Routine neuroimaging (CT scan or MRI) is not required for diagnosing a concussion. A CT scan of the brain or cervical spine is only recommended for cases of a suspected structural intracranial or cervical spine injury.

 Resuming Activity After a Concussion:

Prolonged rest beyond the first 24-48 hours after a concussion is no longer recommended and may cause more harm than good. After an initial rest period (24-48 hours), children/adolescents should gradually resume low-risk activity, even in the presence of post-concussion symptoms. Return to physical and cognitive activity should be gradual and individualized based on activity tolerance and symptom presentation (e.g., the child/adolescent is able to engage in an activity without worsening of post-concussion symptoms). Activities that pose a risk for a repeated concussion must be avoided when still experiencing symptoms. See Recommendation 2.3 for more information. 

Highly active children/adolescents, those in competitive sport, those who are not tolerating a graduated return to physical activity, or those who are slow to recover may benefit from early referral to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment.

Risk Factors for a Delayed Recovery (Risk-Modifiers That May Delay Recovery):

Consider referring children or adolescents who have a higher risk for a delayed recovery to an interdisciplinary concussion team earlier than 4-weeks post-concussion.

Return-to-School and Sports

Children and adolescents should return to a full school load, without accommodation, before they return to full-contact sport and game play.

Baseline testing is not recommended or required for concussion diagnosis or management in children or adolescents.

According to Parachute Canada’s Statement on Baseline Testing, baseline testing is “the practice of having an athlete complete certain concussion assessment tools/tests prior to sports participation to provide baseline measurements that can be compared to post-injury values in the event of a suspected concussion”. Current evidence does not support a significant added benefit of using baseline testing in children and adolescents.  See Recommendation 5.2 for more information.

Mental Health

Early identification of common mental health disorders and risk factors for mental health disorders may prevent/mitigate additional problems such as learning and behavior problems, school avoidance, and exacerbation of pre-existing problems in children/adolescents who are recovering from a concussion.