Section B: Managing Concussion Symptoms

Section B:

Managing Concussion Symptoms

Introduction

icon imgDomain 6: 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 2.1d 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 2.1b: 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:

Babcock, L., Byczkowski, T., Wade, S. L., Ho, M., Mookerjee, S., & Bazarian, J. J. (2013). Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatrics, 167(2), 156–161. https://doi.org/10.1001/jamapediatrics.2013.434

Bock, S., Grim, R., Barron, T. F., Wagenheim, A., Hu, Y. E., Hendell, M., … Deibert, E. (2015). Factors associated with delayed recovery in athletes with concussion treated at a pediatric neurology concussion clinic. Child’s Nervous System, 31(11), 2111–2116. https://doi.org/10.1007/s00381-015-2846-8

Bramley, H., Heverley, S., Lewis, M. M., Kong, L., Rivera, R., & Silvis, M. (2015). Demographics and Treatment of Adolescent Posttraumatic Headache in a Regional Concussion Clinic. Pediatric Neurology, 52(5), 493–498. https://doi.org/10.1016/j.pediatrneurol.2015.01.008

Bresee, N., Aglipay, M., Dubrovsky, A. S., Ledoux, A. A., Momoli, F., Gravel, J., … Zemek, R. (2018). No association between metoclopramide treatment in ED and reduced risk of post-concussion headache. American Journal of Emergency Medicine, 36(12), 2225–2231. https://doi.org/10.1016/j.ajem.2018.04.007

Chan, S., Kurowski, B., Byczkowski, T., & Timm, N. (2015). Intravenous migraine therapy in children with posttraumatic headache in the ED. American Journal of Emergency Medicine, 33(5), 635–639. https://doi.org/10.1016/j.ajem.2015.01.053

Dubrovsky, A. S., Friedman, D., & Kocilowicz, H. (2014). Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: A case series and patient satisfaction survey. Headache, 54(5), 878–887. https://doi.org/10.1111/head.12334

Eckner, J. T., Seifert, T., Pescovitz, A., Zeiger, M., & Kutcher, J. S. (2017). Is migraine headache associated with concussion in athletes? A case-control study. Clinical Journal of Sport Medicine, 27(3), 266–270. https://doi.org/10.1097/JSM.0000000000000346

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

Ellis, M. J., Cordingley, D., Girardin, R., Ritchie, L., & Johnston, J. (2017). Migraine with aura or sports-related concussion: Case report, pathophysiology, and multidisciplinary approach to management. Current Sports Medicine Reports, 16(1), 14–18. https://doi.org/10.1249/JSR.0000000000000323

Ellis, M.J., Leddy, J., Willer, B. (2016) Multi-disciplinary management of athletes with post-concussion syndrome: An evolving pathophysiological approach. Frontiers in Neurology. 7(AUG),136. https://doi.org/10.3389/fneur.2016.00136

Grool, A. M., Aglipay, M., Momoli, F., Meehan, W. P., Freedman, S. B., Yeates, K. O., … Zemek, R. (2016). Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. Jama, 316(23), 2504. https://doi.org/10.1001/jama.2016.17396

Heyer, G. L., & Idris, S. A. (2014). Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients? Pediatric Neurology, 50(5), 464–468. https://doi.org/10.1016/j.pediatrneurol.2014.01.040

Heyer, G. L., Young, J. A., Rose, S. C., McNally, K. A., & Fischer, A. N. (2015). Post-traumatic headaches correlate with migraine symptoms in youth with concussion. Cephalalgia, 36(4), 309–316. https://doi.org/10.1177/0333102415590240

Kacperski, J., Kabbouche, M.A., O’brien, H.L., Weberding, J.L. (2016). The optimal management of headaches in children and adolescents. Therapeutic Advances in Neurological Disorders. 9(1),53-68. https://doi.org/10.1177/1756285615616586

Kontos, A. P., Elbin, R. J., Lau, B., Simensky, S., Freund, B., French, J., & Collins, M. 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. https://doi.org/10.1177/0363546513488751

Kuczynski, A., Crawford, S., Bodell, L., Dewey, D., & Barlow, K. 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. https://doi.org/10.1111/dmcn.12152

Linden, M. (2015). The Effects of QEEG-Guided Neurofeedback on Postconcussion Syndrome. Biofeedback, 43(1), 42–44. https://doi.org/10.5298/1081-5937-43.1.08

Lumba-Brown, A., Harley, J., Lucio, S., Vaida, F., & Hilfiker, M. (2014). Hypertonic Saline as a Therapy for Pediatric Concussive Pain. Pediatric Emergency Care, 30(3), 139–145. https://doi.org/10.1097/PEC.0000000000000084

McConnell, B., Duffield, T., Hall, T., Piantino, J., Seitz, D., Soden, D., & Williams, C. (2019). Post-traumatic Headache After Pediatric Traumatic Brain Injury: Prevalence, Risk Factors, and Association With Neurocognitive Outcomes. Journal of Child Neurology, 35(1), 63–70. https://doi.org/10.1177/0883073819876473

McEvoy, H., Borsook, D., & Holmes, S. A. (2019). Clinical features and sex differences in pediatric post-traumatic headache: A retrospective chart review at a Boston area concussion clinic. Cephalalgia, 0(0), 1–11. https://doi.org/10.1177/0333102419896754

Mihalik, J. P., Register-Mihalik, J., Kerr, Z. Y., Marshall, S. W., McCrea, M. C., & Guskiewicz, K. M. (2013). Recovery of posttraumatic migraine characteristics in patients after mild traumatic brain injury. American Journal of Sports Medicine, 41(7), 1490–1496. https://doi.org/10.1177/0363546513487982

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.

Page, P. (2011). Cervicogenic headaches: an evidence-led approach to clinical management. International journal of sports physical therapy. 6(3),254-266. http://www.ncbi.nlm.nih.gov/pubmed/22034615%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3201065

Pasek, T. A., Locasto, L. W., Reichard, J., Fazio Sumrok, V. C., Johnson, E. W., & Kontos, A. P. (2015). The headache electronic diary for children with concussion. Clinical Nurse Specialist, 29(2), 80–88. https://doi.org/10.1097/NUR.0000000000000108

Pearson, R., Levyim, D., Choe, M., Taraman, S., & Langdon, R. (2019). Survey of Child Neurologists on Management of Pediatric Post-traumatic Headache. Journal of Child Neurology, 34(12), 739–747. https://doi.org/10.1177/0883073819856837

Schneider, K. J., Meeuwisse, W. H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. (2014). Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal of Sports Medicine, 48(17), 1294–1298. https://doi.org/10.1136/bjsports-2013-093267

Seeger, T. A., Orr, S., Bodell, L., Lockyer, L., Rajapakse, T., & Barlow, K. M. (2015). Occipital nerve blocks for pediatric posttraumatic headache: A case series. Journal of Child Neurology, 30(9), 1142–1146. https://doi.org/10.1177/0883073814553973

Seifert, T.D. (2013) Sports concussion and associated post-traumatic headache. Headache. 53(5),726-736. https://doi.org/10.1111/head.12087

Shaw, L., Morozova, M., & Abu-Arafeh, I. (2018). Chronic post-traumatic headache in children and adolescents: systematic review of prevalence and headache features. Pain Management, 8(1), 57–64. https://doi.org/10.2217/pmt-2017-0019

Starling, A.J., Vargas, B.B. (2015). A Narrative Review of Evidence-Based Preventive Options for Chronic Migraine. Current Pain and Headache Reports. 19(10),49. https://doi.org/10.1007/s11916-015-0521-0

Sufrinko, A., McAllister-Deitrick, J., Elbin, R., Collins, M. W., & Kontos, A. P. (2018). Family History of Migraine Associated with Posttraumatic Migraine Symptoms Following Sport-Related Concussion. Journal of Head Trauma Rehabilitation, 33(1), 7–14. https://doi.org/10.1097/HTR.0000000000000315

Sussman, W. I., Mautner, K., Mason, R. A., Bonecutter, K., & Shealy, A. 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. https://doi.org/10.1097/JSM.0000000000000325

The International Classification of Headache Disorders, 3rd edition (beta version). (2013) Cephalalgia: An International Journal of Headache. 33(9),629-808. https://doi.org/10.1177/0333102413485658

Zaremski, J. L., Herman, D. C., Clugston, J. R., Hurley, R. W., & Ahn, A. H. (2015). Occipital neuralgia as a sequela of sports concussion: A case series and review of the literature. Current Sports Medicine Reports, 14(1), 16–19. https://doi.org/10.1249/JSR.0000000000000121

 

Research papers not associated with a current recommendation

Mannix, R., Zemek, R., Yeates, K. O., Arbogast, K., Atabaki, S., Badawy, M., … Wisniewski, S. (2019). Practice patterns in pharmacological and non-pharmacological therapies for children with mild traumatic brain injury: A survey of 15 canadian and United States centers. Journal of Neurotrauma, 36(20), 2886–2894. https://doi.org/10.1089/neu.2018.6290

Papers being considered (January 2021 update):

Cushman DM, Borowski L, Hansen C, et al. Gabapentin and Tricyclics in the Treatment of Post-Concussive Headache, a Retrospective Cohort Study. Headache [Internet]. 2019 Mar 1;59(3):371–82. Available from: http://doi.wiley.com/10.1111/head.13451

Kwan V, Plourde V, Yeates KO, et al. Headache long after pediatric concussion: presence, intensity, interference, and association with cognition. Brain Inj [Internet]. 2020 Mar 20;34(4):575–82. Available from: https://www.tandfonline.com/doi/full/10.1080/02699052.2020.1725842

McEvoy H, Borsook D, Holmes SA. Clinical features and sex differences in pediatric post-traumatic headache: A retrospective chart review at a Boston area concussion clinic. Cephalalgia [Internet]. 2020 Jun 22;40(7):701–11. Available from: http://journals.sagepub.com/doi/10.1177/0333102419896754

Terry DP, Reddi PJ, Cook NE, et al. Acute Effects of Concussion in Youth With Pre-existing Migraines. Clin J Sport Med [Internet]. 2019 Nov 26;Publish Ah. Available from: http://dx.doi.org/10.1097/JSM.0000000000000791

icon imgDomain 7: 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 imgDomain 8: 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 imgDomain 9: 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 imgDomain 10: 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 2.1d: 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

Research papers that support the present guideline recommendations:

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Alsalaheen, B. A., Haines, J., Yorke, A., Stockdale, K., & Broglio, S. 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. https://doi.org/10.1080/00913847.2015.1040717

Alsalaheen, B. A., Whitney, S. L., Marchetti, G. F., Furman, J. M., Kontos, A. P., Collins, M. W., & Sparto, P. 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. https://doi.org/10.1097/JSM.0000000000000185

Alsalaheen, B., McClafferty, A., Haines, J., Smith, L., & Yorke, A. (2016). Reference values for the balance error scoring system in adolescents. Brain Injury, 30(7), 914–918. https://doi.org/10.3109/02699052.2016.1146965

Anzalone, A. J., Blueitt, D., Case, T., McGuffin, T., Pollard, K., Garrison, J. C., … Oliver, J. 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. https://doi.org/10.1177/0363546516668624

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Fino, P. C. (2016). A preliminary study of longitudinal differences in local dynamic stability between recently concussed and healthy athletes during single and dual-task gait. Journal of Biomechanics, 49(9), 1983–1988. https://doi.org/10.1016/j.jbiomech.2016.05.004

Fino, P. C., Nussbaum, M. A., & Brolinson, P. G. (2016). Locomotor deficits in recently concussed athletes and matched controls during single and dual-task turning gait: Preliminary results. Journal of NeuroEngineering and Rehabilitation, 13(1), 1–15. https://doi.org/10.1186/s12984-016-0177-y

Furman, G. R., Lin, C. C., Bellanca, J. L., Marchetti, G. F., Collins, M. W., & Whitney, S. L. (2013). Comparison of the balance accelerometer measure and balance error scoring system in adolescent concussions in sports. American Journal of Sports Medicine, 41(6), 1404–1410. https://doi.org/10.1177/0363546513484446

Galetta, K. M., Morganroth, J., Moehringer, N., Mueller, B., Hasanaj, L., Webb, N., … Balcer, L. J. (2015). Adding vision to concussion testing: A prospective study of sideline testing in youth and collegiate athletes. Journal of Neuro-Ophthalmology, 35(3), 235–241. https://doi.org/10.1097/WNO.0000000000000226

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Heyer, G. L., Young, J. A., & Fischer, A. N. (2017). Lightheadedness After Concussion: Not All Dizziness is Vertigo. Clinical Journal of Sport Medicine, 0(0). https://doi.org/10.1097/JSM.0000000000000445

Howell, D. R., Beasley, M., Vopat, L., & Meehan, W. P. (2017). The Effect of Prior Concussion History on Dual-Task Gait following a Concussion. Journal of Neurotrauma, 34(4), 838–844. https://doi.org/10.1089/neu.2016.4609

Howell, D. R., Brilliant, A. N., Storey, E. P., Podolak, O. E., Meehan, W. P., & Master, C. L. (2018). Objective Eye Tracking Deficits Following Concussion for Youth Seen in a Sports Medicine Setting. Journal of Child Neurology, 33(12), 794–800. https://doi.org/10.1177/0883073818789320

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Howell, D. R., Hanson, E., Sugimoto, D., Stracciolini, A., & Meehan, W. P. (2017). Assessment of the Postural Stability of Female and Male Athletes. Clinical Journal of Sport Medicine, 27(5), 444–449. https://doi.org/10.1097/JSM.0000000000000374

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Howell, D. R., O’Brien, M. J., Raghuram, A., Shah, A. S., & Meehan, W. P. (2017). Receded near point of convergence and gait are associated after concussion. British Journal of Sports Medicine, 51(11), A9.1-A9. https://doi.org/10.1136/bjsports-2016-097270.21

Howell, D. R., O’Brien, M. J., Raghuram, A., Shah, A. S., & Meehan, W. P. (2018). Near Point of Convergence and Gait Deficits in Adolescents after Sport-Related Concussion. Clinical Journal of Sport Medicine, 28(3), 262–267. https://doi.org/10.1097/JSM.0000000000000439

Howell, D. R., Osternig, L. R., & Chou, L. S. (2013). Dual-task effect on gait balance control in adolescents with concussion. Archives of Physical Medicine and Rehabilitation, 94(8), 1513–1520. https://doi.org/10.1016/j.apmr.2013.04.015

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Howell, D. R., Osternig, L. R., Christie, A. D., & Chou, L. S. (2016). Return to physical activity timing and dual-task gait stability are associated 2 months following concussion. Journal of Head Trauma Rehabilitation, 31(4), 262–268. https://doi.org/10.1097/HTR.0000000000000176

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Howell, D. R., Stracciolini, A., Geminiani, E., & Meehan, W. P. (2017). Dual-task gait differences in female and male adolescents following sport-related concussion. Gait and Posture, 54(November 2016), 284–289. https://doi.org/10.1016/j.gaitpost.2017.03.034

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Master, C. L., Master, S. R., Wiebe, D. J., Storey, E. P., Lockyer, J. E., Podolak, O. E., & Grady, M. F. (2018). Vision and Vestibular System Dysfunction Predicts Prolonged Concussion Recovery in Children. Clinical Journal of Sport Medicine, 28(2), 139–145. https://doi.org/10.1097/JSM.0000000000000507

Master, C. L., Scheiman, M., Gallaway, M., Goodman, A., Robinson, R. L., Master, S. R., & Grady, M. F. (2016). Vision Diagnoses Are Common after Concussion in Adolescents. Clinical Pediatrics, 55(3), 260–267. https://doi.org/10.1177/0009922815594367

Mucha, A., Collins, M. W., Elbin, R. J., Furman, J. M., Troutman-Enseki, C., Dewolf, R. M., … Kontos, A. P. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: Preliminary findings. American Journal of Sports Medicine, 42(10), 2479–2486. https://doi.org/10.1177/0363546514543775

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Ozinga, S. J., Linder, S. M., Koop, M. M., Dey, T., Figler, R., Russman, A. N., … Alberts, J. L. (2018). Normative performance on the balance error scoring system by youth, high school, and collegiate athletes. Journal of Athletic Training, 53(7), 636–645. https://doi.org/10.4085/1062-6050-129-17

Pavlou, M., Whitney, S. L., Alkathiry, A. A., Huett, M., Luxon, L. M., Raglan, E., … Bamiou, D. E. (2017). Visually induced dizziness in children and validation of the Pediatric Visually Induced Dizziness Questionnaire. Frontiers in Neurology, 8(DEC), 1–9. https://doi.org/10.3389/fneur.2017.00656

Pearce, K. L., Sufrinko, A., Lau, B. C., Henry, L., Collins, M. W., & Kontos, A. P. (2015). Near point of convergence after a sport-related concussion: Measurement reliability and relationship to neurocognitive impairment and symptoms. American Journal of Sports Medicine, 43(12), 3055–3061. https://doi.org/10.1177/0363546515606430

Quatman-Yates, C. C., Bonnette, S., Hugentobler, J. A., Médé, B., Kiefer, A. W., Kurowski, B. G., & Riley, M. A. (2015). Postconcussion Postural Sway Variability Changes in Youth: The Benefit of Structural Variability Analyses. Pediatric Physical Therapy, 27(4), 316–327. https://doi.org/10.1097/PEP.0000000000000193

Quatman-Yates, C., Hugentobler, J., Ammon, R., Mwase, N., Kurowski, B., & Myer, G. D. (2014). The utility of the balance error scoring system for mild brain injury assessments in children and adolescents. Physician and Sportsmedicine, 42(3), 32–38. https://doi.org/10.3810/psm.2014.09.2073

Rhine, T. D., Byczkowski, T. L., Clark, R. A., & Babcock, L. (2016). Investigating the Feasibility and Utility of Bedside Balance Technology Acutely after Pediatric Concussion: A Pilot Study. Clinical Journal of Sport Medicine, 26(3), 221–225. https://doi.org/10.1097/JSM.0000000000000234

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Rochefort, C., Walters-Stewart, C., Aglipay, M., Barrowman, N., Zemek, R., & Sveistrup, H. (2017). Balance markers in adolescents at 1 month postconcussion. Orthopaedic Journal of Sports Medicine, 5(3), 1–7. https://doi.org/10.1177/2325967117695507

Rochefort, C., Walters-Stewart, C., Aglipay, M., Barrowman, N., Zemek, R., & Sveistrup, H. (2017). Self-reported balance status is not a reliable indicator of balance performance in adolescents at one-month post-concussion. Journal of Science and Medicine in Sport, 20(11), 970–975. https://doi.org/10.1016/j.jsams.2017.04.008

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Scheiman, M. M., Talasan, H., Lynn Mitchell, G., & Alvarez, T. L. (2017). Objective Assessment of Vergence after Treatment of Concussion-Related CI: A Pilot Study. Optometry and Vision Science, 94(1), 74–88. https://doi.org/10.1097/OPX.0000000000000936

Schneider, K. J., Meeuwisse, W. H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. (2014). Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal of Sports Medicine, 48(17), 1294–1298. https://doi.org/10.1136/bjsports-2013-093267

Sinopoli, K. J., Chen, J.-K., Wells, G., Fait, P., Ptito, A., Taha, T., & Keightley, M. (2014). Imaging “Brain Strain” in Youth Athletes with Mild Traumatic Brain Injury during Dual-Task Performance. Journal of Neurotrauma, 31(22), 1843–1859. https://doi.org/10.1089/neu.2014.3326

Storey, E. P., Master, S. R., Lockyer, J. E., Podolak, O. E., Grady, M. F., & Master, C. L. (2017). Near Point of Convergence after Concussion in Children. Optometry and Vision Science, 94(1), 96–100. https://doi.org/10.1097/OPX.0000000000000910

Storey, E. P., Wiebe, D. J., D’Alonzo, B. A., Nixon-Cave, K., Jackson-Coty, J., Goodman, A. M., … Master, C. L. (2018). Vestibular rehabilitation is associated with visuovestibular improvement in pediatric concussion. Journal of Neurologic Physical Therapy, 42(3), 134–141. https://doi.org/10.1097/NPT.0000000000000228

Sufrinko, A. M., Marchetti, G. F., Cohen, P. E., Elbin, R. J., Re, V., & Kontos, A. P. (2017). Using Acute Performance on a Comprehensive Neurocognitive, Vestibular, and Ocular Motor Assessment Battery to Predict Recovery Duration after Sport-Related Concussions. American Journal of Sports Medicine, 45(5), 1187–1194. https://doi.org/10.1177/0363546516685061

Sufrinko, A. M., Mucha, A., Covassin, T., Marchetti, G., Elbin, R. J., Collins, M. W., & Kontos, A. P. (2017). Sex differences in vestibular/ocular and neurocognitive outcomes after sport-related concussion. Clinical Journal of Sport Medicine, 27(2), 133–138. https://doi.org/10.1097/JSM.0000000000000324

Swanson, M. W., Weise, K. K., Dreer, L. E., Johnston, J., Davis, R. D., Ferguson, D., … Swanson, E. (2017). Academic Difficulty and Vision Symptoms in Children with Concussion. Optometry and Vision Science, 94(1), 60–67. https://doi.org/10.1097/OPX.0000000000000977

Vernau, B. T., Grady, M. F., Goodman, A., Wiebe, D. J., Basta, L., Park, Y., … Master, C. L. (2015). Oculomotor and neurocognitive assessment of youth ice hockey players: Baseline associations and observations after concussion. Developmental Neuropsychology, 40(1), 7–11. https://doi.org/10.1080/87565641.2014.971955

Zhou, G., & Brodsky, J. R. (2015). Objective vestibular testing of children with dizziness and balance complaints following sports-related concussions. Otolaryngology – Head and Neck Surgery (United States), 152(6), 1133–1139. https://doi.org/10.1177/0194599815576720

Additional references that helped to inform the domain recommendations:

Baugh, R.F., Bronston, L.J., Whitney, S.L., Haidari, J., Steiner, R.W.P., … Desmond, A.L. (2008). Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. Otolaryngology-Head and Neck Surgery. 139(5_suppl),47-81. https://doi.org/10.1016/j.otohns.2008.08.022

Brodsky, J.R., Lipson, S., Wilber, J., Zhou, G. (2018). Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients. Otology and Neurotology. 39(3),344-350. https://doi.org/10.1097/MAO.0000000000001673

Mcdonnell, M.N., Hillier, S.L. (2015). Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2015(1),CD005397. https://doi.org/10.1002/14651858.CD005397.pub4

Murray, D.A., Meldrum, D., Lennon, O. (2017). Can vestibular rehabilitation exercises help patients with concussion? A systematic review of efficacy, prescription and progression patterns. British Journal of Sports Medicine. 51(5),442-451. https://doi.org/10.1136/bjsports-2016-096081

Reneker, J.C., Clay Moughiman, M., Cook, C.E. (2015).  The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An international Delphi study. Journal of Science and Medicine in Sport. 18(4),366-372. https://doi.org/10.1016/j.jsams.2014.05.002

Schneider KJ, WH. (2014). Vestibular disorders following concussion. In R. Echemendia & G. L. Iverson (Eds.), The Oxford Handbook of Sport-related Concussion. New York: Oxford University Press.  Online Publication Date: December 2014.  https://doi.org/10.1093/oxfordhb/9780199896585.013.14

Ventura, R.E., Balcer, L.J., Galetta, S.L. (2014). The neuro-ophthalmology of head trauma. The Lancet Neurology. 13(10),1006-1016. https://doi.org/10.1016/S1474-4422(14)70111-5

Wallace, B., Lifshitz, J. (2016). Traumatic brain injury and vestibulo-ocular function: current challenges and future prospects. Eye and Brain. Volume 8,153-164. https://doi.org/10.2147/eb.s82670

 

Research papers not associated with a current recommendation:

Linder, S. M., Ozinga, S. J., Koop, M. M., Dey, T., Figler, R., Cruickshank, J., & Alberts, J. 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. https://doi.org/10.1249/MSS.0000000000001660

Last update: November 16, 2019

icon imgDomain 11: 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

icon imgDomain 12: Return-to-school and Work

Introduction:

Parents and/or caregivers need to be made aware that most youth will experience symptom resolution and full return to daily activities following a concussion; however this is highly variable and individual. Complete absence from the school environment for more than one week is generally not recommended, however, it is reasonable for a child/adolescent to miss some school after a concussion, regardless of symptoms. The child/adolescent should gradually return to their school environment as soon as they are able to tolerate engaging in cognitive activities without exacerbating their symptoms, even if they are still experiencing symptoms. It is important not to allow or encourage the child/adolescent to “settle into the habit” of missing school. The school setting provides beneficial contact with peers and social support.

Overview:

  • The return-to-school process should be coordinated by the school’s concussion management team and/or a point person in the school (e.g., guidance counsellor, principal/vice principal, teacher, etc.).
  • A key to the initial management of concussion is a gradual return to the school environment and activities after the initial period of rest (24-48 hours) and as soon as cognitive activities can be tolerated without making symptoms worse.
  • Children/adolescents should be provided fast-acting temporary accommodations to their workload and schedule. Accommodations can be modified as symptoms resolve and/or when children/adolescents are caught up on missed workload and learning.
  • Manage the gradual return to school/activity/sport on a case-by-case basis.

Identifying and managing new or pre-existing school difficulties will:

  • Clarify the most appropriate treatment and management options and accommodations based on the child/adolescent’s characteristics
  • Promotes cognitive recovery and successful reintegration at school or work
  • Support/assist return-to-school, engagement in daily activities, return to social engagement, management and treatment of symptoms

Tools to consider:

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

12.1

The child/adolescent should return to their school environment as soon as they are able to tolerate engaging in cognitive activities without exacerbating their symptoms, even if they are still experiencing symptoms. Recommend a stepwise return-to-school plan. Include temporary accommodations based on symptoms and recommendations from the healthcare professional. Monitor and modify the return-to-school plan based on ongoing assessment of symptoms.
 
Level of Evidence:   

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

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

12.1a

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

Level of Evidence:

12.1b

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

12.2

Assess for school difficulties using clinical judgment.

Level of Evidence:   

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

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

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

12.3

Manage school difficulties. 

Level of Evidence:  

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

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

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

Summary of tools to consider:

12.4

Encourage patients with school difficulties 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. 

12.5

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

Level of Evidence:   

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

12.6

Prioritize return-to-school before return to work.

Level of Evidence:  Need for rest. Ideal duration of rest.  Starting return to activity earlier.

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

Tools and Resources
References

Research papers that support the present guideline recommendations:

Abbassi, E., & Sirmon-Taylor, B. (2017). Recovery progression and symptom resolution in sport-related mild traumatic brain injury. Brain Injury, 31(12), 1667–1673. https://doi.org/10.1080/02699052.2017.1357834

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

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

Brooks, B. L., Mrazik, M., Barlow, K. M., McKay, C. D., Meeuwisse, W. H., & Emery, C. A. (2014). Absence of differences between male and female adolescents with prior sport concussion. Journal of Head Trauma Rehabilitation, 29(3), 257–264. https://doi.org/10.1097/HTR.0000000000000016

Brown, N. J., Mannix, R. C., O’Brien, M. J., Gostine, D., Collins, M. W., & Meehan, W. P. (2014). Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics, 133(2), e299–e304. https://doi.org/10.1542/peds.2013-2125

Chrisman, S. P. D., Whitlock, K. B., Somers, E., Burton, M. S., Herring, S. A., Rowhani-Rahbar, A., & Rivara, F. P. (2017). Pilot study of the Sub-Symptom Threshold Exercise Program (SSTEP) for persistent concussion symptoms in youth. NeuroRehabilitation, 40(4), 493–499. https://doi.org/10.3233/NRE-161436

Cordingley, D., Girardin, R., Reimer, K., Ritchie, L., Leiter, J., Russell, K., & Ellis, M. J. (2016). Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. Journal of Neurosurgery: Pediatrics, 18(6), 693–702. https://doi.org/10.3171/2016.5.PEDS16139

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

Covassin, T., Elbin, R. J., Bleecker, A., Lipchik, A., & Kontos, A. P. (2013). Are there differences in neurocognitive function and symptoms between male and female soccer players after concussions? American Journal of Sports Medicine, 41(12), 2890–2895. https://doi.org/10.1177/0363546513509962

Covassin, T., Elbin, R., & Crutcher, B. (2013). The Relationship Between Coping, Neurocognitive Performance, and Concussion Symptoms in High School and Collegiate Athletes. The Sport Psychologist, 27(4), 372–379. https://doi.org/10.1123/tsp.27.4.372

Crowe, L. M., Anderson, V., Barton, S., Babl, F. E., & Catroppa, C. (2014). Verbal ability and language outcome following traumatic brain injury in early childhood. Journal of Head Trauma Rehabilitation, 29(3), 217–223. https://doi.org/10.1097/HTR.0b013e31829babfd

Darling, S. R., Leddy, J. J., Baker, J. G., Williams, A. J., Surace, A., Miecznikowski, J. C., & Willer, B. (2014). Evaluation of the Zurich Guidelines and exercise testing for return to play in adolescents following concussion. Clin J Sport Med, 24(2), 128–133. https://doi.org/10.1097/JSM.0000000000000026

Darling, S. R., Leddy, J. J., Baker, J. G., Williams, A. J., Surace, A., Miecznikowski, J. C., & Willer, B. (2014). Evaluation of the zurich guidelines and exercise testing for return to play in adolescents following concussion. Clinical Journal of Sport Medicine, 24(2), 128–133. https://doi.org/10.1097/JSM.0000000000000026

De Matteo, C., Greenspoon, D., Levac, D., Harper, J. A., & Rubinoff, M. (2014). Evaluating the Nintendo Wii for assessing return to activity readiness in youth with mild traumatic brain injury. Physical and Occupational Therapy in Pediatrics, 34(3), 229–244. https://doi.org/10.3109/01942638.2014.885103

De Matteo, C., Volterman, K. A., Breithaupt, P. G., Claridge, E. A., Adamich, J., & Timmons, B. W. (2015). Exertion testing in youth with mild traumatic brain injury/concussion. Medicine and Science in Sports and Exercise, 47(11), 2283–2290. https://doi.org/10.1249/MSS.0000000000000682

DeMatteo, C. A., Randall, S., Lin, C. Y. A., & Claridge, E. A. (2019). What comes first: Return to school or return to activity for youth after concussion? Maybe we don’t have to choose. Frontiers in Neurology, 10(JUL), 1–9. https://doi.org/10.3389/fneur.2019.00792

Dobney, D. M., Grilli, L., Kocilowicz, H., Beaulieu, C., Straub, M., Friedman, D., & Gagnon, I. (2017). Evaluation of an active rehabilitation program for concussion management in children and adolescents. Brain Injury, 31(13–14), 1753–1759. https://doi.org/10.1080/02699052.2017.1346294

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

Gabbe, B. J., Brooks, C., Demmler, J. C., Macey, S., Hyatt, M. A., & Lyons, R. A. (2014). The association between hospitalisation for childhood head injury and academic performance: Evidence from a population e-cohort study. Journal of Epidemiology and Community Health, 68(5), 466–470. https://doi.org/10.1136/jech-2013-203427

Gagnon, I., Grilli, L., Friedman, D., & Iverson, G. L. (2016). A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scandinavian Journal of Medicine and Science in Sports, 26(3), 299–306. https://doi.org/10.1111/sms.12441

Gibson, S., Nigrovic, L. E., O’Brien, M., & Meehan, W. P. (2013). The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Injury, 27(7–8), 839–842. https://doi.org/10.3109/02699052.2013.775494

Grabowski, P., Wilson, J., Walker, A., Enz, D., & Wang, S. (2017). Multimodal impairment-based physical therapy for the treatment of patients with post-concussion syndrome: A retrospective analysis on safety and feasibility. Physical Therapy in Sport, 23, 22–30. https://doi.org/10.1016/j.ptsp.2016.06.001

Green, S. L., Keightley, M. L., Lobaugh, N. J., Dawson, D. R., & Mihailidis, A. (2018). Changes in working memory performance in youth following concussion. Brain Injury, 32(2), 182–190. https://doi.org/10.1080/02699052.2017.1358396

Grool, A. M., Aglipay, M., Momoli, F., Meehan, W. P., Freedman, S. B., Yeates, K. O., … Zemek, R. (2016). Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. Jama, 316(23), 2504. https://doi.org/10.1001/jama.2016.17396

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

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

Howell, D. R., Mannix, R. C., Quinn, B., Taylor, J. A., Tan, C. O., & Meehan, W. P. (2015). Physical Activity Level and Symptom Duration Are Not Associated after Concussion. American Journal of Sports Medicine, 44(4), 1040–1046. https://doi.org/10.1177/0363546515625045

Howell, D., Osternig, L., Van Donkelaar, P., Mayr, U., & Chou, L. S. (2013). Effects of concussion on attention and executive function in adolescents. Medicine and Science in Sports and Exercise, 45(6), 1030–1037. https://doi.org/10.1249/MSS.0b013e3182814595

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

Konigs, M., Heij, H. A., van der Sluijs, J. A., Vermeulen, R. J., Goslings, J. C., Luitse, J. S. K., … Oosterlaan, J. (2015). Pediatric Traumatic Brain Injury and Attention Deficit. Pediatrics, 136(3), 534–541. https://doi.org/10.1542/peds.2015-0437

Kurowski, B. G., Hugentobler, J., Quatman-Yates, C., Taylor, J., Gubanich, P. J., Altaye, M., & Wade, S. L. (2017). Aerobic exercise for adolescents with prolonged symptoms after mild traumatic brain injury: An exploratory randomized clinical trial. Journal of Head Trauma Rehabilitation, 32(2), 79–89. https://doi.org/10.1097/HTR.0000000000000238

Lax, I. D., Paniccia, M., Agnihotri, S., Reed, N., Garmaise, E., Azadbakhsh, M., … Keightley, M. (2015). Developmental and gender influences on executive function following concussion in youth hockey players. Brain Injury, 29(12), 1409–1419. https://doi.org/10.3109/02699052.2015.1043344

Manikas, V., Babl, F. E., Hearps, S., Dooley, J., & Anderson, V. (2017). Impact of Exercise on Clinical Symptom Report and Neurocognition after Concussion in Children and Adolescents. Journal of Neurotrauma, 34(11), 1932–1938. https://doi.org/10.1089/neu.2016.4762

McGrath, N., Dinn, W. M., Collins, M. W., Lovell, M. R., Elbin, R. J., & Kontos, A. P. (2013). Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Injury, 27(1), 103–113. https://doi.org/10.3109/02699052.2012.729282

Moser, R. S., Schatz, P., Glenn, M., Kollias, K. E., & Iverson, G. L. (2015). Examining prescribed rest as treatment for adolescents who are slow to recover from concussion. Brain Injury, 29(1), 58–63. https://doi.org/10.3109/02699052.2014.964771

O’Brien, M. J., Howell, D. R., Pepin, M. J., & Meehan, W. P. (2017). Sport-related concussions: Symptom recurrence after return to exercise. Orthopaedic Journal of Sports Medicine, 5(10), 1–6. https://doi.org/10.1177/2325967117732516

Purcell, L. K., Davis, G. A., & Gioia, G. A. (2019). What factors must be considered in “return to school” following concussion and what strategies or accommodations should be followed? A systematic review. British Journal of Sports Medicine, 53(4), 5–18. https://doi.org/10.1136/bjsports-2017-097853

Ransom, D. M., Burns, A. R., Youngstrom, E. A., Vaughan, C. G., Sady, M. D., & Gioia, G. A. (2016). Applying an Evidence-Based Assessment Model to Identify Students at Risk for Perceived Academic Problems following Concussion. Journal of the International Neuropsychological Society, 22(10), 1038–1049. https://doi.org/10.1017/S1355617716000916

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

Russell, K., Hutchison, M. G., Selci, E., Leiter, J., Chateau, D., & Ellis, M. J. (2016). Academic outcomes in high-school students after a concussion: A retrospective population-based analysis. PLoS ONE, 11(10), 1–12. https://doi.org/10.1371/journal.pone.0165116

Russell, K., Selci, E., Black, B., Cochrane, K., & Ellis, M. (2019). Academic outcomes following adolescent sport-related concussion or fracture injury: A prospective cohort study. PLoS ONE, 14(4), 1–14. https://doi.org/10.1371/journal.pone.0215900

Ryan, N. P., Catroppa, C., Beare, R., Coleman, L., Ditchfield, M., Crossley, L., … Anderson, V. A. (2015). Predictors of longitudinal outcome and recovery of pragmatic language and its relation to externalizing behaviour after pediatric traumatic brain injury. Brain and Language, 142, 86–95. https://doi.org/10.1016/j.bandl.2015.01.007

Sarmiento, K., Donnell, Z., Bell, E., & Hoffman, R. (2019). From the CDC: A qualitative study of middle and high school professionals’ experiences and views on concussion: Identifying opportunities to support the return to school process. Journal of Safety Research, 68, 223–229. https://doi.org/10.1016/j.jsr.2018.10.010

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

Silverberg, N. D., Iverson, G. L., McCrea, M., Apps, J. N., Hammeke, T. A., & Thomas, D. G. (2016). Activity-related symptom exacerbations after pediatric concussion. JAMA Pediatrics, 170(10), 946–953. https://doi.org/10.1001/jamapediatrics.2016.1187

Stockbridge, M. D., Doran, A., King, K., & Newman, R. S. (2018). The effects of concussion on rapid picture naming in children. Brain Injury, 32(4), 506–514. https://doi.org/10.1080/02699052.2018.1429660

Sufrinko, A. M., Kontos, A. P., Apps, J. N., McCrea, M., Hickey, R. W., Collins, M. W., & Thomas, D. G. (2017). The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion. Journal of Pediatrics, 185, 167–172. https://doi.org/10.1016/j.jpeds.2017.02.072

Teel, E. F., Marshall, S. W., Shankar, V., McCrea, M., & Guskiewicz, K. M. (2017). Predicting Recovery Patterns After Sport-Related Concussion. Journal of Athletic Training, 52(3), 288–298. https://doi.org/10.4085/1062-6050-52.1.12

Thomas, D. G., Apps, J. N., Hoffmann, R. G., McCrea, M., & Hammeke, T. (2015). Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics, 135(2), 213–223. https://doi.org/10.1542/peds.2014-0966

Van Beek, L., Ghesquière, P., Lagae, L., & De Smedt, B. (2015). Mathematical Difficulties and White Matter Abnormalities in Subacute Pediatric Mild Traumatic Brain Injury. Journal of Neurotrauma, 32(20), 1567–1578. https://doi.org/10.1089/neu.2014.3809

Van Beek, L., Vanderauwera, J., Ghesquière, P., Lagae, L., & De Smedt, B. (2015). Longitudinal changes in mathematical abilities and white matter following paediatric mild traumatic brain injury. Brain Injury, 29(13–14), 1701–1710. https://doi.org/10.3109/02699052.2015.1075172

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

 

Research papers not associated with a current recommendation:

Rozbacher, A., Selci, E., Leiter, J., Ellis, M., & Russell, K. (2017). The Effect of Concussion or Mild Traumatic Brain Injury on School Grades, National Examination Scores, and School Attendance: A Systematic Review. Journal of Neurotrauma, 34(14), 2195–2203. https://doi.org/10.1089/neu.2016.4765

Last update: November 16, 2019

Section A:

Concussion Recognition, Initial Medical Assessment, Management

Section C:

Biomarkers

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