Recent Guideline Updates

Last update: March 1, 2021 Link: All Living Guideline PRISMA diagrams available for download 

Domain

Recommendation

Update

Evidence

% Consensus

Domain 15-Telehealth and Virtual Care

Recommendations 15.1-15.6 Considerations for a virtual medical assessment and follow-up

Tools 15.1 and 15.2 (Algorithm and physical exam)

New set of recommendations. See Domain 15

See Domain 15 Reference list

93% (full expert team vote that included 27/35 of the active panel members (77% quorum)

2- Initial Diagnosis and Management

2.3. Graduated return to physical and cognitive activity

New Recommendation:  Update recommendation 2.3 to include a section “d” that shares the suggestion to consider referring select patients (e.g., highly active or competitive athletes and/or those who are not tolerating a graduated return to physical activity) to a medically supervised inter-disciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment.

Coclick et al 2020,

Haider et al 2020,

DeMatteo et al 2020, Del Rossi et al 2020, Root et al 2020, Sharma et al 2020, Marshall et al 2020, Leddy et al 2019, Chan et al 2018, See domain 2 reference link for a full list.  . New- Dec 2020 paper under consideration: Langevin et al 2020     .

93% (full expert team vote, that included 36/39 of the active panel team member experts)

2- Initial Diagnosis and Management

2.2 Return to School

Minor clarification: Highlight the return to school information from Domain 12 by including information about  Acute academic adjustments for concussion and give examples of academic adjustments to help support students transitioning back to school

Master et al 2020

50% (not added)

1-Diagnosis

1.4 When to suspect concussion

Minor revision: “It is important to note that some patients may experience a delayed onset of concussion symptoms. Delayed concussion symptoms also require medical assessment to exclude more severe injuries.”

Kontos et al 2020,

Gravel et al 2020, Borland et al 2019,

100%

7- Sleep

 

Minor revision: Add in a star to the melatonin recommendation that includes: “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)

Barlow et al 2020

100%

7- Sleep

 

A review of the timing of the recommended use of Melatonin and the dose has been suggested.

Barlow et al 2020 (pediatrics), Iyver et al 2020, Barlow et al 2020 (Ped Neurol)

Vote in progress

2- Initial Diagnosis and Management

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

Minor Revision: Update the list of modifiers for a prolonged recovery to include: High symptom burden at initial presentation, clinical evidence of vestibular or oculomotor dysfunction, duration of recovery from a previous concussion.

Zemek et al 2016, Beauchamp et al 2018, Ellis et al 2018, Fehr et al 2019Guerriero et al 2018, Howell et al 2018, Howell et al 2018, Ledoux et al 2019Master et al 2018Yeates et al 2019

100%

2- Initial Diagnosis and Management

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

Minor Revision: Include a sentence sharing that the information that females aged 13-18 years have an increased risk of a prolonged recovery.

Ledoux et al 2019

83%

7- Sleep

Introduction

Minor Revision: Update the 4th sentence of the introduction to include: “Medication use, headaches and mental health conditions (e.g. anxiety, depression) may also affect sleep. Poor sleep may be related to cognitive complaints and worse post-concussion symptoms. A repeat…”

Murdaugh et al 2018

Wiseman-Hakes et al 2019

100%

4- Medical Clearance

4.1: Child/adolescent has successfully returned to all school activities including writing exams without symptoms above their previous pre-injury level or requiring accommodations related to their concussion/post-concussion symptoms.

Minor revision:

Update level of evidence to

Dematteo et al 2019

100%

12- Return to School and Work

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.

Minor Revision: 

Update level of evidence to

Dematteo et al 2019

80%

* Consensus for minor revisions: Minimum three domain experts vote on minor revisions. 75% consensus is required to proceed with a minor revision. Please see the Methodology Living Guideline pdf for more information. 

* Consensus for minor revisions: Minimum three domain experts vote on minor revisions. 75% consensus is required to proceed with a minor revision. Please see the Methodology Living Guideline pdf for more information. **Consensus for major revisions: A quorum of 75% of active expert panel members are required to vote on the improvement. 75% consensus is required to proceed with a major revision. A pediatric pharmacist will perform an additional review for any proposed changes in dosing. ** Definitions of the A, B, C level of evidence can be found here: Levels of Evidence