Sixty recommendations, along with sub-recommendations that provide more details, have been organized into a guideline website that has three sections:
- A: Concussion Recognition, Initial Medical Assessment, and Management (Domains 1-5);
- B: Managing Symptoms (Domains 6-12);
- C: Biomarkers (Domains 13,14)
The flow of the website and individual recommendations are based on the ONF Post-Concussion Pathway with the goal of providing a guideline website that will be accessible for all users. Users can click through the recommendations in an intuitive manner when looking for information on pediatric concussion.
A: Concussion Recognition, Initial Medical Assessment, and Management: This section provides information on recognizing a concussion in the community. These recommendations include the role of schools, organizations, coaches, and parents in recognizing a suspected concussion. The importance of bringing all children or adolescents for whom a concussion is suspected to a physician or nurse practitioner for a medical assessment to confirm a diagnosis is highlighted.
This section also includes recommendations related to the initial and follow-up medical exam, medical clearance when returning to sports or high-risk activities, and other sports concussion considerations.
B: Managing Symptoms: This section consists of six domains that provide guideline users with symptom-specific information related to managing acute and prolonged post-concussion headaches, sleep disturbances, mental health considerations, cognitive impairments, vestibular, visual, and oculomotor disturbances, prolonged fatigue, and returning to school and work considerations.
C: Biomarkers: This section provides clinical information related to emerging research in the fields on neuroimaging on biomarkers and serology.
Suggested Online Tools and Resources
Many of the guideline recommendations link to a suggested list of online resources and tools. These tools and links are a subset of the online resources related to diagnosing and managing pediatric concussion that are freely available and are only those that were identified by project team members as being specific to pediatric concussion. Many of the identified resources and tools are reflective of the team’s expertise and geographical distribution. A comprehensive search for all available online tools was not performed. The quality and accuracy of the materials on external websites was not evaluated in a systematic manner. All online tools presented should be reviewed by users to ensure that the information is appropriate for the intended use and audience and that the most appropriate tool is selected.
The ONF and the Living Guideline for Managing and Diagnosing Pediatric Concussion Team and its affiliates have no control or jurisdiction over the content within any tools or resources located on servers maintained by third parties. As such, the aforementioned parties make no representation or warranty with respect to the accuracy or content or any other aspect of the content or information contained within these resources. Finally, the ONF and the Living Guideline for Managing and Diagnosing Pediatric Concussion Team and its affiliates do not endorse any physicians or healthcare professionals, services, treatments, opinions, procedures, opinions or any other aspect of information that may be referred to or referenced in the content of third party websites.
Strengths and Limitations of the Body of Evidence
- There is strong evidence (Level A) to guide clinical practice in four areas: Modifiers that may delay recovery; performing a comprehensive physical examination; considering diagnostic brain or cervical spine imaging; and, assessing existing and new mental health symptoms and disorders
- There is still limited evidence on the ideal return to cognitive activity (yet this remains a mainstay of current treatment)
- There is a paucity of literature that has demonstrated clear pharmacological therapies for concussion
- There remains a high need for objective biomarkers (physiological, fluid or imaging) to confirm the diagnosis of concussion and to track recovery
- There is no clear evidence supporting the routine treatment with nutritional supplements, hyperbaric chambers, or laser therapy. These should not be considered for evidence-based treatment for concussion, and are not recommended.