Recommendations


6.1 All patients presenting with headache following acute head trauma should undergo medical assessment by a physician or nurse practitioner that includes a clinical history, physical examination, and consideration for the need for diagnostic tests including imaging.

1.1a

School boards, sports organizations, and community centres should provide pre-season concussion education and conduct a review of all concussion policies in effect within the school or sport setting.

Level of Evidence:  

2.1

Physicians or nurse practitioners should perform a comprehensive medical assessment on all children/adolescents with a suspected concussion or with acute head or spine trauma.  

Include a clinical history, physical examination, and the evidence-based use of diagnostic tests or imaging as needed.

Online resources to consider:

Tool 1.3: Manage Acute and Prolonged Symptoms Algorithm

3.1

Perform a repeat medical assessment on all patients presenting with post-concussion symptoms 1-2 weeks following acute injury.

Tool 1.3: Manage Acute and Prolonged Symptoms Algorithm

Include a focused clinical history, focused physical examination, and consideration for the need for diagnostic tests including imaging. 

4.1

Consider patients for medical clearance to return to full-contact activities and sport/game play if clinical criteria have been met.

The following clinical criteria should be considered or met before recommending that a child/adolescent returns to full-contact activities and sport/game play: 

  • ‘Return-to-Learn’: Return to pre-injury learning activities with no new academic support, including school accommodations or learning adjustments. Child/adolescent has successfully returned to all school activities including writing exams without symptoms above their previous pre-injury level or requiring accommodations related to their concussion/post-concussion symptoms, (i.e., child/adolescent may have pre-existing accommodations or new accommodations related to something other than their concussion).
  • Normal neurological and cervical spine examination.
  • ‘Complete symptom resolution’:  Resolution of symptoms associated with the current concussion at rest with no return of symptoms during or after maximal physical and cognitive exertion (back to the pre-injury state in patients with pre-existing conditions such as baseline headaches or mental health conditions). 
  • Return-to-Sport: Completion of the  Return to Activity/Sport protocol (2023 version) with no symptoms and no clinical findings associated with the current concussion at rest and with maximal physical exertion.
  •  No longer taking any drugs or substances atypical to their pre-injury functioning that could mask symptom presentation.

For children/adolescents with complex medical histories (e.g., repeated concussion, baseline concussion-like symptoms), see Recommendation 5.1 for information regarding returning to full-contact sports or high-risk activities, or retirement from full-contact sports or high-risk activities.

Definitions for ‘Complete symptom resolution’, ‘Return-to-Learn, and Return to sport have been harmonized with the Amsterdam International Consensus Statement on Concussion in Sport)

Updated Sept 2023

Level of Evidence:   

For children/adolescents with complex medical histories (e.g., repeated concussion, baseline concussion-like symptoms), see Recommendation 5.1 for information regarding returning to full-contact sports or high-risk activities, or retirement from full-contact sports or high-risk activities.

5.1

Refer a child/adolescent with multiple concussions or baseline conditions associated with concussion-like symptoms to an interdisciplinary concussion team to help with return to full-contact sports or high-risk activities or retirement decisions from full-contact sports or high-risk activities.

Level of Evidence:  

Return to full-contact sport or high-risk activity decisions can be complicated for children/adolescents with more complex medical histories. The following factors should be taken into consideration in the discussion and decisions made about return-to-sport or retirement: 

  • Concussion history.
  • Co-morbidities (e.g., learning and communication deficits, ADHD, physical disabilities, psychiatric disorders).
  • Absolute contraindications for return-to-sport and high-risk activities.
  • Early recurrence or greater frequency of symptoms.
  • Lower injury threshold.
  • Increasing recovery time.
  • Potential short- and long-term sequelae.

Some patients may benefit from neuropsychological assessment to determine resolution of cognitive problems. If a post-injury cognitive or neuropsychological assessment is deemed clinically necessary, it is recommended that this assessment be interpreted by a pediatric neuropsychologist.

6.1

Perform a repeat medical assessment on all patients presenting with post-concussion headaches 1-2 weeks following acute injury.

Include a focused history, physical examination, and consideration of diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Tool 6.1: Post-Concussion headache algorithm.

7.1

Perform a repeat medical assessment on all patients presenting with post-concussion sleep disturbances 1-2 weeks following acute injury. 

Level of Evidence:  

Include a focused history, physical examination, and consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Screen for factors that may influence the child/adolescent’s sleep/wake cycle and for sleep-wake disturbances such as insomnia or excessive daytime sleepiness.

8.1

Assess existing and new mental health symptoms and disorders. 

Level of Evidence:

Experienced and trained healthcare professionals should use appropriate screening tools to assess the child/adolescent. These assessments should be considered for children/adolescents with a history of mental health problems or with prolonged post-concussive symptoms. 

Use Tool 8.1: Post-concussion mental health considerations algorithm and refer to a mental health specialist using clinical judgment.

Assessment screening tools to consider (direct website links):

9.1

Evaluate a child/adolescent for cognitive symptoms that interfere with daily functioning following the acute injury. 

Level of Evidence:   

For symptoms that interfere with daily functioning for more than 4 weeks following acute injury, further evaluation by experienced professionals to assess cognitive problems may be required. 

Depending on the nature of the cognitive symptoms, examples of professionals may include:

  • Experienced educational professionals.
  • Pediatric neuropsychologists.
  • Occupational therapists.
  • Speech language pathologists.

Other assessments may be required to determine the underlying cause(s) and any pre-existing contributing factors that can be managed:

  • Use a risk score to assess any modifiers that may delay recovery (Recommendation 2.1b).
  • A mental health assessment and a closer look at the family may be recommended (Domain 8: Mental Health).
  • Vision, vestibular, and hearing assessments may be recommended (Domain 10: Vision, Vestibular, and Oculomotor Function).
  • Physical examination (Tool 2.1: Physical Examination).
  • As per usual pediatric clinical practice, broad clinical history taking is recommended to understand the youth’s developmental, medical, social, academic, and family histories. Particular consideration should be given to the interplay between these pre-existing factors and current cognitive profile/presentation/symptoms.

10.1

Perform a repeat medical assessment on all patients presenting with dizziness, blurred or double vision, vertigo, difficulty reading, postural imbalance, or headaches elicited by prolonged visual or vestibular stimulation 1-2 weeks following acute injury.

Level of Evidence:   

Depending on the nature of the symptoms, the medical assessment should include a focused history, focused physical examination, and consideration for the need for diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Tool 10.1: Post-Concussion Vision, Vestibular, and Oculomotor Disturbances Algorithm.

Tool 2.1: Physical examination.

Recommendation 2.1c: When to consider diagnostic brain or cervical spine imaging.

11.1

Perform a repeat medical assessment on all patients presenting with post-concussion fatigue 1-2 weeks following acute injury. 

Level of Evidence:  

The medical assessment should include a clinical history of symptoms, physical examination, and screen for other causes of fatigue (e.g., mononucleosis, anemia, thyroid dysfunction, mood disorders, pregnancy, etc.).

12.1

The child/adolescent should return to their school environment as soon as they are able to tolerate engaging in cognitive activities, even if they are still experiencing symptoms. Recommend a stepwise return-to-school plan. Include temporary accommodations based on symptoms and recommendations from the healthcare professional. Monitor and modify the return-to-school plan based on ongoing assessment of symptoms.
 
Level of Evidence:   

This involves collaboration and communication among healthcare professionals, school-based professionals, the child/adolescent, and/or parents/caregivers.

Summary of tools to consider: These tools are suggestions for initiating a discussion to determine the best pathways for the student in learning environments.

13.1

At this stage, advanced neuroimaging biomarkers are not yet ready for clinical implementation/management. 

Level of Evidence:

Biomarkers such as functional MRI (fMRI), diffusion tensor imaging (DTI), magnetic resonance spectroscopy (MRS), arterial spin labeling (ASL), cerebrovascular-reactivity mapping (CVR), quantitative susceptibility based susceptibility weighted imaging (qSWI), electroencephalography/event-related potential (EEG/ERP), transcranial magnetic stimulation (TMS), while potentially useful as research tools, are not ready for clinical implementation.

14.1

The use of serologic biomarkers is not clinically indicated. Presently there is no validated “concussion blood test” that can be used to accurately detect concussion in children/adolescents.

Level of Evidence:   

At this stage, newer serologic and other clinical biomarkers, while potentially useful as research tools, are not ready for clinical implementation/management.

15.1

Considerations for a Virtual Medical Assessment.

See Recommendation 2.1 “Physicians or nurse practitioners should perform a comprehensive medical assessment on all children/adolescents with a suspected concussion or with acute head or spine trauma.
• Include a clinical history, physical examination, and the evidence-based use of diagnostic tests or imaging as needed.”

In-person medical assessments are ideal for all children/adolescents with suspected or diagnosed concussion, however, telemedicine may be considered to assist in the medical assessment for patients who meet the following criteria:
• A previous medical assessment by a physician or nurse practitioner has been performed.
• Access or travel for an in-person medical assessment is limited or difficult
• There is no history of abnormal diagnostic imaging (e.g., intracranial hemorrhage, spine or facial fracture)

Note: All providers should be aware of current public health recommendations when providing care to their patients.

Tool 15.1: Considerations for telemedicine and virtual care algorithm

Level of Evidence:  


Recommendation 1.1     Mouthguard use should be supported in child and adolescent ice hockey.

  • (GRADE quality rating: low; Level of evidence: B).

 

Recommendation 1.2     Policy disallowing bodychecking should be supported for all children and most levels of adolescent ice hockey.

  • (GRADE quality rating: High quality; Level of evidence: A)

 

Recommendation 1.3     Strategies limiting contact practice in American football should inform related policy and recommendations for all levels.

  • (GRADE quality rating: low; Level of evidence: B).

 

Recommendation 1.4     Neuromuscular training warm-up programs are recommended, based on research in rugby, while more research is needed for females and other team sports. The focus should be on exercise components targeting concussion prevention.

  • (GRADE quality rating: moderate; Level of evidence: B).

 

Recommendation 1.5     Policy mandating optimal concussion management strategies to reduce recurrent concussion rates is recommended.

  • (GRADE quality rating: very low; Level of evidence: B).

Section 1: Quelles sont les stratégies de prévention de la commotion cérébrale liée au sport (CCL) qui réduisent le risque de commotion cérébrale et/ou d'impact sur la tête (par exemple, équipements, politiques/règles, stratégies d'entraînement) ?

Introduction: La prévention de la commotion cérébrale liée au sport peut être envisagée selon un spectre et comprend la prévention primaire (prévention des commotions chez les individus en bonne santé), la prévention secondaire (prévention de la récurrence des commotions) et la prévention tertiaire (prévention des conséquences à long terme). Toutes les facettes de la prévention des blessures sont importantes, mais se concentrer sur la prévention primaire aura le plus grand impact en santé publique en réduisant le fardeau de la commotion et ses conséquences. De manière générale, la recherche évaluant les stratégies de prévention de la commotion a considéré les équipements de protection individuelle, les changements de politique et de règlement, les stratégies d’entraînement et la gestion.

Recommandation 1.1 : L’utilisation de protège-dents devrait être encouragée chez les enfants et les adolescents pratiquant le hockey sur glace.

GRADE: qualité faible

Niveau de preuve: B

Recommandation 1.2: Une politique interdisant les mises en échec corporelles devrait être soutenue pour tous les enfants et la plupart des niveaux de hockey sur glace adolescent.

GRADE: qualité élevée

Niveau de preuve: A

Recommandation 1.3: Les stratégies limitant les entraînements avec contact au football américain devraient éclairer les politiques et recommandations connexes pour tous les niveaux.

GRADE: qualité faible

Niveau de preuve: B

• Recommandation 1.4: Les programmes d’échauffement avec entraînement neuromusculaire sont recommandés, sur la base de recherches en rugby, tandis que des recherches supplémentaires sont nécessaires pour les femmes et d’autres sports d’équipe. L’accent devrait être mis sur les composantes de l’exercice ciblant la prévention de la commotion cérébrale.

GRADE: qualité modérée

Niveau de preuve: B.

• Recommandation 1.5: Il est recommandé de mettre en place des politiques obligeant à utiliser des stratégies de gestion optimales de la commotion cérébrale pour réduire les taux de récidive des commotions

GRADE: qualité très faible

Niveau de preuve: B

(Les recommandations ont été harmonisées avec et sont adaptées de la Déclaration internationale d’Amsterdam sur la commotion cérébrale dans le sport.)


6.2 Provide patients and parents/caregivers with post-concussion education that outlines symptoms of concussion, provides suggestions regarding activity modifications and includes academic accommodations to limit headaches.

1.1b

School boards, sports organizations, and community centres should ensure updated policies are in place to recognize and accommodate a child/adolescent who has sustained a concussion.

Level of Evidence:  

Tool 1.1: Pediatric Concussion- The Role of School Boards, Community Sports Organizations, and Community Centres

2.1a

Take a comprehensive clinical history.

Level of Evidence:

Details that should be collected in the clinical history include:

  • Patient demographics (e.g., age, sex, gender).
  • Assess injury mechanism and symptoms at the time of injury.
  • Assess symptom burden at the time of initial presentation.
    • Number of symptoms.
    • Severity of symptoms.
    • Type of symptoms.
  • Presence of loss of consciousness, post-traumatic amnesia, and red flags (seizures, neck pain, focal neurological deficits).
  • Current post-concussion symptoms (using age-appropriate standardized symptom inventory).
  • Review mental health (Domain 8: Mental Health and Psychosocial Factors).
  • Past medical history (e.g., previous concussions, migraine or non-specific headaches, mental health disorders, coagulopathy, other risk modifiers that may delay recovery). Note the duration until recovery from previous concussions (i.e., within 7-10 days or persisting).
  • Allergies/immunizations.
  • Ask whether the child/adolescent is taking any substances or medications: Prescribed or over-the-counter medications or supplements, alcohol, or recreational drugs including cannabis. These substances may mask or modify concussion symptoms.

Ask about school, activities, work, and sports participation.

3.1a

Take a focused clinical history based on symptoms described.

Level of Evidence:   

 

Consider signs and symptoms in context with the child/adolescent’s normal performance, especially for those with pre-existing conditions (e.g., learning and communication deficits, ADHD, and/or physical disabilities) to identify the underlying causes of the prolonged symptoms or concerns and develop a management strategy.

4.2

Provide patients with a letter indicating medical clearance to return to all activities when medically cleared. 

Level of Evidence:  

Link: Canadian Guideline on Concussion in Sport Medical Clearance Letter (Parachute Canada).

5.2

Baseline testing on children/adolescents using concussion assessment tools or tests (or any combination of tests/tools) is not recommended or required for concussion diagnosis or management following an injury. 

Level of Evidence:   

See the Parachute Statement on Baseline Testing for more information (Parachute Canada). 

“Baseline testing refers to 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 baseline testing athletes. This includes the Child SCAT5 and the SCAT5 tools, as well as neuropsychological and neurocognitive tests, both computerized or not.” (Parachute Statement on Baseline Testing)

See Recommendation 5.3: Special considerations regarding baseline testing.

6.1a

Take a focused clinical history.

Level of Evidence:   

Collect details that help to classify or characterize the headache subtype(s) that are present. 

  • Headache onset, location, quality or character, severity, and frequency.
  • Factors that elicit or worsen headaches (e.g., bright lights, reading, exercise, foods, etc.).
  • Factors that alleviate headaches.
  • Associated symptoms (e.g., aura, photosensitivity, dizziness, eye strain, neck pain).
  • The presence of red flags which may indicate a more severe brain injury or other intracranial pathology (e.g., worsening headaches, repeated vomiting, weakness or numbness of the extremities, visual changes). 
  • The level of disability associated with the headache (e.g., missed days from school).
  • Use of medications or other substances.
  • Psychological or social factors or conditions that can be associated with stress and headaches (e.g., mood or anxiety disorders) (Domain 8: Mental Health).
  • Assess how much headaches affect day-to-day activities.
  • Disturbed sleep.
  • Personal and family history of headaches and headache disorders (e.g., migraine).
  • Future participation in full-contact sport or high-risk activities.

7.2

Provide general education and guidance on sleep hygiene that outlines non-pharmacological strategies to improve sleep.

Level of Evidence:  

8.2

Assess the child/adolescent’s broader environment, including family and caregiver function, mental health, and social connections. 

Level of Evidence:   

  • Ask about socioeconomic status (caregiver education, family income, occupation).
  • Ask about social impacts and life stressors (school setting, friends, teammates).
  • Ask the child/adolescent and parents and/or caregivers to complete the following, as appropriate:

9.2

Manage cognitive symptoms that interfere with daily functioning for more than 4 weeks following acute injury.

Level of Evidence:   

See Domain 3: Medical Follow-up and Management of Prolonged Symptoms.

See Domain 12: Return-to-School and Work for suggestions to guide an initial discussion about the best pathways for the student in school, employment, sports, social, and home environments. Tools and tests should be used in conjunction with an examination of previous school records such as marks and teacher observations.

10.2

Screen for oculomotor or vision deficits.

Level of Evidence:  

Perform an assessment of visual acuity, pupillary function, visual fields, fundoscopy, and extra-ocular movements.

  • With appropriate experience, consider an objective assessment of convergence, accommodation, saccades and smooth pursuits.
  • Consider additional tests such as automated visual field testing, formal vestibular testing or diagnostic imaging.

Consider referral to an interdisciplinary concussion team or neuro-ophthalmologist, neuro-optometrist, developmental optometrist, occupational therapist, or physiotherapist with competency-based training in vestibular rehabilitation to assess for impairments in convergence, accommodation, saccades and other visual oculomotor disorders.

Online instructional video to consider:

11.2

Provide patients with post-concussion fatigue with general education and guidance that outlines non-pharmacological strategies to help cope with fatigue symptoms and set expectations. 

Level of Evidence:  

Strategies and post-concussion education guidance related to fatigue:

13.2

When conventional MRI is performed in the clinical management of concussion patients, the inclusion of susceptibility-weighted images (SWI) sequences could be considered as it may be useful for detecting small hemorrhages. The clinical significance of small hemorrhages on SWI is not clear at present. 

Level of Evidence:

See Recommendation 2.1c for more information on when to consider diagnostic brain or cervical spine imaging.

15.1a

Obtain informed consent from the patient and/or their parent/caregiver to conduct a remote medical assessment via telemedicine.

This process should outline the benefits and limitations of performing clinical care via telemedicine as well as taking measures to ensure privacy and confidentiality. Discuss the important limitation of not being able to perform some aspects of the physical examination virtually (e.g., testing of motor or sensory functioning, fundoscopy, etc.) and outline what arrangements will be made to facilitate an urgent in-person assessment as needed to optimize clinical care.

For other general considerations on how clinicians and patients can be prepared for a virtual visit see the following links:

Level of Evidence:  

12.1a

Complete absence from the school environment for more than one week is not generally recommended. Children/adolescents should receive temporary academic accommodations (e.g, modifications to schedule, classroom environment and workload) to support a return to the school environment in some capacity as soon as possible.

Level of Evidence:

Section 2: Y a-t-il des conséquences non intentionnelles des stratégies de prévention de la CCL ?

Introduction : Idéalement, un programme de prévention des blessures développé et mis en œuvre réduira avec succès les blessures d’un type spécifique ou d’une population spécifique. Cependant, il est important de considérer que le même programme de prévention des blessures peut augmenter involontairement le risque de blessures d’un autre type ou à une population différente ou future. L’évaluation continue après la mise en œuvre d’une mesure de prévention des blessures reste un aspect important de la prévention pour s’assurer qu’il n’y a pas de conséquences non intentionnelles en matière de blessures.

• Recommandation 2.1 : L’expérience antérieure des mises en échec corporelles dans les matchs de hockey sur glace n’était pas associée à des taux de commotion cérébrale globalement plus faibles lorsque les joueurs adolescents jouaient dans des ligues permettant les mises en échec corporelles, suggérant qu’il n’y a pas de conséquences non intentionnelles globales de la politique interdisant les mises en échec corporelles pour refuser la recommandation politique ci-dessus (GRADE : qualité modérée ; Niveau de preuve : B).

• Recommandation 2.2 : Les futures recherches devraient envisager l’évaluation des conséquences non intentionnelles des stratégies de prévention de la commotion cérébrale dans tous les contextes.

(Les recommandations sont adaptées de la Déclaration internationale d’Amsterdam sur la commotion cérébrale dans le sport.)


Recommendation 2.1: Prior body checking experience in ice hockey games was not associated with lower overall concussion rates when adolescent players played in leagues permitting body checking, suggesting no overall unintended consequences of policy disallowing body checking to refuse policy recommendation above.

  • GRADE quality rating: moderate; Level of evidence: B

 

Recommendation 2.2: Future research should consider evaluation of unintended consequences of concussion prevention strategies across all contexts.

(Recommendations are adapted from the Amsterdam International Consensus Statement on Concussion in Sport) 


6.3. Encourage patients with prolonged headaches to engage in cognitive activity and low-risk physical activity as soon as tolerated, while staying below their cognitive and physical symptom-exacerbation thresholds. These low-risk activities should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity. (Recommendation 2.3)

1.2

Remove the child/adolescent from the activity immediately if a concussion is suspected to avoid further injury and have the child/adolescent assessed. 

Level of Evidence:   

Do not leave the child alone and contact the parent/caregiver immediately. Do not let the child/adolescent return to sport (practice or game play) or other physical activities that day. “If in doubt, sit them out.”

A concussion should be suspected:

  • In any child/adolescent who sustains a significant impact to the head, face, neck, or body and demonstrates/exhibits any of the visual signs of a suspected concussion or reports any symptoms of a suspected concussion as detailed in the Concussion Recognition Tool 6 (Tool 1.2). 

Premature return to activities and sport can lead to another injury. Another blow to the head may complicate the injury further and result in a longer recovery time (i.e, higher risk of persisting symptoms). Severe brain swelling or cerebral edema after a concussion is very rare but potentially fatal.

Suggested concussion tools to share with teachers, coaches, parents, peers, and others

2.1b

Perform a comprehensive physical examination.

Level of Evidence:  

  • Vital signs (resting heart rate and blood pressure).
  • Level of consciousness (Glasgow Coma Scale).
  • Mental status.
  • A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait, and balance testing) (Tool 2.1: Physical examination).
  • A cervical spine examination (palpation, range of motion, provocative cervical spine tests) (Tool 2.1: Physical examination).
  • An examination of the visual and vestibular systems.

Online tools to consider:

3.1b

Examine the child/adolescent and perform a focused physical examination.

Level of Evidence:  

  • Vital signs (Resting heart rate and blood pressure).
  • A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait, balance testing) (Tool 2.1: Physical Examination).
  • A cervical spine examination (palpation, range of motion, provocative cervical spine tests) (Tool 2.1: Physical Examination.
  • Review mental health. Perform a post-concussive assessment and a cognitive screen, reassessing for existing and new mental health symptoms such as anxiety and mood. 
  • Screen the child/adolescent for medication/substances that may mask or modify the symptoms.
  • An examination of vestibular, visual, and oculomotor systems (e.g., Vestibular Ocular Motor Screening Tool (VOMS) or Visio-vestibular examination (VVE))
  • Consider a broad differential diagnosis for children/adolescents with prolonged symptoms.
  • Monitor the return-to-activity/sport and return-to-school status.

Further examination of the child/adolescent should be based on symptoms:

4.3

Advise medically cleared patients to seek immediate medical attention if he or she develops new concussion-like symptoms or sustains a new suspected concussion. 

Level of Evidence:   

Tool 1.2: Concussion Recognition Tool 5. To help identify concussion in children, adolescents, and adults.

5.3

Special considerations regarding baseline testing.

Level of Evidence:   

Please consult the Parachute Statement on Baseline Testing for more information (Parachute Canada).

“There may be unique athlete populations and sports environments where baseline testing may be considered. These situations should be considered the exception and not the rule.” 

  • “Clinical neuropsychologists may consider baseline cognitive or neuropsychological testing in select youth athletes (greater than 12 years old) who have pre-existing conditions, such as a history of previous concussion, ADHD, or learning disorders, that may impact the interpretation of post-injury test results.”
  • “Certain teams and sporting federations have well-established physician-supervised concussion protocols with dedicated experienced healthcare professionals working directly and continuously with youth athletes (i.e., that are present at training and competition events). In these sport environments, baseline testing may be considered as an optional assessment within the comprehensive concussion protocol as long as the medical teams caring for these athletes include experienced healthcare professionals who have competency-based training and clinical experience to allow them to administer and interpret these tests.” 

(Reproduced with permission from Parachute Canada: Parachute Statement on Baseline Testing).

 

6.1b

Perform a focused physical examination. 

Level of Evidence:   

  • Vital signs (resting heart rate and blood pressure).
  • A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait and balance testing) Tool 2.1: Physical Examination.
  • A cervical spine examination (palpation, range of motion, provocative cervical spine tests). Tool 2.1: Physical Examination.
  • With appropriate experience, consider performing an examination of vision, oculomotor and vestibular functioning (Domain 10: Vision, Vestibular, and Oculomotor Function).

7.2a

Continue to encourage patients with sleep disturbances to engage in sub-symptom threshold cognitive activities and physical activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) as soon as tolerated. 

Level of Evidence:   Gradual return to physical activity. Gradual return to cognitive activity.

See Recommendation 2.3.

See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

8.3

Treat mental health symptoms or refer to a specialist in pediatric mental health. 

Level of Evidence:   

Base the mental health treatment on individual factors, patient preferences, the severity of symptoms, and co-morbidities.

Tools to assist healthcare professionals to make treatment decisions:

Consider referring to a local healthcare professional, specialized pediatric concussion program or to a specialist with experience in pediatric mental health if child/adolescent has prolonged or urgent mental health symptoms. Provide the name of a specialist with experience in pediatric mental health.

For deciding when to refer a child/adolescent to a specialist, use Tool 8.1: Post-Concussion Mental Health Considerations Algorithm. 

10.3

Screen for benign paroxysmal positional vertigo (BPPV) if the patient reports vertigo or dizziness that occurs for seconds following position changes and consider targeted particle re-positioning manoeuvres.

Level of Evidence:  

After completing a neurological screen and clearing the cervical spine to move into the test position, perform the Dix-Hallpike Test. If positive for BPPV (i.e., reproduction of vertigo, typically for seconds, in addition to a characteristic pattern of nystagmus for the canal that is being assessed), a Particle Repositioning Manoeuvre may be appropriate.

Consider the Epley Manoeuvre which can be used to treat the anterior and posterior canals in the case of a canalithiasis. There are many subtypes of BPPV that may require further assessment or alternate canalith repositioning manoeuvres and referral to a healthcare professional (often a physiotherapist with competency-based training in vestibular rehabilitation) for treatment.  If symptoms are provoked by pressure (i.e., val salva) or accompanied by a change in hearing, referral to an otolaryngologist or neuro-otologist is warranted.    

In patients who continue to experience prolonged vertigo or dizziness despite 3 particle repositioning maneouvers, consider referral to an interdisciplinary concussion team or neuro-otologist or physiotherapist with competency-based training in vestibular rehabilitation. These experienced healthcare professionals should rule out alternative peripheral and central vestibular disorders (e.g., superior semi-circular canal dehiscence (SSCD), vestibular hypofunction) and initiate active management with rehabilitation or referral as appropriate.  

Online instructional videos to consider:

11.3

Encourage patients with post-concussion fatigue to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation thresholds. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence: Gradual return to physical activity. Gradual return to cognitive activity. 

See Recommendation 2.3.

  • Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:
  • Patients who are active may benefit from 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. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:

Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

15.1b

Take a comprehensive virtual clinical history.

Complete a comprehensive virtual clinical history that addresses the same key components of an in-person medical assessment including patient demographics, injury mechanism, symptoms at the time of injury, symptom burden at the time of presentation, loss of consciousness, post-traumatic amnesia, self-reported red flags, mental health, past medical history, assessment of concussion modifiers, current medications and allergies, school, work, and sports participation.

  • See Recommendation 2.1a for details that should be collected in the clinical history. This recommendation includes a validated age-appropriate symptom inventory that can be considered as a tool to assess current symptoms and severity.

Level of Evidence:   

12.1b

Recommendation 2.3c: Recommend that patients avoid school activities associated with a risk of contact, fall, or collisions such as high speed and/or contact activities and full-contact sport that may increase the risk of sustaining another concussion during the recovery period. Advise/emphasize that returning to full-contact sport or high-risk activities before the child/adolescent has recovered increases the risk of delayed recovery and for sustaining another more severe concussion or more serious injury.


6.4 Provide guidance on the proper use of over-the-counter medications such as acetaminophen and ibuprofen for treating severe headaches.

1.3

Recommend an emergency medical assessment for a child/adolescent with any of the “red flag” symptoms. 

Level of Evidence:   

If a child/adolescent demonstrates any of the ‘Red Flags’ symptoms indicated by the Concussion Recognition Tool 6, a more severe head or spine injury should be suspected and an emergency medical assessment is required. These red flag symptoms may appear immediately or within a few hours or days after injury. Delayed red flag symptoms require urgent medical assessment as they may indicate a more severe injury. Consider arranging an ambulance service as necessary to facilitate urgent medical assessment at the nearest hospital and execution of the Emergency Action Plan for your organization. When calling an ambulance, describe the specific red flags symptoms over the phone. 

Red flag symptoms include:

  • Severe or increasing headache 
  • Neck pain or tenderness
  • Double vision or loss of vision
  • Weakness or numbness/tingling in extremities
  • Seizure or convulsions
  • Loss of consciousness
  • Increased confusion or deteriorating conscious state
  • Repeated vomiting
  • Increasingly restless, agitated or combative state
  • Slurred speech 
  • Visible skill deformity

Suggested tools to help identify “Red Flag” symptoms

2.1c

Consider CT of the brain or cervical spine only in patients whom, after a medical assessment, a structural intracranial or cervical spine injury is suspected; do not conduct routine neuroimaging for the purpose of diagnosing concussion. 

Level of Evidence: CT. MRI.

Most children/adolescents who sustain an acute head injury or suspected concussion do not need diagnostic imaging. 

Use the following tools, as appropriate, to determine the need for CT imaging in patients with acute head trauma:

Although validated clinical decision-making rules are highly sensitive, these tools are meant to assist, but not replace, clinical judgment. CT scans should be used judiciously as the exposure of children/adolescents to the effects of ionizing radiation carries a small increased lifetime risk of cancer. If a structural brain injury is suspected in a patient with acute head trauma undergoing initial medical assessment in the office setting, urgent referral to an Emergency Department should be arranged.

Diagnostic imaging of the spine should be considered when symptoms are suggestive of structural cervical spine injury. Imaging should be considered in patients with severe neck pain, tenderness or clinical evidence of radiculopathy or myelopathy. The choice of imaging modality (plain radiographs, CT or MRI of the cervical spine) should be guided by the suspected pathology.

Patients with positive traumatic findings observed on diagnostic imaging of the brain or spine should be urgently referred to a neurosurgeon for consultation.

3.1c

Recommendation 2.1c:  Consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms. 

Level of Evidence:   MRI

Urgent conventional MRI should be considered in concussion patients who present with focal or worrisome symptoms (e.g., deteriorating vision, focal weakness or numbness, altered awareness, prominent behavioural changes, or worsening headaches that are not responding to treatment) and in whom a structural brain injury or abnormality is suspected. 

6.1c

Consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Level of Evidence:   CT.  MRI.

See Recommendation 2.1c for more information on when to consider diagnostic brain or cervical spine imaging.

7.3

Consider managing patients who experience sleep-wake disturbances for more than 4 weeks with cognitive behavioural therapy, treat with daily supplements, and/or refer to an interdisciplinary concussion team.

Level of Evidence:  

10.4

Screen for vestibulo-ocular deficits.

Level of Evidence:   

With appropriate experience, perform an assessment of the vestibulo-ocular reflex (VOR) such as the head thrust test and dynamic visual acuity.

Consider referral to a physiotherapist with competency-based training in vestibular rehabilitation.

Online instructional videos to consider:

11.4

Consider referral to an interdisciplinary concussion team for patients with prolonged post-concussion fatigue (more than 4 weeks following the acute injury) to learn pacing techniques.

Level of Evidence:  

12.2

Assess for school difficulties using clinical judgment.

Level of Evidence:   

Determine how much school the child/adolescent has missed post-concussion and how much missed workload the child/adolescent is expected to catch up on from missed school days.

Obtain school records to determine what issues may have been present prior to the concussion

School or cognitive difficulties may overlap with vision, vestibular, hearing, mental health, and social/family issues. Please assess.

5.4

Recommendation 2.3d: Refer select patients (e.g., highly active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment.

Level of Evidence:  

15.1c

See Recommendation 2.b “Note common modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.”


6.5 Following an initial medical assessment, a follow-up appointment with the patient’s primary care provider should be arranged in 1-2 weeks or in the presence of any deterioration to reassess clinical status.

1.4 

Concussion should be suspected and diagnosed as soon as possible to maintain health and improve outcomes. Concussion can be suspected in the community by healthcare professionals, parents, teachers, coaches, and peers. Those with a suspected concussion should be assessed by a physician or nurse practitioner to perform a thorough medical assessment to exclude more severe injuries, consider a full differential diagnosis, and confirm the diagnosis of concussion. 

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.

Level of Evidence:   

Tool 1.3: Manage Acute and Prolonged Concussion Symptoms Algorithm

Suggested tool for the general community to suspect a concussion

Suggested tools for experienced healthcare professionals to suspect a concussion:

2.2

Note common modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

Level of Evidence:

Link: Predicting Persistent Post-Concussive Problems in Pediatrics (5P): Score Calculator.

Modifiers that may delay recovery:

  • Age (increased risk with increased age).
  • Sex (female).
  • Duration of recovery from a previous concussion.
  • High pre-injury symptom burden.
  • High symptom burden at initial presentation.
  • Clinical evidence of vestibular or oculomotor dysfunction.
  • Vestibular-Ocular Reflex (VOR) and tandem gait parameters.
  • Orthostatic intolerance.
  • Personal and family history of migraines.
  • History of learning or behavioural difficulties.
  • Personal and family history of mental health.
  • Family socioeconomic status/education.

3.2

Provide patients with general education and guidance that outlines mental health considerations, non-pharmacological strategies to minimize symptoms including sleep hygiene, activity modifications, limiting triggers, information on screen time, the importance of social interaction, and how to work with the school team to facilitate school success. 

Level of Evidence:  

 

6.1d

Classify and characterize the headache subtype based on the clinical history and physical examination findings. 

Level of Evidence:   

Tool 6.1: Post-Concussion Headache Algorithm.

Link: International Classification of Headache Disorders (ICHD-III)*.

Common prolonged post-concussion headache subtypes include: 

  • Migraine, tension, or cluster headaches. 
  • Cervicogenic headaches. 
  • Physiological or exercise-induced headaches.
  • Headaches associated with prolonged visual stimulation.
  • Occipital neuralgia.

* “Reproduced with permission of International Headache Society”.

10.5

Screen for balance deficits.

Level of Evidence:  

Assess for prolonged balance deficits and determine which systems (visual reflexes, inner ear, musculoskeletal, nervous system or brain) might be contributing to dizziness, headaches, and balance problems. Vestibular rehabilitation may improve balance and dizziness. If prolonged impairment is identified, refer to a specialist immediately.

Perform assessment of postural stability and balance.

  • Standing balance test (eyes open/closed, tandem stance, single leg stance), Balance Error Scoring System.
  • Dynamic balance: Consider the Functional Gait Assessment and BOT (Bruininks-Oseretsky Test of Motor Proficiency) tests.

Consider referral to an interdisciplinary concussion team or physiotherapist with competency-based training in vestibular rehabilitation.

Online instructional videos to consider:

11.5

Recommend a medical follow-up to re-assess clinical status if fatigue symptoms persist.  Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (before 4 weeks) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence: Medical follow-up. Early referral in the presence of modifiers that may delay recovery.

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. 

Level of Evidence:  

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

12.3

Manage school difficulties. 

Level of Evidence:  

On re-evaluation, experienced health professionals (and school-based educational professionals where available) should manage school cognitive difficulties, provide accommodations, and reduce stressors. This should be done in collaboration with the child/adolescent, parents/caregivers, schools and/or employers to support success in the home, school, and community.

Refer to an interdisciplinary concussion team and/or a school-based educational professional (if available) if symptoms interfere with daily functioning more than 4 weeks following a concussion (Domain 9: Cognition). Refer for a formal evaluation if school difficulties may have been pre-existing.

Use tools to encourage reintegration within the school, employment, sports, social, and home environments.

Summary of tools to consider:

15.1d

Considerations for a virtual physical assessment

A virtual physical examination should aim to assess similar aspects of neurological functioning evaluated during an in-person medical assessment with modifications based on the presence of a remote telepresenter or examiner.

  • The unassisted virtual physical examination should include assessment of mental status, speech, cranial nerves, coordination, balance, gait, cognitive functioning, oculomotor functioning, and the cervical spine.
  • Certain aspects of the physical examination including assessment of motor, sensory and vestibular functioning; palpation and provocative testing of the cervical spine; testing of visual acuity and deep tendon reflexes; as well as fundoscopic and otoscopic examinations cannot be performed virtually.

Tool 15.2: Considerations for a virtual physical examination for medical assessment and follow-up of concussion patients

Tool 15.3: Virtual Care Exam Training Resource. A training manual 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.

Level of Evidence:  

7.3a

Refer the child/adolescent to a cognitive behavioural specialist. The treatment of choice for primary insomnia and insomnia co-morbid to a medical or psychiatric condition is cognitive behavioural therapy (CBT).

Level of Evidence:  

If CBT is unavailable to the patient or the patient is waiting for CBT treatment:

  • Optimize and implement sleep hygiene (Tool 2.7: Strategies to Promote Good Sleep and Alertness)
  • Monitor the patient weekly for the first few weeks.
  • Re-emphasize that patients with sleep disturbances should continue to engage in sub-symptom threshold cognitive and physical activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) as tolerated (Recommendation 2.3).
  • Consider referring to an interdisciplinary concussion team.

2.2

Provide verbal information and written (electronic) handouts regarding the course of recovery and when the child/adolescent can return to school/activity/sport/work.

Level of Evidence:  

Consider the following anticipatory guidance (verbal reassurance) in order to reduce anxiety, set realistic expectations, promote recovery, and prevent re-injury: 

  • Most patients recover fully from concussion even though the recovery rate is variable and unpredictable.
  • Current symptoms are expected and common.
  • The burden and distress parents/caregivers of children/adolescents who have sustained a concussion may experience is common.
  • Children typically recover in 1-4 weeks but some children/adolescents will have symptoms at one month and beyond and need to be monitored/seek additional care. Females aged 13-18 years have an increased risk of prolonged recovery.
  • Tool 2.0: Living Guideline Return to Activity Sports and School Protocol (Updated Sept 2023)
  • Recommendation 2.3 Recommend graduated return to physical and cognitive activity. 
  • Return to school should be step-wise as soon as the student is able and include temporary academic modifications based on the student’s symptom tolerance. See Domain 12: Return-to-School and Work for more recommendations and a list of return-to-school resources.

Summary of online tools to consider related to lifestyle strategies and expectations:

3.3

Encourage patients with post-concussion symptoms to engage in cognitive activity and low-risk physical activity as soon as tolerated  Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity. Level of Evidence: A Gradual Return to physical activity aerobic exercise treatment. B Gradual return to cognitive activity. See Recommendation 2.3.

  • Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:
  • Patients who are active may benefit from referral to a medically supervised interdisciplinary team with the ability to individually assess aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:

See the Living Guideline Post-Concussion Information Sheet for examples of low-risk activities. 

Links to exertion test resources:

 
Recommendation Updated: Sept 2023

6.2

Provide general post-concussion education and guidance on headache management.

10.6

Screen for and consider underlying psychosocial contributors to vestibular, vision, and oculomotor dysfunction.

Level of Evidence:  

Domain 8: Mental Health and Psychosocial Factors.

12.4

Encourage patients with school difficulties to engage in cognitive activity and low-risk physical activity as soon as tolerated. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   A Gradual return to physical activity. B Gradual return to cognitive activity.

See Recommendation 2.3. 

15.1e

Considerations for a virtual physical examination for medical assessment and follow-up of concussion patients

Link: Recommendation 2.1c -recommendations on an in-person medical assessment.

Level of Evidence:  

7.3b

Consider suggesting non-pharmacological supplements such as magnesium, melatonin*, and zinc to improve sleep and recovery without the use of medication that may have side effects.

Level of Evidence:  

*Melatonin was not found to be effective when used for youth with concussion symptoms 4-6 weeks after injury in a single-center double-blinded randomized controlled trial” (Barlow et al 2020. Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial. Pediatrics

3.4

Refer patients at elevated risk for delayed recovery to an interdisciplinary concussion team. Level of Evidence:

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. Level of Evidence:  

6.2a

Advise on non-pharmacological strategies to minimize headaches including sleep hygiene, activity modifications, limiting triggers, and information on screen time. 

Level of Evidence:  

7.4

Refer patients with prolonged post-concussion sleep disturbances (more than 6 weeks) to a sleep specialist or an interdisciplinary concussion team if the interventions introduced at 4 weeks have been unsuccessful and sleep issues persist.

Level of Evidence:  

If sleep issues persist for more than 6 weeks post-acute injury, sleep hygiene can’t be optimized, and if poor sleep quality is impacting the ability to return-to-school or ability to recondition:

  • Refer to a sleep specialist who has experience with concussion and polysomnography or to an interdisciplinary concussion team that has the expertise to understand sleep disturbances in the context of concussion-related symptoms.

Consider ordering sleep tests to rule out possible sleep-related breathing disorders, nocturnal seizures, periodic limb movements, or narcolepsy.

  • Examples of sleep tests include Sleep Study, Multiple Sleep Latency Test, and the Maintenance of Wakefulness Test.

10.7

Provide general post-concussion education that outlines symptoms of concussion, provides suggestions regarding activity modification and includes academic accommodations to manage visual, vestibular and oculomotor symptoms. 

Level of Evidence:  

Guidance about how to make a gradual return-to-school, cognitive activities, and physical activities:

12.5

Return-to-school and return-to-sport strategies can be performed simultaneously. Recommend that the child/adolescent return-to-school full-time at a full academic load, including writing exams without accommodations related to their concussion/post-concussion symptoms, before returning to full-contact sport or high-risk activities. 

Level of Evidence:   

See Domain 4: Medical clearance for full-contact sport or high-risk activity.

2.3

Recommend graduated return to cognitive and physical activity to promote recovery.

While most children/adolescents fully recover, the recovery rate can be variable. Return to physical and cognitive activity should be individualized based on activity tolerance and symptom presentation.

15.1f

Recommendation 2.1c: “Consider CT of the brain or cervical spine only in patients whom, after a medical assessment, a structural intracranial or cervical spine injury is suspected; do not conduct routine neuroimaging for the purpose of diagnosing concussion.” 

2.3a

Recommend an initial 24-48 hour period of relative rest*.

Level of Evidence: A Gradual return to physical activity. B Gradual return to cognitive activity.

*Relative rest: activities of daily living including walking and other light physical and cognitive activities are permitted as tolerated. (this definition has been harmonized with and adapted from the Amsterdam International Consensus Statement on Concussion in Sport)

See Living Guideline Return to Sport/Activity and School Protocols

Updated Sept 2023

3.5

For those who are not referred initially (See recommendation 3.4), refer to specialized care with an interdisciplinary concussion team if post-concussion symptoms do not resolve by 2-4 weeks. Medical follow-ups may be needed to guide appropriate referrals.

Level of Evidence:   

See Tool 1.3 Manage Acute and Prolonged Symptoms Algorithm.

Assessment by an interdisciplinary concussion team can assist in identifying the type of management that is required, along with the medical and health professions on the interdisciplinary concussion team or external to this team who can provide the required management. Not all children/adolescents will require care from all members of the interdisciplinary concussion team and care should be targeted based on identified symptoms and patient needs. Symptoms that persist beyond 4 weeks (persisting symptoms after a concussion (PSAC) or persistent post-concussion symptoms (PPCS) may be related to the concussion, due to pre-existing conditions, or both.

Recommendation updated: Sept 2023

6.2b

Encourage patients with headaches to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation threshold. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   Physical activity. Cognitive activity.

See Recommendation 2.3.

See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

7.5

Consider prescribing medication on a short-term basis if sleep has not improved after 6 weeks following the acute injury. 

Level of Evidence:  

Ensure that medications do not result in dependency and that the patient has minimal adverse effects. The aim is to establish a more routine sleep pattern.

If sleep disturbances persist after pharmacological treatment refer to a pediatric sleep specialist ideally with experience with concussion and polysomnography. 

10.8

Encourage patients with post-concussion vestibular, visual, or oculomotor symptoms to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation thresholds. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   Gradual return to physical activity. Gradual return to cognitive activity.

See Recommendation 2.3.

  • Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:
  • Patients who are active may benefit from 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. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:

See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

12.6

Prioritize return-to-school before return to work.

Level of Evidence:  A Starting return to activity earlier.

For teens who work, please consult the “Guidelines for Concussion/ Mild Traumatic Brain Injury and Persistent Symptoms 3rd Edition For Adults (18+ years of age)” for recommendations on how to work with the adolescent’s employer regarding non-academic accommodations so that the adolescent can gradually return to work while promoting recovery.

15.2

Provide verbal information and written (electronic) handouts regarding the course of recovery and when the child/adolescent can return to school/activity/sport/driving/work and strategies to promote recovery.

This should include the following:

  • Guidance on the appropriate use of rest and guidance on making a gradual return to symptom-limiting cognitive, school, social, and low-risk physical activities.
    • Recommendation 2.3 Recommend graduated return to cognitive and physical activity to promote recovery.
    • Domain 12: Return to school
  • Guidance on sleep (Recommendation 2.4 a)
  • Recommendation on social networks and interactions (Recommendation 2.4b)
  • Recommendation on driving (Recommendation 2.4e)
  • Guidance on the appropriate use of over-the-counter medications for symptom management (Recommendation 2.5)
  • Recommendation on screen time and electronic device use (Recommendation 2.4c)
  • Recommendation to avoid alcohol and recreational drugs (Recommendation 2.4d)

Where available, provide post-injury education that is appropriate for the patient’s culture and/or preferred language.

Summary of online tools to consider related to lifestyle strategies and expectations:

Level of Evidence:  

2.3b

2.3b Recommend that physical and cognitive activity be started 24-48 hours after a concussion increasing the intensity gradually as part of the initial treatment for acute concussion. Activities that pose no/low risk of sustaining a concussion should be resumed even if mild residual symptoms are present.

Start with ‘light-intensity’ aerobic exercise, progressing to ‘moderate-intensity’ aerobic exercise, and continue to increase the intensity over time as symptoms are tolerated.* Suggest taking a break from the activity if the increase in symptoms is more than mild and brief** or the symptoms cannot be tolerated. 

Level of Evidence:  A- Physical activity, B- Cognitive activity

Updated: Sept 2023

*Light-intensity aerobic exercise: Target heart rate of up to approximately 55% of the person’s maximum heart rate (estimated according to age- 220 beats/min minus age in years)

Moderate-intensity aerobic exercise: Target heart rate of up to approximately 70% of the person’s maximum heart rate

**More than mild and brief symptom exacerbation: An increase in current concussion symptoms of no more than 2 points on a 0-10 point scale for less than an hour compared to the resting value prior to the physical activity. Example of a 0-10 point Symptom severity scale: Visual Analog Scale (VAS)

(these definitions have been harmonized with and adapted from the Amsterdam International Consensus Statement on Concussion in Sport)

3.6

Iniate treatment for specific symptoms or concerns while waiting for a referral to an interdisciplinary concussion team or sub-specialist. 

Level of Evidence:   

 

6.2c

Consider suggesting the use of a headache and medication diary in order to monitor symptoms and medications taken. Use clinical judgment and an individualized approach on use or duration of this strategy. 

Level of Evidence:  

Link: Headache and Medication Diary (Boston Children’s Hospital)

7.6

Recommend a medical follow-up to reassess clinical status if sleep disturbances persist. Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (before 4 weeks) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence: Medical follow-up.  Early referral in the presence of modifiers that may delay recovery.

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. 

Level of Evidence: B 

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

10.9

Refer patients with prolonged post-concussion vestibular functioning, balance or visual dysfunction (more than 4 weeks following the acute injury) to an interdisciplinary concussion team with appropriate experience. Consider early referral (before 4 weeks) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence:   Medical follow-up. Early referral in the presence of modifiers that may delay recovery.

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. Level of Evidence:  

Tool 10.1: Post-Concussion Vision, Vestibular, and Oculomotor Disturbances Algorithm

Assessment by an interdisciplinary concussion team can assist in identifying the type of management that is required, along with the medical and health professions on the interdisciplinary concussion team or external to this team who can provide the required management. Not all children/adolescents will require care from all members of the interdisciplinary concussion team and care should be targeted based on identified symptoms and patient needs.

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

15.3

Provide a written (electronic) medical assessment or clearance letter to the child/adolescent and the parent/caregiver.

Link: Canadian Guideline on Concussion in Sport Medical Assessment Letter

Link: Canadian Guideline on Concussion in Sport Medical Clearance Letter

Level of Evidence:  

2.3c

Recommend that patients avoid activities associated with a risk of contact, fall, or collisions such as high-speed and/or contact activities and full-contact sport that may increase the risk of sustaining another concussion until medically cleared (see Recommendation 4.1: Consider patients for medical clearance to return to full-contact activities and sport/gameplay if clinical criteria have been met. Note: An update to Rec 4.1 was performed Sept 2023). 

Level of Evidence:  

  • Advise/emphasize that returning to full-contact sport or high-risk activities before the child/adolescent has recovered increases the risk of delayed recovery and for sustaining another more severe concussion or more serious injury.

3.7

Recommend regular medical follow-up if a child/adolescent is still experiencing post-concussion symptoms or has not completed the return-to-school or return-to-sport/activity stages. Recommend an immediate medical follow-up in the presence of any deterioration.

Level of Evidence:  

6.2d

Over-the-counter medications such as acetaminophen and ibuprofen may be recommended to treat acute headache. Advise on limiting the use of these medications to less than 15 days a month and avoiding “around-the-clock” dosing to prevent overuse or rebound headaches. I.e., advise that children/adolescents avoid using over the counter medications at regular scheduled times throughout the day.

Level of Evidence:  

10.10

Recommend a medical follow-up to reassess clinical status if vestibular functioning, balance or visual dysfunction symptoms persist. Recommend an immediate medical follow-up in the presence of any deterioration.  

Level of Evidence:  

15.4

Provide a medical follow-up assessment on children/adolescents with concussion in 1-2 weeks to re-assess and monitor clinical status. A regular medical follow-up is also recommended if a child/adolescent is still experiencing post-concussion symptoms or has not completed the return-to-school or return-to-sport/activity stages. Recommend immediate in-person medical attention in the presence of any deterioration.

 

While in-person medical follow-up is ideal, telemedicine (e.g., real-time in-person videoconferencing) may be considered for follow-up appointments for the following patients with concussion:

  1. Those for whom access or travel for follow-up is limited or unavailable such as those who live in rural and remote communities.
  2. Those who have undergone a previous in-person medical assessment by the treating physician or nurse practitioner
  3. Those whose symptoms are stable, improving, or resolved
  4. Those who do not report any subjective red flags (e.g., blurred or double vision, weakness or numbness, vertigo) and who have a satisfactory virtual physical examination with no objective red flags (e.g., diplopia on extraocular movement testing, positive pronator drift, pain on testing of cervical spine range of motion)
  5. Those who do not require supplemental testing (diagnostic imaging, neuropsychological testing, graded aerobic exercise testing), and/or inter-disciplinary referrals to optimize patient care

Tool 15.1: Considerations for telemedicine and virtual care algorithm

Level of Evidence:  

Please refer to Domain 3: Medical follow-up and Management of Prolonged Symptoms for a full list of clinical guideline recommendations to consider when performing a medical follow-up assessment and managing prolonged concussion symptoms.

6.3

Refer patients who have prolonged post-concussion headaches for more than 4 weeks to an interdisciplinary concussion team or to a sub-specialist for further evaluation and management. Consider early referral (prior to 4-weeks after the acute injury) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence:  

Prolonged headaches in pediatric concussion patients can be difficult to classify and manage and can co-occur with other prolonged post-concussion symptoms (dizziness, neck pain, sleep disturbance, cognitive or mood challenges). 

If an interdisciplinary concussion team member is not available:

  • Consider appropriate referral to interdisciplinary professionals who have competency-based training and clinical experience to independently manage the identified headaches and headache disorders.

If a child/adolescent with prolonged post-concussion headache has not had a recent vision assessment, refer to an optometrist for an assessment.

2.3d

Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:

Links to exertion test resources:
 
(Updated: Sept 2023)

15.5

Please refer to Domain 4: Medical Clearance for full-contact sports and high-risk activities for a full list of clinical recommendations to consider when determining if a child/adolescent is ready to return to full-contact sports or high-risk activities. Medical clearance is not required to return to school.

6.4

Consider initiating pharmacological therapy to treat and manage prolonged headaches while waiting for the interdisciplinary concussion team or sub-specialist referral. 

Level of Evidence:   

For patients with post-traumatic headaches that are migrainous in nature, the use of migraine-specific abortants such as triptan class medications may be used if effective. Due to the risk of developing medication-induced headaches, limit use of abortants to fewer than 6-10 days per month.

Tool 6.2: General Considerations Regarding Pharmacotherapy.

Tool 6.3: Approved Medications for Pediatric Indications.

Prophylactic therapy should be considered:

  • If headaches are occurring frequently.
  • If headaches are disabling.
  • If acute headache medications are contraindicated or poorly tolerated or are being used too frequently.

15.6

Recommendations for inter-disciplinary healthcare professionals involved in the care of concussion patients:

Neuropsychologists

Virtual care may be considered to assist in the assessment and longitudinal care of concussion patients who develop persistent cognitive and mood-related symptoms or who are having persistent problems in school. Neuropsychologists should be aware of the limitations of performing certain neuropsychological tests via in-person videoconferencing. Specific symptom assessments can be administered virtually or completed before the virtual appointment and sent to the neuropsychologist ahead of time.

Level of Evidence:  

 

Physiotherapists

Virtual care may be considered by physiotherapists to advance vestibular, cervical spine and medically supervised individually tailored sub-symptom threshold aerobic exercise treatment plans in patients who have undergone previous in-person assessment by the treating physiotherapist. Physiotherapists should recognize that a comprehensive assessment of the cervical spine and vestibular system as well as graded aerobic exercise testing, which are required to provide initial recommendations regarding targeted rehabilitation, cannot be performed virtually. If a physiotherapist is providing virtual care, they must be able to arrange an urgent in-person assessment as needed.

Level of Evidence:  

 

Psychiatrists

Telemedicine may be considered to assist in the assessment and longitudinal care of concussion patients who develop persistent psychiatric and sleep-related symptoms and disorders.

Level of Evidence:  

 

Headache neurologists

Telemedicine may be considered to assist in the assessment and longitudinal care of concussion patients who develop persistent headaches.

Level of Evidence:  

 

Occupational therapists

Virtual care may be considered to assist in the assessment and longitudinal care of concussion patients who develop prolonged cognitive and mood-related symptoms and to assist with a successful return to school and other activities of daily living.

Level of Evidence:  

2.3e

Patients who are active may benefit from referral to a medically supervised interdisciplinary team with the ability to individually assess aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:
Links to exertion test resources:
 
(Updated: Sept 2023)

2.4

Provide education and guidance regarding strategies to promote recovery.

6.5

Recommend a medical follow-up to reassess clinical status if headaches persist. Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (prior to 4-weeks after the acute injury) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence: Medical follow-up. Early referral in the presence of modifiers that may delay recovery.

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. 

Level of Evidence: B 

See Recommendation 2.2: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

2.4a

Advise on the importance of sleep and discuss sleep hygiene.

Level of Evidence:

Advise that consistent sleep schedules and duration of sleep may contribute to general recovery from a concussion and alleviate symptoms such as mood, anxiety, pain, fatigue, and cognitive difficulties if these are present. 

Summary of tools to consider:

2.4b

Advise on maintaining social networks and interactions (as tolerated). Children/adolescents should participate (modified as needed) in rewarding social activities that avoid the risk of re-injury. Social engagement may promote recovery and reduce the risk of mental health issues. 

Level of Evidence:  

Updated Sept 2023

2.4c

Screentime should be minimized in the first 48 hours after injury. After the initial period of relative rest, the use of devices with screens may be gradually resumed. The use of these devices can be increased according to symptom tolerance as the child/adolescent recovers.

Level of Evidence: B

Updated Sept 2023

2.4d

Advise on avoiding alcohol and other recreational drugs after a concussion.

Level of Evidence:

Alcohol and recreational drugs may have a negative effect on concussion recovery. Avoiding alcohol or drugs prevents a child/adolescent from self-medicating and resorting to drugs to relieve symptoms. Impaired judgment after a concussion could lead to risky behaviour that causes further harm or may delay the identification of complications.

2.4e

Advise to avoid driving during the first 24-48 hours after a concussion. Advise patients to begin driving when they are feeling improved, can concentrate sufficiently to feel safe behind the wheel, and when the act of driving does not provoke significant concussion symptoms.

Level of Evidence:

Provide verbal information related to when an adolescent should return to driving during recovery from a concussion. Driving is a complex coordinated process that requires vision, balance, reaction time, judgment, cognition, and attention. Concussion may have affected some or all of these skills. Driving impairments have been shown to exist even in asymptomatic patients 48 hours after a concussion. Avoiding driving for at least 24-48 hours after a concussion may potentially prevent motor vehicle accidents and, therefore, injury to the adolescent or to others.

2.5

Over-the-counter medications such as acetaminophen and ibuprofen may be recommended to treat acute headache. Limit the use of these short-term acting medications to the first week post-injury and avoid “around-the-clock” dosing to prevent overuse or rebound headaches.

Level of Evidence:  

Updated Sept 2023

2.6

At present, there is limited evidence to support the administration of intravenous medication to treat acute headaches in pediatric concussion patients in the Emergency Department setting.

Level of Evidence:

2.7

After assessment, nearly all children/adolescents with concussion may be safely discharged from clinics and Emergency Departments for observation at home.

Level of Evidence:  

The decision to observe in the hospital will depend on clinical judgment. Indicators for longer in-hospital observation (or to return to emergency for re-assessment) may include:

  • Worsening symptoms (headache, confusion, irritability).
  • Decreased level of consciousness.
  • Prolonged clinical symptoms (persistent/prolonged vomiting, severe headache, etc.).
  • Bleeding disorders.
  • Multi-system injuries. 
  • Co-morbid symptoms. 

Other discharge considerations:

  • Observe the child/adolescent for a period of time to verify that they do not develop “red flag” symptoms prior to discharge. Use clinical judgment.
  • Verify that the child/adolescent has a normal mental status (alertness/behaviour/cognition) and their symptoms are improving prior to discharge. 
  • Verify that an assessment of clinical risk factors indicating the need for a CT scan was performed or a normal result was obtained if a CT scan was performed prior to discharge.
  • See Recommendation 2.1c for more information on when to consider diagnostic brain or cervical spine imaging.

2.8

Recommend a medical follow-up visit in 1-2 weeks to re-assess and monitor clinical status. Recommend an immediate medical follow-up in the presence of any deterioration.

Level of Evidence:

Those with a confirmed diagnosis of concussion may be managed by a healthcare professional who within their formally designated scope of practice has the capacity to manage ongoing concussion-related symptoms.

2.9

Refer patients at elevated risk for delayed recovery to an interdisciplinary concussion team. Level of Evidence: 

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

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. Level of Evidence:  

2.10

Provide post-concussion information and a written medical assessment to the child/adolescent and the parent/caregiver prior to sending the child/adolescent home. 

Level of Evidence:  

Write the discharge note/written medical assessment with the following information:

Verbal and written (or electronic) guidance should include:

Other patient information handouts to consider: