Section B:
Managing Concussion Symptoms
Introduction
Domain 6: Headache
Introduction:
For patients with post-concussion headaches 1-2 weeks following acute injury, a repeat medical assessment must be conducted including a clinical history, physical examination, and the evidence-informed use of diagnostic imaging. The assessment should also include proper classification or characterization of the patient’s headache. This assessment will help identify co-morbid medical disorders (e.g., a history of migraine or non-specific headaches or psychiatric disorders) and other factors (e.g., overuse of analgesics) that can contribute to prolonged headaches. Some prolonged post-concussion headaches can be classified according to the International Classification of Headache Disorders (ICHD-III), while others cannot. Proper characterization of prolonged post-concussion headaches can help provide information to execute appropriate interdisciplinary referrals and guide evidence-based management.
Tool 6.1:Post-Concussion Headache Algorithm.
Recommendations
LEVEL OF EVIDENCE
A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)
B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)
C = Consensus, usual practice, opinion or weaker-level evidence
6.1
Perform a repeat medical assessment on all patients presenting with post-concussion headaches 1-2 weeks following acute injury.
Include a focused history, physical examination, and consideration of diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.
Tool 6.1: Post-Concussion headache algorithm.
6.1a
Take a focused clinical history.
Level of Evidence:
Collect details that help to classify or characterize the headache subtype(s) that are present.
- Headache onset, location, quality or character, severity, and frequency.
- Factors that elicit or worsen headaches (e.g., bright lights, reading, exercise, foods, etc.).
- Factors that alleviate headaches.
- Associated symptoms (e.g., aura, photosensitivity, dizziness, eye strain, neck pain).
- The presence of red flags which may indicate a more severe brain injury or other intracranial pathology (e.g., worsening headaches, repeated vomiting, weakness or numbness of the extremities, visual changes).
- The level of disability associated with the headache (e.g., missed days from school).
- Use of medications or other substances.
- Psychological or social factors or conditions that can be associated with stress and headaches (e.g., mood or anxiety disorders) (Domain 8: Mental Health).
- Assess how much headaches affect day-to-day activities.
- Disturbed sleep.
- Personal and family history of headaches and headache disorders (e.g., migraine).
- Future participation in full-contact sport or high-risk activities.
6.1b
Perform a focused physical examination.
Level of Evidence:
- Vital signs (resting heart rate and blood pressure).
- A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait and balance testing) Tool 2.1: Physical Examination.
- A cervical spine examination (palpation, range of motion, provocative cervical spine tests). Tool 2.1: Physical Examination.
- With appropriate experience, consider performing an examination of vision, oculomotor and vestibular functioning (Domain 10: Vision, Vestibular, and Oculomotor Function).
6.1c
Consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.
Level of Evidence: CT.
MRI.
See Recommendation 2.1c for more information on when to consider diagnostic brain or cervical spine imaging.
6.1d
Classify and characterize the headache subtype based on the clinical history and physical examination findings.
Level of Evidence:
Tool 6.1: Post-Concussion Headache Algorithm.
Link: International Classification of Headache Disorders (ICHD-III)*.
Common prolonged post-concussion headache subtypes include:
- Migraine, tension, or cluster headaches.
- Cervicogenic headaches.
- Physiological or exercise-induced headaches.
- Headaches associated with prolonged visual stimulation.
- Occipital neuralgia.
* “Reproduced with permission of International Headache Society”.
6.2
Provide general post-concussion education and guidance on headache management.
6.2a
Advise on non-pharmacological strategies to minimize headaches including sleep hygiene, activity modifications, limiting triggers, and information on screen time.
Level of Evidence:
- Tool 2.7: Strategies to Promote Good Sleep and Alertness.
- Link: Sleep for Youth. CHEO Sleep Hygiene handout
- Recommendation 2.4c: Advise on the use of computers, phones, and other screen devices.
6.2b
Encourage patients with headaches to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation threshold. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.
Level of Evidence: Physical activity.
Cognitive activity.
See Recommendation 2.3.
See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.
6.2c
Consider suggesting the use of a headache and medication diary in order to monitor symptoms and medications taken. Use clinical judgment and an individualized approach on use or duration of this strategy.
Level of Evidence:
Link: Headache and Medication Diary (Boston Children’s Hospital)
6.2d
Over-the-counter medications such as acetaminophen and ibuprofen may be recommended to treat acute headache. Advise on limiting the use of these medications to less than 15 days a month and avoiding “around-the-clock” dosing to prevent overuse or rebound headaches. I.e., advise that children/adolescents avoid using over the counter medications at regular scheduled times throughout the day.
Level of Evidence:
6.3
Refer patients who have prolonged post-concussion headaches for more than 4 weeks to an interdisciplinary concussion team or to a sub-specialist for further evaluation and management. Consider early referral (prior to 4-weeks after the acute injury) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.
Level of Evidence:
Prolonged headaches in pediatric concussion patients can be difficult to classify and manage and can co-occur with other prolonged post-concussion symptoms (dizziness, neck pain, sleep disturbance, cognitive or mood challenges).
If an interdisciplinary concussion team member is not available:
- Consider appropriate referral to interdisciplinary professionals who have competency-based training and clinical experience to independently manage the identified headaches and headache disorders.
If a child/adolescent with prolonged post-concussion headache has not had a recent vision assessment, refer to an optometrist for an assessment.
6.4
Consider initiating pharmacological therapy to treat and manage prolonged headaches while waiting for the interdisciplinary concussion team or sub-specialist referral.
Level of Evidence:
For patients with post-traumatic headaches that are migrainous in nature, the use of migraine-specific abortants such as triptan class medications may be used if effective. Due to the risk of developing medication-induced headaches, limit use of abortants to fewer than 6-10 days per month.
Tool 6.2: General Considerations Regarding Pharmacotherapy.
Tool 6.3: Approved Medications for Pediatric Indications.
Prophylactic therapy should be considered:
- If headaches are occurring frequently.
- If headaches are disabling.
- If acute headache medications are contraindicated or poorly tolerated or are being used too frequently.
6.5
Recommend a medical follow-up to reassess clinical status if headaches persist. Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (prior to 4-weeks after the acute injury) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.
Level of Evidence: Medical follow-up.
Early referral in the presence of modifiers that may delay recovery.
Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury.
Level of Evidence: B
See Recommendation 2.2: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.
Tools and Resources
Living Guideline Tools:
- Tool 2.1: Physical Examination
- Tool 6.1: Post-Concussion Headache Algorithm
- Tool 2.6 Post-Concussion Information Sheet
- Tool 2.7: Strategies to Promote Good Sleep and Alertness
- Tool 6.2: General Considerations Regarding Pharmacotherapy
- Tool 6.3: Approved Medications for Pediatric Indications
Online Tools to Consider:
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
Domain 7: Sleep
Introduction:
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.
- Potential medication options include trazodone 12.5 mg or amitriptyline 5.0 – 10.0 mg.
- Tool 6.2: General Considerations Regarding Pharmacotherapy.
- Tool 6.3: Approved Medications for Pediatric Indications.
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
Living Guideline Tools:
- Tool 2.6: Post-Concussion Information Sheet
- Tool 2.7: Strategies to Promote Good Sleep and Alertness
- Tool 6.2: General Considerations Regarding Pharmacotherapy
- Tool 6.3: Approved Medications for Pediatric Indications
- Tool 7.1: Managing Post-Concussion Sleep Disturbances Algorithm
- Tool 7.2: Factors that may influence the child/adolescent’s sleep/wake cycle
Online Tools to Consider:
- Concussion & You Handbook (Holland Bloorview Kids Rehabilitation Hospital)
- Sleep for Youth. CHEO Sleep Hygiene handout
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
Domain 8: Mental Health and Psychosocial Factors
Introduction:
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):
- Link: PHQ-SADS (somatic)
- Link: Severity Measure for Depression- Child Age 11–17 (adapted from PHQ-9 modified for Adolescents [PHQ-A])
- Link: Severity Measure for Generalized Anxiety Disorder-Child Age 11–17 (adapted from GAD-7)
- Link: HEADS-ED Tool—Screening for Pediatric Mental Health (online interactive tool)
- Link: PROMIS Anxiety (pediatric and parent versions are available via HealthMeasures.net)
- Link: PROMIS Depression (pediatric and parent versions are available via HealthMeasures.net)
- Link: PROMIS Profile (25 questions, 37 questions, 49 questions versions are available via HealthMeasures.net)
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:
- Link: PROMIS Family Function (pediatric and parent versions are available via HealthMeasures.net)
- Link: Patient Health Questionnaire (PHQ-9) (Self-administered screen for depression in adults)
- Link: Generalized Anxiety Disorder scale (GAD-7)
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:
- Tool 8.1: Post-Concussion Mental Health Considerations Algorithm.
- Tool 8.2: Management of Prolonged Mental Health Disorders Algorithm.
- Tool 6.2: General Considerations Regarding Pharmacotherapy.
- Tool 6.3: Approved Medications for Pediatric Indications.
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:
- Tool 6.2: General Considerations Regarding Pharmacotherapy
- Tool 6.3: Approved Medications for Pediatric Indications.
- Tool 8.1: Post-Concussion Mental Health Considerations Algorithm
- Tool 8.2: Management of Prolonged Mental Health Disorders Algorithm
Assessment screening tools to consider (website links):
- Generalized Anxiety Disorder scale (GAD-7)
- HEADS-ED Tool—Screening for Pediatric Mental Health (online interactive tool)
- Patient Health Questionnaire (PHQ-9) (A self-administered screen for depression in adults)
- PHQ-SADS (somatic)
- PROMIS Anxiety (pediatric and parent versions are available via HealthMeasures.net)
- PROMIS Depression (pediatric and parent versions are available via HealthMeasures.net)
- PROMIS Profile (25 questions, 37 questions, 49 questions versions are available via HealthMeasures.net)
- PROMIS Family Function (pediatric and parent versions are available via HealthMeasures.net)
- Severity Measure for Depression- Child Age 11–17 (adapted from PHQ-9 modified for Adolescents [PHQ-A])
- Severity Measure for Generalized Anxiety Disorder-Child Age 11–17 (adapted from GAD-7)
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
Domain 9: Cognition
Introduction:
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
- Tool 2.1: Physical Examination
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
Domain 10: Vision, Vestibular and Oculomotor Function
Introduction:
A repeat medical assessment on concussion patients with prolonged dizziness, blurred or double vision, vertigo, difficulty reading, postural imbalance, or headaches elicited by prolonged visual or vestibular stimulation is required 1-2 weeks following the acute injury. Although the cause of these prolonged symptoms can be multi-factorial, the assessment often reveals impairments in vestibular functioning, balance, or vision. The repeat medical assessment should include a focused clinical history, focused physical examination, and a consideration for the use of additional diagnostic tests as indicated (i.e., screening vestibular oculomotor assessment, visual field testing, and neuroimaging). The medical assessment must consider conditions such as intraparenchymal hemorrhage, stroke, traumatic cranial neuropathy, or temporal bone fractures.
Tool 10.1: Post-Concussion Vestibular (balance/dizziness) and Vision Disturbances Algorithm.
Oculomotor or Vision Deficits
Visual and oculomotor deficits can be due to cranial neuropathies, structural brain injuries, or functional impairments in convergence, accommodation, smooth pursuits, saccades, and vestibulo-ocular reflex functioning. Visual deficits are common symptoms following a concussion. In some patients, these deficits will spontaneously recover and will only need monitoring, supportive care, and anticipatory guidance. However, there is evidence that these deficits may also be associated with increased risk for prolonged symptoms. Identifying these deficits early will allow for early targeted supportive care, management, close monitoring for prolonged, and early referral for further treatment.
Benign Paroxysmal Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) can be caused by the traumatic displacement of the crystals (otoconia) of the inner ear into one of the semi-circular canals. This displacement results in intermittent brief episodes of vertigo and a characteristic pattern of nystagmus (involuntary eye movement) with head movements that stimulate fluid flow in the affected canal (e.g., laying down, sitting up, rolling in bed, looking up, bending over, rapid horizontal head movements). If the patient reports vertigo or dizziness that occurs for seconds following position changes, a screen for BPPV and consideration for targeted particle re-positioning manoeuvres should be conducted. In patients who continue to experience prolonged vertigo or dizziness after completing 3 particle repositioning maneouvers, consideration should be given to a referral to an interdisciplinary concussion team or sub-specialist (i.e., otolaryngology) for further assessment and management.
Vestibulo-Ocular Deficits
The vestibulo-ocular reflex (VOR) enables clear vision with head motion. In many cases, difficulties with clear vision during head motion are reported following a concussion and there is emerging evidence that alterations in VOR function may predict a longer recovery following concussion. Dizziness and/or blurred vision with head motion may be reported and should be further investigated by a healthcare professional with experience in this area. Vestibular rehabilitation has been reported to facilitate recovery when a child/adolescent is experiencing altered gain of the VOR.
Recommendations
LEVEL OF EVIDENCE
A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)
B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)
C = Consensus, usual practice, opinion or weaker-level evidence
10.1
Perform a repeat medical assessment on all patients presenting with dizziness, blurred or double vision, vertigo, difficulty reading, postural imbalance, or headaches elicited by prolonged visual or vestibular stimulation 1-2 weeks following acute injury.
Level of Evidence:
Depending on the nature of the symptoms, the medical assessment should include a focused history, focused physical examination, and consideration for the need for diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.
Tool 10.1: Post-Concussion Vision, Vestibular, and Oculomotor Disturbances Algorithm.
Tool 2.1: Physical examination.
Recommendation 2.1c: When to consider diagnostic brain or cervical spine imaging.
10.2
Screen for oculomotor or vision deficits.
Level of Evidence:
Perform an assessment of visual acuity, pupillary function, visual fields, fundoscopy, and extra-ocular movements.
- With appropriate experience, consider an objective assessment of convergence, accommodation, saccades and smooth pursuits.
- Consider additional tests such as automated visual field testing, formal vestibular testing or diagnostic imaging.
Consider referral to an interdisciplinary concussion team or neuro-ophthalmologist, neuro-optometrist, developmental optometrist, occupational therapist, or physiotherapist with competency-based training in vestibular rehabilitation to assess for impairments in convergence, accommodation, saccades and other visual oculomotor disorders.
Online instructional video to consider:
- Link: Visio-Vestibular Examination (The Children’s Hospital of Philadelphia).
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:
- Link: Dix-Hallpike Test (University of Calgary)
- Link: Epley Manoeuvre (University of Calgary)
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:
- Link: Head Thrust Test and Dynamic Visual Acuity (University of Calgary)
- Link: Visio-Vestibular Examination (The Children’s Hospital of Philadelphia)
- Link: Dynamic Visual Acuity (University of Calgary)
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:
- Link: Visio-Vestibular Examination (The Children’s Hospital of Philadelphia)
- Link: Balance Error Scoring System (The University of North Carolina at Chapel Hill)
- Link: Functional Gait Assessment (University of Calgary)
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:
- Recommendation 2.3: Recommend graduated return to cognitive and physical activity.
- Recommendation 2.4c: Advise on the use of computers, phones, and other screen devices.
- Domain 12: Return-to-School and Work.
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
- Tool 2.1: Physical Examination
- Tool 2.6: Post-Concussion Information Sheet
- Tool 10.1: Post-Concussion Vestibular (balance/dizziness) and Vision Disturbances Algorithm
Online videos to consider:
- Dix-Hallpike Test (University of Calgary)
- Epley Manoeuvre (University of Calgary)
- Head Thrust Test and Dynamic Visual Acuity (University of Calgary)
- Visio-Vestibular Examination (The Children’s Hospital of Philadelphia)
- Balance Error Scoring System (The University of North Carolina at Chapel Hill)
References
Research papers that support the present guideline recommendations:
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Santo, A., Lynall, R. C., Guskiewicz, K. M., & Mihalik, J. P. (2017). Clinical utility of the sport concussion assessment tool 3 (SCAT3) tandem-gait test in high school athletes. Journal of Athletic Training, 52(12), 1096–1100. https://doi.org/10.4085/1062-6050-52.11.26
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
Domain 11: Fatigue
Introduction:
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:
- Emphasize that spreading activities throughout the day helps patients achieve more and that they should avoid doing too much at once.
- Encourage good diet and hydration.
- Encourage good sleep hygiene.
- Avoid daytime napping.
- Identify the triggers of fatigue.
- Encourage the child/adolescent to plan meaningful goals, record activity achievement, and identify patterns of fatigue by using a notebook or diary.
- Link: Sleep for Youth. CHEO Sleep Hygiene handout
- Inform that fatigue can be worsened by low mood or stress.
- Inform that deconditioning can compound fatigue.
- Encourage a gradual return to school with accommodation (Domain 12: Return-to-School and Work).
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
Domain 12: Return-to-school and Work
Introduction:
Overview:
- The return-to-school process should be coordinated by the school’s concussion management team and/or a point person in the school using the post-concussion return to school protocol and medical advice from the student’s health team (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 modified activities (24-48 hours) and as soon as cognitive activities can be tolerated.
- 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 to school/activity/sport on a case-by-case basis.
- Post-concussion return to school and activity protocols: Living Guideline Return to School and Activities Protocols
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:
- Tool 2.0: Living Guideline Return to School and Activities Protocols (SEPT 2023 VERSION)
- Tool 1.2: Living Guideline Patient Information Sheet (SEPT 2023 VERSION)
- Tool 12.1: Concussion Implications and Interventions for the Classroom
- Tool 12.2: Template: Letter of Accommodation from the concussion care team to the school
- Tool 12.3: Template Letter of Accommodation from Physician to School
- Tool 12.4: Sample Letter/Email from School to Parents
- Link: CATT Return to School Strategy (2023 UPDATE COMING SOON)
- Link: CATT Student Return to Learn Plan (2023 UPDATE COMING SOON)
- Link: Heads Up Schools: Helping Students Recover from a Concussion: Classroom Tips for Teachers
- Link: Parachute’s Protocol for Return to Learn After a Concussion (Parachute Canada) (2023 UPDATE COMING SOON)
- Link: Post-Concussion Academic Accommodation Protocol (University of Oregon)
- Link: SCHOOLFirst: Enabling successful return to school for Canadian youth following a concussion (Holland Bloorview Kids Rehabilitation Hospital)
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

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.
- Tool 2.0: Living Guideline Return to School and Learn Protocol (UPDATED SEPT 2023)
- Tool 12.1: Concussion Implications and Interventions for the Classroom
- Tool 12.2: Template: Letter of Accommodation from the concussion care team to the school
- Tool 12.3: Template Letter of Accommodation from Physician to School
- Tool 12.4: Sample Letter/Email from School to Parents
- Link: CATT Return to School Strategy (UPDATE IN PROGRESS)
- Link: CATT Student Return to Learn Plan (UPDATE IN PROGRESS)
- Link: Heads Up Schools: Helping Students Recover from a Concussion: Classroom Tips for Teachers
- Link: Parachute’s Protocol for Return to Learn After a Concussion (Parachute Canada)
- Link: Post-Concussion Academic Accommodation Protocol (University of Oregon)
- Link: SCHOOLFirst: Enabling successful return to school for Canadian youth following a concussion (Holland Bloorview Kids Rehabilitation Hospital)
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:
- Tool 2.0: Living Guideline Return to School Protocol (UPDATED SEPT 2023)
- Tool 12.1: Concussion Implications and Interventions for the Classroom
- Tool 12.2: Template: Letter of Accommodation from the concussion care team to the school
- Tool 12.3: Template Letter of Accommodation from Physician to School
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.
- Domain 8: Mental Health
- Domain 9: Cognition
- Domain 10: Vision, Vestibular, and Oculomotor Function
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:
- Tool 2.0: Living Guideline Return to School Protocol (UPDATED SEPT 2023)
- Tool 12.1: Concussion Implications and Interventions for the Classroom
- Tool 12.2: Template: Letter of Accommodation from the Concussion Care Team to the School
- Tool 12.3: Template Letter of Accommodation from Physician to School
- Tool 12.4: Sample Letter/Email from School to Parents
- Link: SCHOOLFirst Handbook: Enabling successful return to school for Canadian youth following a concussion, page 6 (Holland Bloorview Kids Rehabilitation Hospital)
12.4
Encourage patients with school difficulties to engage in cognitive activity and low-risk physical activity as soon as tolerated. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.
Level of Evidence: A Gradual return to physical activity. B Gradual return to cognitive activity.
See Recommendation 2.3.
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: A Starting return to activity earlier.
For teens who work, please consult the “Guidelines for Concussion/ Mild Traumatic Brain Injury and Persistent Symptoms 3rd Edition For Adults (18+ years of age)” for recommendations on how to work with the adolescent’s employer regarding non-academic accommodations so that the adolescent can gradually return to work while promoting recovery.
Tools and Resources
Living Guideline Tools:
- Tool 12.1: Concussion Implications and Interventions for the Classroom
- Tool 12.2: Template: Letter of Accommodation from the Concussion Care Team to the School
- Tool 12.3: Template Letter of Accommodation from Physician to School
- Tool 12.4: Sample Letter/Email from School to Parents
Online Tools to Consider:
- CATT Return to School Strategy
- CATT Student Return to Learn Plan
- CATT Concussion Resources for School Professionals
- Heads Up Schools: Helping Students Recover from a Concussion: Classroom Tips for Teachers (CDC)
- Parachute’s Protocol for Return to Learn After a Concussion
- Post-Concussion Academic Accommodation Protocol (University of Oregon)
- SCHOOLFirst Handbook: Enabling successful return to school for Canadian youth following a concussion (Holland Bloorview Kids Rehabilitation Hospital)
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