New concussion protocols and clinical guideline recommendations

Living Guideline for Pediatric Concussion Care: list of recently updated concussion protocols and clinical guideline recommendations. For a full list of updates and information on the consensus process please see “download updates“.

Update Overview
Rest and recovery Strong recommendation that the previous clinical management approach of prescribing complete rest to treat pediatric patients with concussion is associated with prolonged recovery
Prescribed aerobic exercise Strong recommendation to prescribe sub-symptom threshold aerobic exercise testing for certain pediatric patients including those who are highly active or competitive athletes
Prescribed aerobic exercise Expert level consensus recommendation to prescribe sub-symptom threshold aerobic exercise testing for pediatric patients including those who are active
Mental Health New tool under review, added psychologists for referral as per their scope of practice
Virtual Concussion Care  (new domain) Considerations for a virtual medical assessment and follow-up. Tools 15.1 and 15.2 (Algorithm and physical exam)
Virtual Concussion Care  (new tool) Virtual concussion care manual (VCE)
Return to school and recovery from concussion The child/adolescent should return to their school environment as soon as they are able to tolerate engaging in cognitive activities without exacerbating their symptoms, even if they are still experiencing symptoms. Complete absence from the school environment for more than one week is generally not recommended.
Concussion recognition and directing to care Update to recommendation 1.4: It is important to note that some patients may experience a delayed onset of concussion symptoms. Delayed concussion symptoms also require medical assessment to exclude more severe injuries
Timing of referral to interdisciplinary concussion clinic (new) 2.9a Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury

(Last update: Nov 18, 2022)

The information below highlights several new concussion protocols and clinical guideline recommendations related to the 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

In January 2021 the Living Guideline team released a new set of recommendations that include a clinical algorithm for determining when a child or adolescent would benefit from a virtual consultation (versus in-person). In January 2022 a new resource has been added to this domain, an interactive training manual that includes videos designed to assist front-line healthcare professionals who are caring for patients that cannot be seen in person or have already had an in-person assessment and require follow-up.

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.      

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