Managing Concussion Symptoms

Managing Concussion Symptoms

Introduction

icon img Medical Follow-up and Management of Prolonged Symptoms

Introduction:

A medical follow-up is recommended if a child/adolescent is experiencing post-concussion symptoms, has not completed the return-to-school or return-to-activity/sport stages, or experiences any deterioration. Post-concussion symptoms and return-to-school/ activity/sport/work status should be reassessed. A medical assessment including clinical history, comprehensive physical examination, and consideration for diagnostic tests or imaging should be considered in patients with red flag symptoms or worrisome clinical findings. Those with a confirmed diagnosis of concussion may be managed by a healthcare professional that, within their formally designated scope of practice, has the capacity to manage ongoing concussion-related symptoms.

Patients who are experiencing clinical improvement in their post-concussion symptoms should continue to be provided with education, reassurance, and guidance on advancing through their return-to-school/activity/sport protocols. At follow-up visits, patients should be provided with an updated medical clearance letter indicating if they are medically cleared to participate in full-contact sport or high-risk activities.

If post-concussion symptoms have not resolved by 2-4 weeks, or if the child/adolescent’s condition/symptoms worsen, consider referral to specialized care with an interdisciplinary concussion team and ensure that the child/adolescent is well supported at school and at home. Additionally, early identification of patients with modifiers that may delay recovery allows for early targeted supportive care, close monitoring for prolonged symptoms, and consideration for early referral (before 2-4 weeks following acute injury) to an interdisciplinary concussion team.

For those at risk of a prolonged or persistent recovery, specialized interdisciplinary concussion care is ideally initiated within the first two weeks post-injury. Patients who are active, competitive athletes, and those who are not tolerating a gradual return to physical activity may benefit from early assessment of their aerobic exercise tolerance and prescribed aerobic exercise as early as 48 hours following acute injury.

Tool 1.3: Manage Acute and Prolonged Concussion Symptoms Algorithm

Living Guideline Return to Activity, Sports and School Protocols (Updated Sept 2023)

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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. 

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.

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:

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. 

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:  

 

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

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:  

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

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:   

 

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:  

Tools and Resources
References

Research papers that support the present guideline recommendations:

Boutis, K., Weerdenburg, K., Koo, E., Schneeweiss, S., & Zemek, R. (2015). The diagnosis of concussion in a pediatric emergency department. Journal of Pediatrics, 166(5), 1214–1220.e1. https://doi.org/10.1016/j.jpeds.2015.02.013

Bramley, H., McFarland, C., Lewis, M. M., Shaffer, M. L., Cilley, R., Engbrecht, B., … Dias, M. S. (2014). Short-term outcomes of sport- and recreation-related concussion in patients admitted to a pediatric trauma service. Clinical Pediatrics, 53(8), 784–790. https://doi.org/10.1177/0009922814533403

Clark R, Stanfill AG. A Systematic Review of Barriers and Facilitators for Concussion Reporting Behavior among Student Athletes. Vol. 26, Journal of Trauma Nursing. Lippincott Williams and Wilkins; 2019. p. 297–311.

DePadilla PhD L, Miller PhD GF, Everett Jones PhD, MPH, JD S. Characteristics of Schools with Youth Sports Concussion-Related Educational Policies and Practices. J Sch Health. 2020;90(7):520–6.

Donnell, Z., Hoffman, R., Sarmiento, K., & Hays, C. (2018). Concussion attitudes, behaviors, and education among youth ages 12–17: Results from the 2014 YouthStyles survey. Journal of Safety Research, 64, 163–169. https://doi.org/10.1016/j.jsr.2017.12.001

Elbin, R. J., Sufrinko, A., Schatz, P., French, J., Henry, L., Burkhart, S., … Kontos, A. P. (2016). Removal From Play After Concussion and Recovery Time. Pediatrics, 138(3), e20160910–e20160910. https://doi.org/10.1542/peds.2016-0910

Feiss R, Lutz M, Reiche E, et al. A systematic review of the effectiveness of concussion education programs for coaches and parents of youth athletes. Vol. 17, International Journal of Environmental Research and Public Health. MDPI AG; 2020.

Fremont P, Schneider K, Laroche A, et al. Could a massive open online course be part of the solution to sport-related concussion? Participation and impact among 8368 registrants. BMJ Open Sport Exerc Med. 2020;6(1):1–7.

Howell, D. R., OʼBrien, M. J., Fraser, J., & Meehan, W. P. (2018). Continuing Play, Symptom Severity, and Symptom Duration After Concussion in Youth Athletes. Clinical Journal of Sport Medicine, 0(0), 1. https://doi.org/10.1097/jsm.0000000000000570

Linder, S. M., Cruickshank, J., Zimmerman, N. M., Figler, R., & Alberts, J. L. (2019). A technology-enabled electronic incident report to document and facilitate management of sport concussion: A cohort study of youth and young adults. Medicine, 98(14), e14948. https://doi.org/10.1097/MD.0000000000014948

Matveev, R., Sergio, L., Fraser-Thomas, J., & Macpherson, A. K. (2018). Trends in concussions at Ontario schools prior to and subsequent to the introduction of a concussion policy – An analysis of the Canadian hospitals injury reporting and prevention program from 2009 to 2016. BMC Public Health, 18(1), 1–10. https://doi.org/10.1186/s12889-018-6232-9

McCart, M., Glang, A. E., Slocumb, J., Gau, J., Beck, L., & Gomez, D. (2019). A quasi-experimental study examining the effects of online traumatic brain injury professional development on educator knowledge, application, and efficacy in a practitioner setting. Disability and Rehabilitation, 0(0), 1–7. https://doi.org/10.1080/09638288.2019.1578423

McGuine, T. A., Pfaller, A. Y., Post, E. G., Hetzel, S. J., Brooks, A., & Broglio, S. P. (2018). The influence of athletic trainers on the incidence and management of concussions in high school athletes. Journal of Athletic Training, 53(11), 1017–1024. https://doi.org/10.4085/1062-6050-209-18

Mckinlay, A., Ligteringen, V., & Than, M. (2014). A comparison of concussive symptoms reported by parents for preschool versus school-aged children. Journal of Head Trauma Rehabilitation, 29(3), 233–238. https://doi.org/10.1097/HTR.0b013e3182a2dd7f

Shendell, D. G., Gonzalez, L., Listwan, T. A., Pancella, J., Blackborow, M., & Boyd, J. (2019). Developing and Piloting a School-Based Online Adolescent Student-Athlete Concussion Surveillance System. Journal of School Health, 89(7), 527–535. https://doi.org/10.1111/josh.12775

Taubman, B., Rosen, F., McHugh, J., Grady, M. F., & Elci, O. U. (2016). The Timing of Cognitive and Physical Rest and Recovery in Concussion. Journal of Child Neurology, 31(14), 1555–1560. https://doi.org/10.1177/0883073816664835

Terwilliger, V. K., Pratson, L., Vaughan, C. G., & Gioia, G. A. (2016). Additional Post-Concussion Impact Exposure May Affect Recovery in Adolescent Athletes. Journal of Neurotrauma, 33(8), 761–765. https://doi.org/10.1089/neu.2015.4082

Zynda AJ, Sabatino MJ, Ellis HB, et al. Continued play following sport-related concussion in United States youth soccer. Int J Exerc Sci [Internet]. 2020;13(6):87–100. Available from: http://www.intjexersci.com

Research papers not associated with a current recommendation:

Dobney, D. M., Grilli, L., Kocilowicz, H., Beaulieu, C., Straub, M., Friedman, D., & Gagnon, I. J. (2018). Is There an Optimal Time to Initiate an Active Rehabilitation Protocol for Concussion Management in Children? A Case Series. Journal of Head Trauma Rehabilitation, 33(3), E11–E17. https://doi.org/10.1097/HTR.0000000000000339

Jones, K. M., Barker-Collo, S., Parmar, P., Starkey, N., Theadom, A., Ameratunga, S., & Feigin, V. L. (2018). Trajectories in health recovery in the 12 months following a mild traumatic brain injury in children: Findings from the BIONIC Study. Journal of Primary Health Care, 10(1), 81–89. https://doi.org/10.1071/HC17038

Date of last update: January 4, 2021

icon img Headache

Introduction:

Headache is one of the most common symptoms reported by children/adolescents who sustain a concussion. In most cases, headache associated with an acute concussion will resolve spontaneously within 1-4 weeks of injury along with other concussion symptoms. In some cases, headaches can persist beyond this time frame.

For patients with post-concussion headaches 1-2 weeks following acute injury, a repeat medical assessment must be conducted including a clinical history, physical examination, and the evidence-informed use of diagnostic imaging. The assessment should also include proper classification or characterization of the patient’s headache. This assessment will help identify co-morbid medical disorders (e.g., a history of migraine or non-specific headaches or psychiatric disorders) and other factors (e.g., overuse of analgesics) that can contribute to prolonged headaches. Some prolonged post-concussion headaches can be classified according to the International Classification of Headache Disorders (ICHD-III), while others cannot. Proper characterization of prolonged post-concussion headaches can help provide information to execute appropriate interdisciplinary referrals and guide evidence-based management.

Tool 6.1:Post-Concussion Headache Algorithm.

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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.

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.

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).

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.

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”.

6.2

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

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:  

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.

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)

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:  

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.

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.

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.

Tools and Resources
References

Click here to access the Living Guideline Evidence Map (powered by EPPIreviewer and EPPIvisualizer)

Reference List: Last updated Sept 2023, update in progress (April 2024).

Ali Muhammad, Asghar Nek, Hannah Theodore, Schupper Alexander J, Li Adam, Dreher Nickolas, Murtaza-Ali Muhammad, Vasan Vikram, Nakadar Zaid, Alasadi Husni, Lin Anthony, Hrabarchuk Eugene, Quinones Addison, McCarthy Lily, Asfaw Zerubabbel, Dullea Jonathan, Gometz Alex, Lovell Mark, and Choudhri Tanvir (2023) A multicenter, longitudinal survey of headaches and concussions among youth athletes in the United States from 2009 to 2019. The Journal of Headache and Pain 24(1), 6

Bramley Harry, Heverley Steven, Lewis Mechelle M, Kong Lan, Rivera Rowena, and Silvis Matthew (2015) Demographics and Treatment of Adolescent Posttraumatic Headache in a Regional Concussion Clinic. Pediatric Neurology 52(5), 493-498 DOI: 10.1016/j.pediatrneurol.2015.01.008

Bresee Natalie, Aglipay Mary, Dubrovsky Alexander Sasha, Ledoux Andrée-anne Anne, Momoli Franco, Gravel Jocelyn, Freedman Stephen B, Barlow Karen, Richer Lawrence, Barrowman Nicholas J, and Zemek Roger (2018) No association between metoclopramide treatment in ED and reduced risk of post-concussion headache. American Journal of Emergency Medicine 36(12), 2225-2231 DOI: 10.1016/j.ajem.2018.04.007

Cushman Daniel M, Borowski Lauren, Hansen Colby, Hendrick John, Bushman Troy, and Teramoto Masaru (2019) Gabapentin and Tricyclics in the Treatment of Post-Concussive Headache, a Retrospective Cohort Study. Headache 59(3), 371-382 DOI: 10.1111/head.13451

Eckner James T, Seifert Tad, Pescovitz Allison, Zeiger Max, and Kutcher Jeffrey S (2017) Is migraine headache associated with concussion in athletes? A case-control study. Clinical Journal of Sport Medicine 27(3), 266-270 DOI: 10.1097/JSM.0000000000000346

Ellis Michael J, Cordingley Dean, Girardin Richard, Ritchie Lesley, and Johnston Janine (2017) Migraine with aura or sports-related concussion: Case report, pathophysiology, and multidisciplinary approach to management. Current Sports Medicine Reports 16(1), 14-18 DOI: 10.1249/JSR.0000000000000323

Heyer Geoffrey L, Young Julie A, Rose Sean C, McNally Kelly A, and Fischer Anastasia N (2015) Post-traumatic headaches correlate with migraine symptoms in youth with concussion. Cephalalgia 36(4), 309-316 DOI: 10.1177/0333102415590240

Kamins Joshua, Richards Rachel, Barney Bradley J, Locandro Christopher, Pacchia Christina F, Charles Andrew C, Cook Lawrence J, Gioia Gerard, Giza Christopher C, and Blume Heidi K (2021) Evaluation of Posttraumatic Headache Phenotype and Recovery Time After Youth Concussion. JAMA network open 4(3), e211312

Klein Susan K, Brown Cynthia B, Ostrowski-Delahanty Sarah, Bruckman David, and Victorio M Cristina (2022) Identifying Migraine Phenotype Post Traumatic Headache (MPTH) to Guide Overall Recovery From Traumatic Brain Injury. Journal of Child Neurology , 8830738221100327

Kontos Anthony P, Elbin R J, Lau Brian, Simensky Steven, Freund Brin, French Jonathan, and Collins Michael W (2013) Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. American Journal of Sports Medicine 41(7), 1497-1504 DOI: 10.1177/0363546513488751

Kuczynski Andrea, Crawford Susan, Bodell Lisa, Dewey Deborah, and Barlow Karen M (2013) Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: A prospective cohort. Developmental Medicine and Child Neurology 55(7), 636-641 DOI: 10.1111/dmcn.12152

Kwan Vivian, Plourde Vickie, Yeates Keith Owen, Noel Melanie, and Brooks Brian L (2020) Headache long after pediatric concussion: presence, intensity, interference, and association with cognition. Brain Injury 34(4), 575-582 DOI: 10.1080/02699052.2020.1725842

Lambrinakos-Raymond Kristen, Dubrovsky Alexander Sasha, Gagnon Isabelle, Zemek Roger, and Burstein Brett (2021) Management of Pediatric Post-Concussion Headaches: National Survey of Abortive Therapies Used in the Emergency Department. Journal of Neurotrauma ,

Ledoux Andree, Tang Ken, Freedman Stephen B, Gravel Jocelyn, Boutis Kathy, Yeates Keith O, Mannix Rebekah C, Richer Lawrence R, Bell Michael J, Zemek Roger L, Pediatric Emergency, and Research Canada (2022) Early analgesic administration and headache presence 7 days post-concussion in children. CJEM ,

Marbil Mica Gabrielle, Ware Ashley L, Galarneau Jean Michel, Minich Nori Mercuri, Hershey Andrew D, Orr Serena L, Defta Dana M, Taylor H Gerry, Bigler Erin D, Cohen Daniel M, Mihalov Leslie K, Bacevice Ann, Bangert Barbara A, and Yeates Keith Owen (2023) Longitudinal trajectories of posttraumatic headache after pediatric mild traumatic brain injury. Cephalalgia : an international journal of headache 43(5), 3331024231161740

McCarthy Lily, Hannah Theodore C, Li Adam Y, Schupper Alexander J, Hrabarchuk Eugene, Kalagara Roshini, Ali Muhammad, Gometz Alex, Lovell Mark R, and Choudhri Tanvir F (2022) Effects of a history of headache and migraine treatment on baseline neurocognitive function in young athletes. The Journal of Headache and Pain 23(1), 62

McEvoy Haley, Borsook David, and Holmes Scott A (2020) Clinical features and sex differences in pediatric post-traumatic headache: A retrospective chart review at a Boston area concussion clinic. Cephalalgia 40(7), 701-711 DOI: 10.1177/0333102419896754

Mihalik Jason P, Register-Mihalik Johna, Kerr Zachary Y, Marshall Stephen W, McCrea Michael C, and Guskiewicz Kevin M (2013) Recovery of posttraumatic migraine characteristics in patients after mild traumatic brain injury. American Journal of Sports Medicine 41(7), 1490-1496 DOI: 10.1177/0363546513487982

Murray Thomas R, Ferderer Tanner, Gehred Alison, and Rose Sean C (2021) Treatment of Post-traumatic Headaches in Children: A Systematic Review. Seminars in Pediatric Neurology 40, 100935

Pasek Tracy Annz, Locasto Lisa W, Reichard Joseph, Fazio Sumrok, Vanessa C, Johnson Eric W, and Kontos Anthony P (2015) The headache electronic diary for children with concussion. Clinical Nurse Specialist 29(2), 80-88 DOI: 10.1097/NUR.0000000000000108

Patterson Gentile Carlyn, Shah Ryan, Irwin Samantha L, Greene Kaitlin, and Szperka Christina L (2021) Acute and chronic management of posttraumatic headache in children: A systematic review. Headache 61(10), 1475-1492

Seeger Trevor A, Orr Serena, Bodell Lisa, Lockyer Lisette, Rajapakse Thilinie, and Barlow Karen M (2015) Occipital nerve blocks for pediatric posttraumatic headache: A case series. Journal of Child Neurology 30(9), 1142-1146 DOI: 10.1177/0883073814553973

Shaw Lauren, Morozova Maria, and Abu-Arafeh Ishaq (2018) Chronic post-traumatic headache in children and adolescents: systematic review of prevalence and headache features. Pain management 8(1), 57-64 DOI: 10.2217/pmt-2017-0019

Sufrinko Alicia, McAllister-Deitrick Jamie, Elbin Rj, Collins Michael W, and Kontos Anthony P (2018) Family History of Migraine Associated with Posttraumatic Migraine Symptoms Following Sport-Related Concussion. Journal of Head Trauma Rehabilitation 33(1), 7-14 DOI: 10.1097/HTR.0000000000000315

Sussman Walter I, Mautner Ken, Mason R Amadeus, Bonecutter Kathryn, and Shealy Anna K (2017) Sphenopalatine ganglion block for management of refractory chronic posttraumatic headaches after a sport-related concussion. Clinical Journal of Sport Medicine 27(2), e6-e8 DOI: 10.1097/JSM.0000000000000325

Terry Douglas P, Reddi Preethi J, Cook Nathan E, Seifert Tad, Maxwell Bruce A, Zafonte Ross, Berkner Paul D, and Iverson Grant L (2019) Acute Effects of Concussion in Youth With Pre-existing Migraines. Clinical Journal of Sport Medicine Publish Ahead of Print(00),  DOI: 10.1097/jsm.0000000000000791

van Ierssel Jacqueline Josee, Tang Ken, Beauchamp Miriam, Bresee Natalie, Cortel-LeBlanc Achelle, Craig William, Doan Quynh, Gravel Jocelyn, Lyons Todd, Mannix Rebekah, Orr Serena, Zemek Roger, and Yeates Keith Owen (2023) Association of Posttraumatic Headache With Symptom Burden After Concussion in Children. JAMA network open 6(3), e231993

Yengo-Kahn Aaron M, Hibshman Natalie, Bonfield Christopher M, Torstenson Eric S, Gifford Katherine A, Belikau Daniil, Davis Lea K, Zuckerman Scott L, and Dennis Jessica K (2022) Association of Preinjury Medical Diagnoses With Pediatric Persistent Postconcussion Symptoms in Electronic Health Records. The Journal of head trauma rehabilitation 37(2), E80-E89

icon img Telemedicine and Virtual Concussion Care

Introduction:

Preliminary research has demonstrated that telemedicine can be used to provide timely access to safe and cost-effective medical care of carefully selected concussion patients living in underserved regions. Research from the teleneurology, telepsychiatry and teleneuropsychology literature suggests that patients with prolonged concussion symptoms including those with headaches, mental health disorders, and cognitive impairment may also benefit from accessing care via telemedicine. While the COVID-19 pandemic has propelled greater use of virtual care, healthcare professionals using virtual platforms to deliver concussion care should be aware of the limitations of these approaches in order to ensure they are practicing in accordance with regional guidelines and policies outlined by their respective professional regulatory bodies. The future use of telemedicine and virtual care to assist in delivering primary and interdisciplinary concussion care will continue to be refined by future research and experience.

Definitions:

Telemedicine: Telemedicine has been defined as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.” (WHO, 2010). Telemedicine can be delivered synchronously (e.g., in-person videoconferencing) or asynchronously (e.g., store and forward or EConsultation).

Virtual care: Virtual care has been defined as “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care” (Shaw et al, 2018).

The following clinical recommendations and preliminary algorithm have been developed to share evidence and expert opinion on how to guide the medical and interdisciplinary care of pediatric concussion patients using telemedicine and include suggestions to optimize a virtual medical assessment.

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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:  

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:  

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:   

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.”

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:  

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:  

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.” 

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:  

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:  

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.

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.

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:  

Tools and Resources
References

General guidelines and tools related to telemedicine and virtual care

Canadian Medical Association. Scaling up virtual care in Canada: CMA a key player in new national task force. February 2020. https://www.cma.ca/scaling-virtual-care-canada-cma-key-player-new-national-task-force

Canadian Medical Association. Virtual care guide for patients. June 2020. https://www.cma.ca/sites/default/files/pdf/Patient-Virtual-Care-Guide-E.pdf

Shaw J, Jamieson T, Agarwal P, et al. Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique. J Telemed Telecare 2017;0(0):1–8. 2 Federation of Medical Regulatory Authorities of Canada. FMRAC framework on telemedicine. Available: http://fmrac.ca/fmrac-framework-on-telemedicine/

TR-Telerehab Toolkit: https://kite-uhn.com/tools/tr-telerehab-toolkit

World Health Organization. Report on the second global survey on eHealth. 2010. https://www.who.int/goe/publications/goe_telemedicine_2010.pdf

Wechsler LR, Tsao JW, Levine SR, Swain-Eng RJ, Adams RJ, Demaerschalk BM, et al. Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology. 2013;80(7):670-6.

 

Articles related to medical assessment and management

Ellis MJ, Boles S, Derksen V, Dawyduk B, Amadu A, Stelmack K, et al. Evaluation of a pilot paediatric concussion telemedicine programme for northern communities in Manitoba. International Journal of Circumpolar Health. 2019;78(1):1573163.

Ellis MJ, Russell K. The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada. Frontiers in Neurology. 2019;10:840.

Ellis M, Mendez, Russell K. (2020). Preliminary clinical algorithm to optimize delivery of remote pediatric concussion care in Canada’s North. International Journal of Circumpolar Health (published online October 22, 2020) https://doi.org/10.1080/22423982.2020.1832390

Vargas BB, Channer DD, Dodick DW, Demaerschalk BM. Teleconcussion: an innovative approach to screening, diagnosis, and management of mild traumatic brain injury. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2012;18(10):803-6.

Blue R et al.: Telemedicine in the era of coronavirus disease 2019 (COVID-10): a neurosurgical perspective. World Neurosurg 2020; 139; 549-557

Vargas BB, Shepard M, Hentz JG, Kutyreff C, Hershey LG, Starling AJ. Feasibility and accuracy of teleconcussion for acute evaluation of suspected concussion. Neurology. 2017;88(16):1580-3.

Wechsler LR. Advantages and limitations of teleneurology. JAMA neurology. 2015;72(3):349-54.

Wechsler LR, Tsao JW, Levine SR, Swain-Eng RJ, Adams RJ, Demaerschalk BM, et al. Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology. 2013;80(7):670-6.

Vierhile A, Tuttle J, Adams H, tenHoopen C, Baylor E. Feasibility of Providing Pediatric Neurology Telemedicine Care to Youth with Headache. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners. 2018;32(5):500-6.

 

Articles related to telepsychiatry

Hubley S, Lynch SB, Schneck C, Thomas M, Shore J. Review of key telepsychiatry outcomes. World journal of psychiatry. 2016;6(2):269-82.

Nelson EL, Cain S, Sharp S. Considerations for Conducting Telemental Health with Children and Adolescents. Child and adolescent psychiatric clinics of North America. 2017;26(1):77-91.

Roth DE, Ramtekkar U, Zekovic-Roth S. Telepsychiatry: A New Treatment Venue for Pediatric Depression. Child and adolescent psychiatric clinics of North America. 2019;28(3):377-95.

 

Articles related to general tele-neuropsychology practice

Bilder RM et al. (2020). Inter organizational practice committee recommendations/guidance for teleneurology in response to the COVID-19 pandemic. Arch Clin Neuropsychol. 34;1314-1334.

Cullum M. Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment. J Int Neuropsychol Soc. 2014: 20; 1028-33

Brearly TW et al. Neuropsychological test administration by videoconference: a systematic review and meta-analysis. Neuropsychol Rev. 2017: 27; 174-186.

Grosch MC et al. Initial practice recommendations for teleneuropsychology. Clin Neuropsychol. 2011: 25; 1119-1133.

 

Articles related to general telerehabilitation

Tenforde AS, Hefner JE, Kodish-Wachs JE, Iaccarino MA, Paganoni S. Telehealth in Physical Medicine and Rehabilitation: A Narrative Review. PM & R : the journal of injury, function, and rehabilitation. 2017;9(5S):S51-S8.

 

 

icon img Mental Health and Psychosocial Factors

Introduction:

There is evidence that 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. Having a mental health disorder prior to concussion is a critical risk factor for a post-concussion mental health disorder.

Early identification of family problems or parental mental health disorders permits healthcare professionals to watch for environmental factors that are known to influence recovery from a  concussion and identify any associated negative outcomes.

It is important to:

  • Assess if there is an association between concussion symptoms and restrictions to activity that may be related to the child/adolescent’s mental health.
  • Treat and manage the mental health disorder itself and prevent it from becoming a long-term problem.
  • Encourage the child/adolescent to remain connected and engage with their peers, friends, and teammates.

Tool 8.1: Post-Concussion Mental Health Considerations Algorithm.

Tool 8.2: Management of Prolonged Mental Health Disorders Algorithm.

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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):

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:

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. 

Tools and Resources
Living Guideline Tools:
Assessment screening tools to consider (website links):
References

Research papers that support the present guideline recommendations:

Babikian, T., McArthur, D., & Asarnow, R. F. (2013). Predictors of 1-month and 1-year neurocognitive functioning from the UCLA longitudinal mild, uncomplicated, pediatric traumatic brain injury study. Journal of the International Neuropsychological Society, 19(2), 145–154. https://doi.org/10.1017/S135561771200104X

Bellerose, J., Bernier, A., Beaudoin, C., Gravel, J., & Beauchamp, M. H. (2017). Long-term brain-injury-specific effects following preschool mild TBI: A study of theory of mind. Neuropsychology, 31(3), 229–241. https://doi.org/10.1037/neu0000341

Bernard, C. O., Ponsford, J. A., McKinlay, A., McKenzie, D., & Krieser, D. (2016). Predictors of post-concussive symptoms in young children: Injury versus non-injury related factors. Journal of the International Neuropsychological Society, 22(8), 793–803. https://doi.org/10.1017/S1355617716000709

Biederman, J., Feinberg, L., Chan, J., Adeyemo, B. O., Woodworth, K. Y., Panis, W., … Faraone, S. V. (2015). Mild traumatic brain injury and attention-deficit hyperactivity disorder in young student athletes. Journal of Nervous and Mental Disease, 203(11), 813–819. https://doi.org/10.1097/NMD.0000000000000375

Bonfield, C. M., Lam, S., Lin, Y., & Greene, S. (2013). The impact of attention deficit hyperactivity disorder on recovery from mild traumatic brain injury. Journal of Neurosurgery: Pediatrics, 12(2), 97–102. https://doi.org/10.3171/2013.5.PEDS12424

Brooks, B. L., Plourde, V., Beauchamp, M. H., Tang, K., Yeates, K. O., Keightley, M., … Zemek, R. (2019). Predicting Psychological Distress after Pediatric Concussion. Journal of Neurotrauma, 36(5), 679–685. https://doi.org/10.1089/neu.2018.5792

Chasle, V., Riffaud, L., Longuet, R., Martineau-Curt, M., Collet, Y., Le Fournier, L., & Pladys, P. (2016). Mild head injury and attention deficit hyperactivity disorder in children. Child’s Nervous System, 32(12), 2357–2361. https://doi.org/10.1007/s00381-016-3230-z

Chrisman, S. P. D., & Richardson, L. P. (2014). Prevalence of diagnosed depression in adolescents with history of concussion. Journal of Adolescent Health, 54(5), 582–586. https://doi.org/10.1016/j.jadohealth.2013.10.006

Connolly, E. J., & McCormick, B. F. (2019). Mild Traumatic Brain Injury and Psychopathology in Adolescence: Evidence From the Project on Human Development in Chicago Neighborhoods. Journal of Adolescent Health, 65(1), 79–85. https://doi.org/10.1016/j.jadohealth.2018.12.023

Cook, N. E., Kelshaw, P. M., Caswell, S. V., & Iverson, G. L. (2019). Children with Attention-Deficit/Hyperactivity Disorder Perform Differently on Pediatric Concussion Assessment. Journal of Pediatrics, 214, 168-174.e1. https://doi.org/10.1016/j.jpeds.2019.07.048

Corwin, D. J., Zonfrillo, M. R., Master, C. L., Arbogast, K. B., Grady, M. F., Robinson, R. L., … Wiebe, D. J. (2014). Characteristics of Prolonged Concussion Recovery in a Pediatric Subspecialty Referral Population. The Journal of Pediatrics, 165(6), 1207–1215. https://doi.org/10.1016/j.jpeds.2014.08.034

Donders, J., & DeWit, C. (2017). Parental ratings of daily behavior and child cognitive test performance after pediatric mild traumatic brain injury. Child Neuropsychology, 23(5), 554–570. https://doi.org/10.1080/09297049.2016.1161015

Eisenberg, M. A., Meehan, W. P., & Mannix, R. (2014). Duration and Course of Post-Concussive Symptoms. Pediatrics, 133(6), 999–1006. https://doi.org/10.1542/peds.2014-0158

Elbin, R. J., Kontos, A. P., Kegel, N., Johnson, E., Burkhart, S., & Schatz, P. (2013). Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: Evidence for separate norms. Archives of Clinical Neuropsychology, 28(5), 476–484. https://doi.org/10.1093/arclin/act024

Ellis, M. J., Ritchie, L. J., Koltek, M., Hosain, S., Cordingley, D., Chu, S., … Russell, K. (2015). Psychiatric outcomes after pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics, 16(6), 709–718. https://doi.org/10.3171/2015.5.PEDS15220

Gardner, R. M., Yengo-Kahn, A., Bonfield, C. M., & Solomon, G. S. (2017). Comparison of baseline and post-concussion ImPACT test scores in young athletes with stimulant-treated and untreated ADHD. Physician and Sportsmedicine, 45(1), 1–10. https://doi.org/10.1080/00913847.2017.1248221

Gornall, A., Takagi, M., Clarke, C., Babl, F. E., Davis, G. A., Dunne, K., … Anderson, V. (2019). Behavioral and Emotional Difficulties after Pediatric Concussion. Journal of Neurotrauma, 1–26. https://doi.org/10.1089/neu.2018.6235

Guerriero, R. M., Kuemmerle, K., Pepin, M. J., Taylor, A. M., Wolff, R., & Meehan, W. P. (2018). The Association Between Premorbid Conditions in School-Aged Children With Prolonged Concussion Recovery. Journal of Child Neurology, 33(2), 168–173. https://doi.org/10.1177/0883073817749655

Guo, X., Edmed, S. L., & Anderson, V. (2017). Neurocognitive predictors of posttraumatic stress disorder symptoms in children 6 months after traumatic brain injury: A prospective study. Neuropsychology, 31(1), 84–92. https://doi.org/http://dx.doi.org/10.1037/neu0000305

Hunt, A. W., Paniccia, M., Reed, N., & Keightley, M. (2016). Concussion-Like Symptoms in Child and Youth Athletes at Baseline: What Is “Typical”? Journal of Athletic Training, 51(10), 749–757. https://doi.org/10.4085/1062-6050-51.11.12

Jimenez, N., Quistberg, A., Vavilala, M. S., Jaffe, K. M., & Rivara, F. P. (2017). Utilization of Mental Health Services After Mild Pediatric Traumatic Brain Injury. Pediatrics, 139(3), e20162462. https://doi.org/10.1542/peds.2016-2462

Jones, K. M., Prah, P., Starkey, N., Theadom, A., Barker-Collo, S., Ameratunga, S., … Brown, P. (2019). Longitudinal patterns of behavior, cognition, and quality of life after mild traumatic brain injury in children: BIONIC study findings. Brain Injury, 33(7), 884–893. https://doi.org/10.1080/02699052.2019.1606445

Kaldoja, M.-L., & Kolk, A. (2015). Does Gender Matter? Differences in Social-Emotional Behavior Among Infants and Toddlers Before and After Mild Traumatic Brain Injury. Journal of Child Neurology, 30(7), 860–867. https://doi.org/10.1177/0883073814544705

Kirkwood, M. W., Peterson, R. L., Connery, A. K., Baker, D. A., & Forster, J. (2016). A Pilot Study Investigating Neuropsychological Consultation as an Intervention for Persistent Postconcussive Symptoms in a Pediatric Sample. Journal of Pediatrics, 169, 244–249e1. https://doi.org/10.1016/j.jpeds.2015.10.014

Liou, Y. J., Wei, H. T., Chen, M. H., Hsu, J. W., Huang, K. L., Bai, Y. M., … Chen, T. J. (2018). Risk of Traumatic Brain Injury Among Children, Adolescents, and Young Adults With Attention-Deficit Hyperactivity Disorder in Taiwan. Journal of Adolescent Health, 63(2), 233–238. https://doi.org/10.1016/j.jadohealth.2018.02.012

Mac Donald, C. L., Barber, J., Wright, J., Coppel, D., De Lacy, N., Ottinger, S., … Temkin, N. (2019). Longitudinal Clinical and Neuroimaging Evaluation of Symptomatic Concussion in 10-to 14-year-old Youth Athletes. Journal of Neurotrauma, 36(2), 264–274. https://doi.org/10.1089/neu.2018.5629

Max, J. E., Friedman, K., Wilde, E. A., Bigler, E. D., Hanten, G., Schachar, R. J., … Levin, H. S. (2015). Psychiatric disorders in children and adolescents 24 months after mild traumatic brain injury. Journal of Neuropsychiatry & Clinical Neurosciences, 27(2), 112–120. https://doi.org/http://dx.doi.org/10.1176/appi.neuropsych.13080190

Max, J. E., Pardo, D., Hanten, G., Schachar, R. J., Saunders, A. E., Ewing-Cobbs, L., … Levin, H. S. (2013). Psychiatric disorders in children and adolescents six-to-twelve months after mild traumatic brain injury. Journal of Neuropsychiatry and Clinical Neurosciences, 25(4), 272–282. https://doi.org/http://dx.doi.org/10.1176/appi.neuropsych.12040078

McNally, K. A., Patrick, K. E., LaFleur, J. E., Dykstra, J. B., Monahan, K., & Hoskinson, K. R. (2018). Brief cognitive behavioral intervention for children and adolescents with persistent post-concussive symptoms: A pilot study. Child Neuropsychology, 24(3), 396–412. https://doi.org/10.1080/09297049.2017.1280143

Morgan, C. D., Zuckerman, S. L., Lee, Y. M., King, L., Beaird, S., Sills, A. K., & Solomon, G. S. (2015). Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. Journal of Neurosurgery: Pediatrics, 15(June), 589–598. https://doi.org/10.3171/2014.10.PEDS14356

Mrazik, M., Brooks, B. L., Jubinville, A., Meeuwisse, W. H., & Emery, C. A. (2016). Psychosocial outcomes of sport concussions in youth hockey players. Archives of Clinical Neuropsychology, 31(4), 297–304. https://doi.org/10.1093/arclin/acw013

Nikles, C. J., McKinlay, L., Mitchell, G. K., Carmont, S. A. S., Senior, H. E., Waugh, M. C. A., … Lloyd, O. T. (2014). Aggregated n-of-1 trials of central nervous system stimulants versus placebo for paediatric traumatic brain injury – a pilot study. Trials, 15(1), 1–11. https://doi.org/10.1186/1745-6215-15-54

Peterson, R. L., Connery, A. K., Baker, D. A., & Kirkwood, M. W. (2015). Preinjury Emotional-Behavioral Functioning of Children With Lingering Problems After Mild Traumatic Brain Injury. The Journal of Neuropsychiatry and Clinical Neurosciences, 27(4), 280–286. https://doi.org/10.1176/appi.neuropsych.14120373

Plourde, V., Daya, H., Low, T. A., Barlow, K. M., & Brooks, B. L. (2019). Evaluating anxiety and depression symptoms in children and adolescents with prior mild traumatic brain injury: Agreement between methods and respondents. Child Neuropsychology, 25(1), 44–59. https://doi.org/10.1080/09297049.2018.1432585

Plourde, V., Yeates, K. O., & Brooks, B. L. (2018). Predictors of long-term psychosocial functioning and health-related quality of life in children and adolescents with prior concussions. Journal of the International Neuropsychological Society, 24(6), 540–548. https://doi.org/10.1017/S1355617718000061

Poysophon, P., & Rao, A. L. (2018). Neurocognitive Deficits Associated With ADHD in Athletes: A Systematic Review. Sports Health, 10(4), 317–326. https://doi.org/10.1177/1941738117751387

Reddy, C. C., Collins, M., Lovell, M., & Kontos, A. P. (2013). Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. Journal of Head Trauma Rehabilitation, 28(4), 260–265. https://doi.org/10.1097/HTR.0b013e318257fbc6

Rieger, B. P., Lewandowski, L. J., Callahan, J. M., Spenceley, L., Truckenmiller, A., Gathje, R., & Miller, L. A. (2013). A prospective study of symptoms and neurocognitive outcomes in youth with concussion vs orthopaedic injuries. Brain Injury, 27(2), 169–178. https://doi.org/10.3109/02699052.2012.729290

Root, J. M., Zuckerbraun, N. S., Wang, L., Winger, D. G., Brent, D., Kontos, A., & Hickey, R. W. (2016). History of Somatization Is Associated with Prolonged Recovery from Concussion. Journal of Pediatrics, 174, 39–44.e1. https://doi.org/10.1016/j.jpeds.2016.03.020

Ryan, N. P., van Bijnen, L., Catroppa, C., Beauchamp, M. H., Crossley, L., Hearps, S., & Anderson, V. (2016). Longitudinal outcome and recovery of social problems after pediatric traumatic brain injury (TBI): Contribution of brain insult and family environment. International Journal of Developmental Neuroscience, 49, 23–30. https://doi.org/10.1016/j.ijdevneu.2015.12.004

Salinas, C. M., Dean, P., LoGalbo, A., Dougherty, M., Field, M., & Webbe, F. M. (2016). Attention-Deficit Hyperactivity Disorder Status and Baseline Neurocognitive Performance in High School Athletes. Applied Neuropsychology: Child, 5(4), 264–272. https://doi.org/10.1080/21622965.2015.1052814

Segev, S., Shorer, M., Rassovsky, Y., Peleg, T. P., Apter, A., & Fennig, S. (2016). The contribution of posttraumatic stress disorder and mild traumatic brain injury to persistent post concussive symptoms following motor vehicle accidents. Neuropsychology, 30(7), 800–810. https://doi.org/10.1037/neu0000299

Stazyk, K., DeMatteo, C., Moll, S., & Missiuna, C. (2017). Depression in youth recovering from concussion: Correlates and predictors. Brain Injury, 31(5), 631–638. https://doi.org/10.1080/02699052.2017.1283533

Stein, E., Howard, W., Rowhani-Rahbar, A., Rivara, F. P., Zatzick, D., & McCarty, C. A. (2017). Longitudinal trajectories of post-concussive and depressive symptoms in adolescents with prolonged recovery from concussion. Brain Injury, 31(13–14), 1736–1744. https://doi.org/10.1080/02699052.2017.1380843

Truss, K., Godfrey, C., Takagi, M., Babl, F. E., Bressan, S., Hearps, S., … Anderson, V. (2017). Trajectories and Risk Factors for Post-Traumatic Stress Symptoms following Pediatric Concussion. Journal of Neurotrauma, 34(14), 2272–2279. https://doi.org/10.1089/neu.2016.4842

Yang, M. N., Clements-Nolle, K., Parrish, B., & Yang, W. (2019). Adolescent concussion and mental health outcomes: A population-based study. American Journal of Health Behavior, 43(2), 258–265. https://doi.org/10.5993/AJHB.43.2.3

Yengo-Kahn, A. M., & Solomon, G. (2015). Are psychotropic medications associated with differences in baseline neurocognitive assessment scores for young athletes? A pilot study. Physician and Sportsmedicine, 43(3), 227–235. https://doi.org/10.1080/00913847.2015.1071638

Last update: November 16, 2019

icon img Sleep

Introduction:

Sleep disturbances may occur following a concussion. Symptoms vary between different children/adolescents and within an individual child/adolescent. Examples include having difficulties falling asleep/staying asleep or excessive daytime sleeping. Medication use, headaches and mental health conditions (e.g. anxiety, depression) may also affect sleep. Poor sleep may be related to cognitive complaints and worse post-concussion symptoms. A repeat medical exam to rule out a more severe injury is required for children/adolescents who are experiencing sleep disturbances that last more than 1-2 weeks following a concussion. The presence of sleep disturbances following concussion is a risk factor for a prolonged recovery from concussion. Early identification allows for early targeted supportive care, close monitoring for prolonged symptoms, and consideration for early referral.

Information related to sleep hygiene and non-pharmacological strategies to improve sleep should be shared with families. Children/adolescents with prolonged sleep disturbances should be encouraged to engage in low-risk physical activity and resume sub-symptom cognitive activities. Children/adolescents who are experiencing sleep disturbances more than 4 weeks following a concussion should be referred to a cognitive behavioural therapist or an interdisciplinary concussion team. If sleep disturbances are present for more than 6 weeks following a concussion the child/adolescent may require more specialized care from a sleep specialist.

Tool 7.1: Managing post-concussion sleep disturbances algorithm.

Tool 7.2: Factors that may influence the child/adolescent’s sleep/wake cycle.

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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.

7.2

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

Level of Evidence:  

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.

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:  

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.

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

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.

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. 

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.

Tools and Resources
References

Research papers that support the present guideline recommendations:

Beebe, D. W., Powers, S. W., Slattery, E. W., & Gubanich, P. J. (2017). Short Sleep and Adolescentsʼ Performance on a Concussion Assessment Battery: An Experimental Sleep Manipulation Study. Clinical Journal of Sport Medicine, 0(0), 1. https://doi.org/10.1097/JSM.0000000000000454

Blake, M., Schwartz, O., Waloszek, J.M., Raniti, M., Simmons, J.G., … Allen, N.B. (2017). The SENSE Study: Treatment Mechanisms of a Cognitive Behavioral and Mindfulness-Based Group Sleep Improvement Intervention for At-Risk Adolescents. Sleep. 40(6). https://doi.org/10.1093/sleep/zsx061

Botchway, E. N., Godfrey, C., Anderson, V., & Catroppa, C. (2019). A Systematic Review of Sleep-Wake Disturbances in Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life. The Journal of Head Trauma Rehabilitation, 34(4), 241–256. https://doi.org/10.1097/HTR.0000000000000446

Bramley, H., Henson, A., Lewis, M. M., Kong, L., Stetter, C., & Silvis, M. (2017). Sleep Disturbance Following Concussion Is a Risk Factor for a Prolonged Recovery. Clinical Pediatrics, 56(14), 1280–1285. https://doi.org/10.1177/0009922816681603

Brooks, B. L., Sayers, P. Q., Virani, S., Rajaram, A. A., & Tomfohr-Madsen, L. (2019). Insomnia in adolescents with slow recovery from concussion. Journal of Neurotrauma, 36(16), 2391–2399. https://doi.org/10.1089/neu.2018.6257

Crichton, A., Oakley, E., Babl, F. E., Greenham, M., Hearps, S., Delzoppo, C., … Anderson, V. (2018). Predicting Fatigue 12 Months after Child Traumatic Brain Injury: Child Factors and Postinjury Symptoms. Journal of the International Neuropsychological Society, 24(3), 224–236. https://doi.org/10.1017/S1355617717000893

de Bruin, E.J., Bögels, S.M., Oort, F.J., Meijer, A.M. (2015). Efficacy of Cognitive Behavioral Therapy for Insomnia in Adolescents: A Randomized Controlled Trial with Internet Therapy, Group Therapy and A Waiting List Condition. Sleep. 38(12),1913-1926. https://doi.org/10.5665/sleep.5240

Gradisar, M., Dohn, H., Gardner, G., Paine, S., Starkey, K … Trenowden, S. (2011). A Randomized Controlled Trial of Cognitive-Behavior Therapy Plus Bright Light Therapy for Adolescent Delayed Sleep Phase Disorder. Sleep. 34(12),1671-1680. https://doi.org/10.5665/sleep.1432

Howell, D. R., Oldham, J. R., Brilliant, A. N., & Meehan, W. P. (2019). Trouble Falling Asleep After Concussion Is Associated With Higher Symptom Burden Among Children and Adolescents. Journal of Child Neurology, 34(5), 256–261. https://doi.org/10.1177/0883073818824000

Kostyun, R. O., Milewski, M. D., & Hafeez, I. (2015). Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents. American Journal of Sports Medicine, 43(3), 633–640. https://doi.org/10.1177/0363546514560727

Landry-Roy, C., Bernier, A., Gravel, J., & Beauchamp, M. H. (2018). Executive Functions and Their Relation to Sleep Following Mild Traumatic Brain Injury in Preschoolers. Journal of the International Neuropsychological Society, 24(8), 769–780. https://doi.org/10.1017/S1355617718000401

Lin, K., & Tung, C. (2016). Acupuncture for Recovery from Pediatric Sport-Related Concussion. Medical Acupuncture, 28(4), 217–222. https://doi.org/10.1089/acu.2016.1181

Meng, X., Li, Y., Li, S., Zhou, Y., Gan, R. Y., Xu, D. P., & Li, H. B. (2017). Dietary Sources and Bioactivities of Melatonin. Nutrients, 9(4), 367. https://doi.org/10.3390/nu9040367

Murdaugh, D. L., Ono, K. E., Reisner, A., & Burns, T. G. (2018). Assessment of Sleep Quantity and Sleep Disturbances During Recovery From Sports-Related Concussion in Youth Athletes. Archives of Physical Medicine and Rehabilitation, 99(5), 960–966. https://doi.org/10.1016/j.apmr.2018.01.005

Schmidt, A. T., Li, X., Hanten, G. R., McCauley, S. R., Faber, J., & Levin, H. S. (2015). A longitudinal investigation of sleep quality in adolescents and young adults after mild traumatic brain injury. Cognitive and Behavioral Neurology, 28(2), 53–62. https://doi.org/10.1097/WNN.0000000000000056

Sunnybrook Health Science Centre. Sleep Issues After Concussion. https://sunnybrook.ca/content/?page=bsp-concussion-sleep-tips

Tham, S. W., Fales, J., & Palermo, T. M. (2015). Subjective and Objective Assessment of Sleep in Adolescents with Mild Traumatic Brain Injury. Journal of Neurotrauma, 32(11), 847–852. https://doi.org/10.1089/neu.2014.3559

Theadom, A., Starkey, N., Jones, K., Cropley, M., Parmar, P., Barker-Collo, S., & Feigin, V. L. (2016). Sleep difficulties and their impact on recovery following mild traumatic brain injury in children. Brain Injury, 30(10), 1243–1248. https://doi.org/10.1080/02699052.2016.1183171

Wiseman-Hakes, C., Gosselin, N., Sharma, B., Langer, L., & Gagnon, I. (2019). A Longitudinal Investigation of Sleep and Daytime Wakefulness in Children and Youth With Concussion. ASN Neuro, 11. https://doi.org/10.1177/1759091418822405

 

Research papers not associated with a current recommendation:

van Markus-Doornbosch, F., Peeters, E., van der Pas, S., Vlieland, T. V., & Meesters, J. (2019). Physical activity after mild traumatic brain injury: What are the relationships with fatigue and sleep quality? European Journal of Paediatric Neurology, 23(1), 53–60. https://doi.org/10.1016/j.ejpn.2018.11.002

Last update: November 16, 2019

icon img Vision, Vestibular and Oculomotor Function

Introduction:

Patients with acute head and neck trauma can present with symptoms such as dizziness, blurred or double vision, vertigo, postural imbalance, difficulty focusing, motion sensitivity, and/or headaches during reading. These symptoms may be suggestive of dysfunction within the neurological systems responsible for visual, vestibular, and oculomotor functioning, including balance, and gait. Identification of these deficits can aid in the provision of academic and activity-related accommodations during the acute stage after injury. Most acute concussion patients with these clinical features will experience symptom resolution and return to daily activities within 4 weeks following the acute injury and these patients will only need supportive care and anticipatory guidance. By conducting early screening for impairments in visual, vestibular, and oculomotor functioning as well as balance and gait, appropriate referrals to an interdisciplinary concussion team and sub-specialists can be initiated to provide evidence-based targeted interventions.

A repeat medical assessment on concussion patients with prolonged dizziness, blurred or double vision, vertigo, difficulty reading, postural imbalance, or headaches elicited by prolonged visual or vestibular stimulation is required 1-2 weeks following the acute injury. Although the cause of these prolonged symptoms can be multi-factorial, the assessment often reveals impairments in vestibular functioning, balance, or vision. The repeat medical assessment should include a focused clinical history, focused physical examination, and a consideration for the use of additional diagnostic tests as indicated (i.e., screening vestibular oculomotor assessment, visual field testing, and neuroimaging). The medical assessment must consider conditions such as intraparenchymal hemorrhage, stroke, traumatic cranial neuropathy, or temporal bone fractures.

Tool 10.1: Post-Concussion Vestibular (balance/dizziness) and Vision Disturbances Algorithm.

Oculomotor or Vision Deficits

Visual and oculomotor deficits can be due to cranial neuropathies, structural brain injuries, or functional impairments in convergence, accommodation, smooth pursuits, saccades, and vestibulo-ocular reflex functioning. Visual deficits are common symptoms following a concussion. In some patients, these deficits will spontaneously recover and will only need monitoring, supportive care, and anticipatory guidance.  However, there is evidence that these deficits may also be associated with increased risk for prolonged symptoms. Identifying these deficits early will allow for early targeted supportive care, management, close monitoring for prolonged, and early referral for further treatment.

Benign Paroxysmal Positional Vertigo 

Benign paroxysmal positional vertigo (BPPV) can be caused by the traumatic displacement of the crystals (otoconia) of the inner ear into one of the semi-circular canals. This displacement results in intermittent brief episodes of vertigo and a characteristic pattern of nystagmus (involuntary eye movement) with head movements that stimulate fluid flow in the affected canal (e.g., laying down, sitting up, rolling in bed, looking up, bending over, rapid horizontal head movements). If the patient reports vertigo or dizziness that occurs for seconds following position changes, a screen for BPPV and consideration for targeted particle re-positioning manoeuvres should be conducted. In patients who continue to experience prolonged vertigo or dizziness after completing 3 particle repositioning maneouvers, consideration should be given to a referral to an interdisciplinary concussion team or sub-specialist (i.e., otolaryngology) for further assessment and management.

Vestibulo-Ocular Deficits

The vestibulo-ocular reflex (VOR) enables clear vision with head motion. In many cases, difficulties with clear vision during head motion are reported following a concussion and there is emerging evidence that alterations in VOR function may predict a longer recovery following concussion. Dizziness and/or blurred vision with head motion may be reported and should be further investigated by a healthcare professional with experience in this area. Vestibular rehabilitation has been reported to facilitate recovery when a child/adolescent is experiencing altered gain of the VOR.

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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.

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:

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:

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:

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:

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.

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:

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.

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.

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:  

Tools and Resources
Online videos to consider:
References

Click here to access the Living Guideline Evidence Map (powered by EPPIreviewer and EPPIvisualizer)

Reference List: Last updated Sept 2023, update in progress (April 2024).

ALBERTS JAY L, THOTA ANIL, HIRSCH JOSHUA, OZINGA SARAH, DEY TANUJIT, SCHINDLER DAVID D, KOOP MANDY M, BURKE DANIEL, and LINDER SUSAN M (2015) Quantification of the Balance Error Scoring System with Mobile Technology. Medicine & Science in Sports & Exercise 47(10), 2233-2240 DOI: 10.1249/MSS.0000000000000656

Albrecht Ted J, Makwana Mehmel Bindal, Rossi Ethan A, Trbovich Alicia M, Eagle Shawn R, and Kontos Anthony P (2024) Temporal Changes in Fixational Eye Movements After Concussion in Adolescents and Adults: Preliminary Findings. Journal of Neurotrauma 41(1-2), 199-208

Alexander Amy, Hattrup Nicholas, Gerkin Richard, and Pardini Jamie E (2022) Gaze stability in youth athletes: A normative observational study. Journal of vestibular research : equilibrium & orientation 32(6), 511-515

Alkathiry Abdulaziz A, Kontos Anthony P, Furman Joseph M, Whitney Susan L, Anson Eric R, and Sparto Patrick J (2019) Vestibulo-Ocular Reflex Function in Adolescents With Sport-Related Concussion: Preliminary Results. Sports Health 11(6), 479-485 DOI: 10.1177/1941738119865262

Alkathiry Abdulaziz A, Alsubaie Saud F, Alsalaheen Bara A, and Whitney Susan L (2022) Validation of the Gait Disorientation Test in children with concussion. Frontiers in Pediatrics 10, 927708

Alsalaheen Bara A, Haines Jamie, Yorke Amy, Stockdale Kayla, and Broglio Steven P (2015) Reliability and concurrent validity of instrumented balance error scoring system using a portable force plate system. Physician and Sportsmedicine 43(3), 221-226 DOI: 10.1080/00913847.2015.1040717

Alsalaheen Bara, McClafferty Adam, Haines Jamie, Smith Laura, and Yorke Amy (2016) Reference values for the balance error scoring system in adolescents. Brain Injury 30(7), 914-918 DOI: 10.3109/02699052.2016.1146965

Alsalaheen Bara A, Whitney Susan L, Marchetti Gregory F, Furman Joseph M, Kontos Anthony P, Collins Michael W, and Sparto Patrick J (2016) Relationship between cognitive assessment and balance measures in adolescents referred for vestibular physical therapy after concussion. Clinical Journal of Sport Medicine 26(1), 46-52 DOI: 10.1097/JSM.0000000000000185

Alsalaheen Bara, Carender Wendy, Grzesiak Melissa, Munday Cindy, Almeida Andrea, Lorincz Matthew, and Marchetti Gregory F (2020) Changes in Vestibular/Ocular-Motor Screen Scores in Adolescents Treated With Vestibular Therapy After Concussion. Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association 32(4), 331-337

Anderson Stevi L, Gatens Dustin, Glatts Colette, and Russo Stephen A (2019) Normative Data Set of SWAY Balance Mobile Assessment in Pediatric Athletes. Clinical Journal of Sport Medicine 29(5), 413-420 DOI: 10.1097/JSM.0000000000000545

Anzalone Anthony J, Blueitt Damond, Case Tami, McGuffin Tiffany, Pollard Kalyssa, Garrison J Craig, Jones Margaret T, Pavur Robert, Turner Stephanie, and Oliver Jonathan M (2017) A Positive Vestibular/Ocular Motor Screening (VOMS) Is Associated with Increased Recovery Time after Sports-Related Concussion in Youth and Adolescent Athletes. American Journal of Sports Medicine 45(2), 474-479 DOI: 10.1177/0363546516668624

Arbogast Kristy B, Ghosh Riddhi P, Corwin Daniel J, McDonald Catherine C, Mohammed Fairuz N, Margulies Susan S, Barnett Ian, and Master Christina L (2022) Trajectories of Visual and Vestibular Markers of Youth Concussion. Journal of Neurotrauma 39(19-20), 1382-1390

Babicz Michelle A, Woods Steven Paul, Cirino Paul, Presley Chase, Colton Zachary, and Podell Kenneth (2022) Vestibular/Ocular Motor Screening is Independently Associated With Concussion Symptom Severity in Youths. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 32(1), 40-45

Barnes Alice, Smulligan Katherine, Wingerson Mathew J, Little Casey, Lugade Vipul, Wilson Julie C, and Howell David R (2024) A Multifaceted Approach to Interpreting Reaction Time Deficits After Adolescent Concussion. Journal of Athletic Training 59(2), 145-152

Białuńska Anita, and Salvatore Anthony P (2017) The auditory comprehension changes over time after sport-related concussion can indicate multisensory processing dysfunctions. Brain and Behavior 7(12), 1-8 DOI: 10.1002/brb3.874

Brett Benjamin L, Zuckerman Scott L, Terry Douglas P, Solomon Gary S, and Iverson Grant L (2018) Normative Data for the Sway Balance System. Clinical Journal of Sport Medicine (00), 1-1 DOI: 10.1097/jsm.0000000000000632

Chinn Ryan N, Marusic Sophia, Wang Alicia, Vyas Neerali, Staffa Steven J, Brodsky Jacob R, and Raghuram Aparna (2022) Vergence and Accommodation Deficits in Children and Adolescents with Vestibular Disorders. Optometry and vision science : official publication of the American Academy of Optometry 99(12), 859-867

Conder Robert L, Conder Alanna A, Register-Mihalik Johna, Conder Lauren H, and Newton Shannon (2015) Preliminary Normative Data on the Penn State University Symbol Cancellation Task With Nonconcussed Adolescents. Applied Neuropsychology: Child 4(3), 141-147 DOI: 10.1080/21622965.2013.816849

Corwin Daniel J, Wiebe Douglas J, Zonfrillo Mark R, Grady Matthew F, Robinson Roni L, Goodman Arlene M, and Master Christina L (2015) Vestibular Deficits following Youth Concussion. The Journal of Pediatrics 166(5), 1221-1225 DOI: 10.1016/j.jpeds.2015.01.039

Corwin Daniel J, Zonfrillo Mark R, Wiebe Douglas J, Master Christina L, Grady Matthew F, and Arbogast Kristy B (2018) Vestibular and oculomotor findings in neurologically-normal, non-concussed children. Brain Injury 32(6), 794-799 DOI: 10.1080/02699052.2018.1458150

Corwin Daniel J, Propert Kathleen J, Zorc Joseph J, Zonfrillo Mark R, and Wiebe Douglas J (2019) Use of the vestibular and oculomotor examination for concussion in a pediatric emergency department. American Journal of Emergency Medicine 37(7), 1219-1223 DOI: 10.1016/j.ajem.2018.09.008

Corwin Daniel J, McDonald Catherine C, Arbogast Kristy B, Mohammed Fairuz N, Metzger Kristina B, Pfeiffer Melissa R, Patton Declan A, Huber Colin M, Margulies Susan S, Grady Matthew F, and Master Christina L (2020) Clinical and Device-based Metrics of Gait and Balance in Diagnosing Youth Concussion. Medicine and science in sports and exercise 52(3), 542-548

Corwin Daniel J, Arbogast Kristy B, Swann Casey, Haber Rebecca, Grady Matthew F, and Master Christina L (2020) Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department. American Journal of Emergency Medicine 38(9), 1847-1853 DOI: 10.1016/j.ajem.2020.06.020

Corwin Daniel J, McDonald Catherine C, Arbogast Kristy B, Mohammed Fairuz N, Grady Matthew F, and Master Christina L (2021) Visio-Vestibular Deficits in Healthy Child and Adolescent Athletes. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine ,

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Crampton Adrienne, Schneider Kathryn J, Grilli Lisa, Chevignard Mathilde, Katz-Leurer Michal, Beauchamp Miriam H, Debert Chantel, and Gagnon Isabelle J (2022) Determining the Agreement Between Common Measures Related to Vestibulo-ocular Reflex Function After a Mild Traumatic Brain Injury in Children and Adolescents. Archives of rehabilitation research and clinical translation 4(3), 100217

Del Rossi Gianluca (2022) Examination of Near Point of Convergence Scores in High-School Athletes: Implications for Identifying Binocular Vision Dysfunction After Concussion Injury. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 32(5), e451-e456

Donner Julia R, Corwin Daniel J, Master Christina L, and Zonfrillo Mark R (2022) Documented Visio-Vestibular Examination and Anticipatory Guidance for Pediatric Concussion Patients. Pediatric Emergency Care ,

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Elbin R J, Eagle Shawn R, Marchetti Gregory F, Anderson Morgan, Schatz Philip, Womble Melissa N, Stephenson Katie, Covassin Tracey, Collins Michael W, Mucha Anne, and Kontos Anthony P (2021) Using change scores on the vestibular ocular motor screening (VOMS) tool to identify concussion in adolescents. Applied neuropsychology.Child , 1-7

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Hansen Colby, Cushman Dan, Chen Wei, Bounsanga Jerry, and Hung Man (2017) Reliability testing of the balance error scoring system in children between the ages of 5 and 14. Clinical Journal of Sport Medicine 27(1), 64-68 DOI: 10.1097/JSM.0000000000000293

Heyer Geoffrey L, Young Julie A, and Fischer Anastasia N (2017) Lightheadedness After Concussion: Not All Dizziness is Vertigo. Clinical Journal of Sport Medicine 0(0),  DOI: 10.1097/JSM.0000000000000445

Howell David R, Osternig Louis R, and Chou Li Shan (2013) Dual-task effect on gait balance control in adolescents with concussion. Archives of Physical Medicine and Rehabilitation 94(8), 1513-1520 DOI: http://dx.doi.org/10.1016/j.apmr.2013.04.015

Howell David R, Osternig Louis R, Koester Michael C, and Chou Li-Shan (2014) The effect of cognitive task complexity on gait stability in adolescents following concussion. Experimental Brain Research 232(6), 1773-1782 DOI: 10.1007/s00221-014-3869-1

Howell David R, Osternig Louis R, and Chou Li Shan (2015) Adolescents demonstrate greater gait balance control deficits after concussion than young adults. American Journal of Sports Medicine 43(3), 625-632 DOI: 10.1177/0363546514560994

Howell David R, Osternig Louis R, and Chou Li Shan (2015) Return to activity after concussion affects dual-task gait balance control recovery. Medicine and Science in Sports and Exercise 47(4), 673-680 DOI: 10.1249/MSS.0000000000000462

Howell David R, Osternig Louis R, and Chou Li Shan (2016) Consistency and cost of dual-task gait balance measure in healthy adolescents and young adults. Gait and Posture 49, 176-180 DOI: 10.1016/j.gaitpost.2016.07.008

Howell David R, Shore Benjamin J, Hanson Emily, and Meehan William P (2016) Evaluation of postural stability in youth athletes: the relationship between two rating systems. Physician and Sportsmedicine 44(3), 304-310 DOI: 10.1080/00913847.2016.1197763

Howell David R, Stracciolini Andrea, Geminiani Ellen, and Meehan William P (2017) Dual-task gait differences in female and male adolescents following sport-related concussion. Gait and Posture 54(November 2016), 284-289 DOI: 10.1016/j.gaitpost.2017.03.034

Howell David R, Brilliant Anna, Berkstresser Brant, Wang Francis, Fraser Joana, and Meehan William P (2017) The Association between Dual-Task Gait after Concussion and Prolonged Symptom Duration. Journal of Neurotrauma 34(23), 3288-3294 DOI: 10.1089/neu.2017.5191

Howell David R, OʼBrien Michael J, Raghuram Aparna, Shah Ankoor S, and Meehan William P (2017) Near Point of Convergence and Gait Deficits in Adolescents After Sport-Related Concussion. Clinical Journal of Sport Medicine 0(0),  DOI: 10.1097/JSM.0000000000000439

Howell David R, Hanson Emily, Sugimoto Dai, Stracciolini Andrea, and Meehan William P (2017) Assessment of the Postural Stability of Female and Male Athletes. Clinical Journal of Sport Medicine 27(5), 444-449 DOI: 10.1097/JSM.0000000000000374

Howell David R, Beasley Michael, Vopat Lisa, and Meehan William P (2017) The Effect of Prior Concussion History on Dual-Task Gait following a Concussion. Journal of Neurotrauma 34(4), 838-844 DOI: 10.1089/neu.2016.4609

Howell David R, Brilliant Anna N, Storey Eileen P, Podolak Olivia E, Meehan William P. 3rd, and Master Christina L (2018) Objective Eye Tracking Deficits Following Concussion for Youth Seen in a Sports Medicine Setting. Journal of Child Neurology 33(12), 794-800 DOI: 10.1177/0883073818789320

Howell David R, Lugade Vipul, Potter Morgan N, Walker Gregory, and Wilson Julie C (2019) A multifaceted and clinically viable paradigm to quantify postural control impairments among adolescents with concussion. Physiological Measurement 40(8),  DOI: 10.1088/1361-6579/ab3552

Howell David R, Myer Gregory D, Grooms Dustin, Diekfuss Jed, Yuan Weihong, and Meehan William P. 3rd (2019) Examining Motor Tasks of Differing Complexity After Concussion in Adolescents.. Archives of Physical Medicine and Rehabilitation 100(4), 613-619 DOI: 10.1016/j.apmr.2018.07.441

Howell David R, Bonnette Scott, Diekfuss Jed A, Grooms Dustin R, Myer Gregory D, and Meehan William P (2020) Youth With Concussion Have Less Adaptable Gait Patterns Than Their Uninjured Peers: Implications for Concussion Management. The Journal of orthopaedic and sports physical therapy 50(8), 438-446

Hsu Jerry, Stec Magdalena, Ranaivo Hantamalala Ralay, Srdanovic Nina, and Kurup Sudhi P (2020) Concussion Alters Dynamic Pupillary Light Responses in Children. Journal of Child Neurology , 883073820964040

Hugentobler Jason A, Gupta Resmi, Slater Robert, Paterno Mark V, Riley Michael A, and Quatman-Yates Catherine (2016) Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment. Clinical Journal of Sport Medicine 26(6), 510-517 DOI: 10.1097/JSM.0000000000000286

Hunfalvay Melissa, Murray Nicholas P, Roberts Claire Marie, Tyagi Ankur, Barclay Kyle William, and Carrick Frederick Robert (2020) Oculomotor Behavior as a Biomarker for Differentiating Pediatric Patients With Mild Traumatic Brain Injury and Age Matched Controls. Frontiers in behavioral neuroscience 14, 581819

Hunfalvay Melissa, Murray Nicholas P, and Carrick Frederick Robert (2021) Fixation stability as a biomarker for differentiating mild traumatic brain injury from age matched controls in pediatrics. Brain Injury 35(2), 209-214

Hunfalvay Melissa, Murray Nicholas P, Mani Revathy, and Carrick Frederick Robert (2021) Smooth Pursuit Eye Movements as a Biomarker for Mild Concussion within 7-Days of Injury. Brain Injury 35(14), 1682-1689

Hunt Danielle L, Oldham Jessie, Aaron Stacey E, Tan Can Ozan, Meehan William P, and Howell David R (2022) Dizziness, Psychosocial Function, and Postural Stability Following Sport-Related Concussion. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 32(4), 361-367

Jain Divya, Arbogast Kristy B, McDonald Catherine C, Podolak Olivia E, Margulies Susan S, Metzger Kristina B, Howell David R, Scheiman Mitchell M, and Master Christina L (2022) Eye Tracking Metrics Differences among Uninjured Adolescents and Those with Acute or Persistent Post-Concussion Symptoms. Optometry and vision science : official publication of the American Academy of Optometry 99(8), 616-625

King Laurie A, Horak Fay B, Mancini Martina, Pierce Donald, Priest Kelsey C, Chesnutt James, Sullivan Patrick, and Chapman Julie C (2014) Instrumenting the balance error scoring system for use with patients reporting persistent balance problems after mild traumatic brain injury. Archives of Physical Medicine and Rehabilitation 95(2), 353-359 DOI: 10.1016/j.apmr.2013.10.015

Knell Gregory, Caze Todd, and Burkhart Scott O (2021) Evaluation of the vestibular and ocular motor screening (VOMS) as a prognostic tool for protracted recovery following paediatric sports-related concussion. BMJ Open Sport & Exercise Medicine 7(1), e000970

Königs Marsh, Weeda Wouter D, Van Heurn L W.Ernest, Vermeulen R Jeroen, Goslings J Carel, Luitse Jan S.K, Poll-Thé Bwee Tien, Beelen Anita, Van Der Wees Marleen, Kemps Rachèl J.J.K, Catsman-Berrevoets Coriene E, and Oosterlaan Jaap (2015) Impaired Visual Integration in Children with Traumatic Brain Injury: An Observational Study. PLoS ONE 10(12), 1-15 DOI: 10.1371/journal.pone.0144395

Kontos Anthony P, Eagle Shawn R, Mucha Anne, Kochick Victoria, Reichard Jessica, Moldolvan Claire, Holland Cyndi L, Blaney Nicholas A, and Collins Michael W (2021) A Randomized Controlled Trial of Precision Vestibular Rehabilitation in Adolescents following Concussion: Preliminary Findings. The Journal of Pediatrics ,

Kraus Nina, Thompson Elaine C, Krizman Jennifer, Cook Katherine, White-Schwoch Travis, and LaBella Cynthia R (2016) Auditory biological marker of concussion in children. Scientific Reports 6(August), 1-10 DOI: 10.1038/srep39009

Leonard Bianca T, Kontos Anthony P, Marchetti Gregory F, Zhang Min, Eagle Shawn R, Reecher Hope M, Bensinger Ethan S, Snyder Valerie C, Holland Cyndi L, Sheehy Christy K, and Rossi Ethan A (2021) Fixational eye movements following concussion. Journal of vision 21(13), 11

Leung Felix T, Mendis M Dilani, Franettovich Smith Melinda M, Rahmann Ann, Treleaven Julia, and Hides Julie A (2022) Sensorimotor system changes in adolescent rugby players post-concussion: A prospective investigation from the subacute period through to return-to-sport. Musculoskeletal Science & Practice 57, 102492

Linder Susan M, Ozinga Sarah J, Koop Mandy Miller, Dey Tanujit, Figler Richard, Cruickshank Jason, and Alberts Jay L (2018) Cleveland Clinic Postural Stability Index Norms for the Balance Error Scoring System. Medicine and Science in Sports and Exercise 50(10), 1998-2006 DOI: 10.1249/MSS.0000000000001660

Lowe Leah, Castillo Fernando, Gokun Yevgeniya, Williams David K, Israel Michael, and Yates Charlotte (2022) Static and Dynamic Balance Assessment in Healthy and Concussed Adolescent Athletes. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 32(4), 385-390

Manaseer Thaer S, Gross Douglas P, Dennett Liz, Schneider Kathryn, and Whittaker Jackie L (2020) Gait Deviations Associated With Concussion: A Systematic Review. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 30 Suppl 1, S11-S28

Mang Cameron S, Whitten Tara A, Cosh Madeline S, Dukelow Sean P, and Benson Brian W (2020) Assessment of Postural Stability During an Upper Extremity Rapid, Bimanual Motor Task After Sport-Related Concussion. Journal of Athletic Training 55(11), 1160-1173

Mani Revathy, Ngo Steven, Walz Jacinta, and Khuu Sieu K (2022) Evaluating the extent of change in near point of convergence in traumatic brain injury: a systematic review and meta-analysis. Brain Injury 36(3), 306-320

Master Christina L, Scheiman Mitchell, Gallaway Michael, Goodman Arlene, Robinson Roni L, Master Stephen R, and Grady Matthew F (2016) Vision Diagnoses Are Common after Concussion in Adolescents. Clinical Pediatrics 55(3), 260-267 DOI: 10.1177/0009922815594367

Master Christina L, Master Stephen R, Wiebe Douglas J, Storey Eileen P, Lockyer Julia E, Podolak Olivia E, and Grady Matthew F (2018) Vision and Vestibular System Dysfunction Predicts Prolonged Concussion Recovery in Children. Clinical Journal of Sport Medicine 28(2), 139-145 DOI: 10.1097/JSM.0000000000000507

Master Christina L, Curry Allison E, Pfeiffer Melissa R, Metzger Kristina B, Kessler Ronni S, Haarbauer-Krupa Juliet, DePadilla Lara, Greenspan Arlene, Breiding Matthew J, and Arbogast Kristy B (2020) Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management. Journal of Pediatrics 223, 128-135 DOI: 10.1016/j.jpeds.2020.04.001

Mayer Andrew R, Wertz Christopher J, Robertson-Benta Cidney R, Pabbathi Reddy Sharvani, Stephenson David D, Dodd Andrew B, Oglesbee Scott J, Bedrick Edward J, Master Christina L, Grady Mathew, Shaff Nicholas A, Hanlon Faith M, Campbell Richard A, Phillips John P, Zemek Roger L, Yeates Keith Owen, Meier Timothy B, Mannix Rebekah, Leddy John J, Arbogast Kristy B, and Park Grace (2020) Neurosensory Screening and Symptom Provocation in Pediatric Mild Traumatic Brain Injury. The Journal of head trauma rehabilitation 35(4), 270-278

Moran Ryan N, and Bretzin Abigail C (2023) Long-term test-retest reliability of the vestibular/ocular motor screening for concussion in child athletes: A preliminary study. Applied neuropsychology.Child , 1-6

Mucha Anne, Collins Michael W, Elbin R J, Furman Joseph M, Troutman-Enseki Cara, DeWolf Ryan M, Marchetti Greg, and Kontos Anthony P (2014) A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions. The American Journal of Sports Medicine 42(10), 2479-2486 DOI: 10.1177/0363546514543775

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icon img Cognition

Introduction:

Prolonged cognitive problems post-concussion that are affecting a child/adolescent’s daily functioning (e.g., problems with speech, learning, attention, memory, information processing, etc.) need to be identified and managed appropriately. Identifying the nature and interaction between pre-existing and concussion-related cognitive problems will help to clarify the most appropriate supports based on the child/adolescent’s characteristics, including return-to-school and return-to-activity/sport. Experienced school-based educational professionals, where available, can support the healthcare professionals in this area. Examples of school-based educational professionals vary and may include: vice-principals, learning support teachers (LST), guidance counsellors, student success teachers, and school board services such as psychology, social work, speech language pathology (SLP), etc.

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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.

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.

Tools and Resources
References

Research papers that support the present guideline recommendations:

Babcock, L., Kurowski, B. G., Zhang, N., Dexheimer, J. W., Dyas, J., & Wade, S. L. (2017). Adolescents with Mild Traumatic Brain Injury Get SMART: An Analysis of a Novel Web-Based Intervention. Telemedicine and E-Health, 23(7), 600–607. https://doi.org/10.1089/tmj.2016.0215

Grubenhoff, J. A., Currie, D., Comstock, R. D., Juarez-Colunga, E., Bajaj, L., & Kirkwood, M. W. (2016). Psychological Factors Associated with Delayed Symptom Resolution in Children with Concussion. Journal of Pediatrics, 174(303), 27–32.e1. https://doi.org/10.1016/j.jpeds.2016.03.027

Heyworth, B. E., Carroll, K. M., Rizza, A. J., McInnis, K. C., & Gill, T. J. (2014). Treatment of Concussion in High School Athletes: A Proposed Protocol for Athletic and Academic Return to Activity. Orthopaedic Journal of Sports Medicine, 2(7), 2015. https://doi.org/10.1177/2325967114S00079

McNally, K. A., Patrick, K. E., LaFleur, J. E., Dykstra, J. B., Monahan, K., & Hoskinson, K. R. (2018). Brief cognitive behavioral intervention for children and adolescents with persistent post-concussive symptoms: A pilot study. Child Neuropsychology, 24(3), 396–412. https://doi.org/10.1080/09297049.2017.1280143

Newman, J. B., Reesman, J. H., Vaughan, C. G., & Gioia, G. A. (2013). Assessment of processing speed in children with mild tbi: A “first look” at the validity of pediatric ImPACT. Clinical Neuropsychologist, 27(5), 779–793. https://doi.org/10.1080/13854046.2013.789552

Nikles, C. J., McKinlay, L., Mitchell, G. K., Carmont, S. A. S., Senior, H. E., Waugh, M. C. A., … Lloyd, O. T. (2014). Aggregated n-of-1 trials of central nervous system stimulants versus placebo for paediatric traumatic brain injury – a pilot study. Trials, 15(1), 1–11. https://doi.org/10.1186/1745-6215-15-54

Peltonen, K., Vartiainen, M., Laitala-Leinonen, T., Koskinen, S., Luoto, T., Pertab, J., & Hokkanen, L. (2019). Adolescent athletes with learning disability display atypical maturational trajectories on concussion baseline testing: Implications based on a Finnish sample. Child Neuropsychology, 25(3), 336–351. https://doi.org/10.1080/09297049.2018.1474865

Ransom, D. M., Vaughan, C. G., Pratson, L., Sady, M. D., McGill, C. A., & Gioia, G. A. (2015). Academic Effects of Concussion in Children and Adolescents. Pediatrics, 135(6), 1043–1050. https://doi.org/10.1542/peds.2014-3434

Reddy, C. C., Collins, M., Lovell, M., & Kontos, A. P. (2013). Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. Journal of Head Trauma Rehabilitation, 28(4), 260–265. https://doi.org/10.1097/HTR.0b013e318257fbc6

Reed, N., Taha, T., Monette, G., & Keightley, M. (2016). A Preliminary Exploration of Concussion and Strength Performance in Youth Ice Hockey Players. International Journal of Sports Medicine, 37(9), 708–713. https://doi.org/10.1055/s-0042-104199

Taylor, K. M., Kioumourtzoglou, M. A., Clover, J., Coull, B. A., Dennerlein, J. T., Bellinger, D. C., & Weisskopf, M. G. (2018). Concussion History and Cognitive Function in a Large Cohort of Adolescent Athletes. American Journal of Sports Medicine, 46(13), 3262–3270. https://doi.org/10.1177/0363546518798801

Wasserman, E. B., Bazarian, J. J., Mapstone, M., Block, R., & Van Wijngaarden, E. (2016). Academic dysfunction after a concussion among US high school and college students. American Journal of Public Health, 106(7), 1247–1253. https://doi.org/10.2105/AJPH.2016.303154

Last update: November 16, 2019

icon img Fatigue

Introduction:

Physical, mental, or cognitive fatigue is common following a concussion. Fatigue can be defined as weariness or tiredness following physical and/or cognitive/mental exertion. A repeat medical exam is necessary for children/adolescents experiencing fatigue 1-2 weeks following a concussion to rule out a serious medical condition or injury. Children/adolescents experiencing prolonged post-concussion fatigue should be encouraged to participate in low-risk physical and cognitive activities below their symptom exacerbation threshold (at a level that does not bring on symptoms or make symptoms worse). Pacing and energy management techniques should be shared with the child/adolescent (Tool 2.5 “Four P’s” – Prioritize, Plan, Pace and Position). If a child/adolescent experiences fatigue for more than 4 weeks following the acute injury consider referring to an interdisciplinary concussion team.

Recommendations

LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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.).

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:

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.

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:  

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.

Tools and Resources
References

Research papers that support the present guideline recommendations:

Botchway, E. N., Godfrey, C., Anderson, V., & Catroppa, C. (2019). A Systematic Review of Sleep-Wake Disturbances in Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life. The Journal of Head Trauma Rehabilitation, 34(4), 241–256. https://doi.org/10.1097/HTR.0000000000000446

Bramley, H., Henson, A., Lewis, M. M., Kong, L., Stetter, C., & Silvis, M. (2017). Sleep Disturbance Following Concussion Is a Risk Factor for a Prolonged Recovery. Clinical Pediatrics, 56(14), 1280–1285. https://doi.org/10.1177/0009922816681603

Brooks, B. L., Sayers, P. Q., Virani, S., Rajaram, A. A., & Tomfohr-Madsen, L. (2019). Insomnia in adolescents with slow recovery from concussion. Journal of Neurotrauma, 36(16), 2391–2399. https://doi.org/10.1089/neu.2018.6257

Crichton, A., Oakley, E., Babl, F. E., Greenham, M., Hearps, S., Delzoppo, C., … Anderson, V. (2018). Predicting Fatigue 12 Months after Child Traumatic Brain Injury: Child Factors and Postinjury Symptoms. Journal of the International Neuropsychological Society, 24(3), 224–236. https://doi.org/10.1017/S1355617717000893

Howell, D. R., Oldham, J. R., Brilliant, A. N., & Meehan, W. P. (2019). Trouble Falling Asleep After Concussion Is Associated With Higher Symptom Burden Among Children and Adolescents. Journal of Child Neurology, 34(5), 256–261. https://doi.org/10.1177/0883073818824000

Kostyun, R. O., Milewski, M. D., & Hafeez, I. (2015). Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents. American Journal of Sports Medicine, 43(3), 633–640. https://doi.org/10.1177/0363546514560727

Landry-Roy, C., Bernier, A., Gravel, J., & Beauchamp, M. H. (2018). Executive Functions and Their Relation to Sleep Following Mild Traumatic Brain Injury in Preschoolers. Journal of the International Neuropsychological Society, 24(8), 769–780. https://doi.org/10.1017/S1355617718000401

Murdaugh, D. L., Ono, K. E., Reisner, A., & Burns, T. G. (2018). Assessment of Sleep Quantity and Sleep Disturbances During Recovery From Sports-Related Concussion in Youth Athletes. Archives of Physical Medicine and Rehabilitation, 99(5), 960–966. https://doi.org/10.1016/j.apmr.2018.01.005

Tham, S. W., Fales, J., & Palermo, T. M. (2015). Subjective and Objective Assessment of Sleep in Adolescents with Mild Traumatic Brain Injury. Journal of Neurotrauma, 32(11), 847–852. https://doi.org/10.1089/neu.2014.3559

Theadom, A., Starkey, N., Jones, K., Cropley, M., Parmar, P., Barker-Collo, S., & Feigin, V. L. (2016). Sleep difficulties and their impact on recovery following mild traumatic brain injury in children. Brain Injury, 30(10), 1243–1248. https://doi.org/10.1080/02699052.2016.1183171

Wiseman-Hakes, C., Gosselin, N., Sharma, B., Langer, L., & Gagnon, I. (2019). A Longitudinal Investigation of Sleep and Daytime Wakefulness in Children and Youth With Concussion. ASN Neuro, 11. https://doi.org/10.1177/1759091418822405

 

Research papers not associated with a current recommendation:

van Markus-Doornbosch, F., Peeters, E., van der Pas, S., Vlieland, T. V., & Meesters, J. (2019). Physical activity after mild traumatic brain injury: What are the relationships with fatigue and sleep quality? European Journal of Paediatric Neurology, 23(1), 53–60. https://doi.org/10.1016/j.ejpn.2018.11.002

Last update: November 16, 2019

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