Section B:

Managing Concussion Symptoms

Introduction

icon imgDomain 6: Headache

Introduction:

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

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

Tool 6.1:Post-Concussion Headache Algorithm.

Recommendations

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

6.1

Perform a repeat medical assessment on all patients presenting with post-concussion headaches 1-2 weeks following acute injury.

Include a focused history, physical examination, and consideration of diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Tool 6.1: Post-Concussion headache algorithm.

6.1a

Take a focused clinical history.

Level of Evidence:   

Collect details that help to classify or characterize the headache subtype(s) that are present. 

  • Headache onset, location, quality or character, severity, and frequency.
  • Factors that elicit or worsen headaches (e.g., bright lights, reading, exercise, foods, etc.).
  • Factors that alleviate headaches.
  • Associated symptoms (e.g., aura, photosensitivity, dizziness, eye strain, neck pain).
  • The presence of red flags which may indicate a more severe brain injury or other intracranial pathology (e.g., worsening headaches, repeated vomiting, weakness or numbness of the extremities, visual changes). 
  • The level of disability associated with the headache (e.g., missed days from school).
  • Use of medications or other substances.
  • Psychological or social factors or conditions that can be associated with stress and headaches (e.g., mood or anxiety disorders) (Domain 8: Mental Health).
  • Assess how much headaches affect day-to-day activities.
  • Disturbed sleep.
  • Personal and family history of headaches and headache disorders (e.g., migraine).
  • Future participation in full-contact sport or high-risk activities.

6.1b

Perform a focused physical examination. 

Level of Evidence:   

  • Vital signs (resting heart rate and blood pressure).
  • A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait and balance testing) Tool 2.1: Physical Examination.
  • A cervical spine examination (palpation, range of motion, provocative cervical spine tests). Tool 2.1: Physical Examination.
  • With appropriate experience, consider performing an examination of vision, oculomotor and vestibular functioning (Domain 10: Vision, Vestibular, and Oculomotor Function).

6.1c

Consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Level of Evidence:   CT.  MRI.

See Recommendation 2.1d for more information on when to consider diagnostic brain or cervical spine imaging.

6.1d

Classify and characterize the headache subtype based on the clinical history and physical examination findings. 

Level of Evidence:   

Tool 6.1: Post-Concussion Headache Algorithm.

Link: International Classification of Headache Disorders (ICHD-III)*.

Common prolonged post-concussion headache subtypes include: 

  • Migraine, tension, or cluster headaches. 
  • Cervicogenic headaches. 
  • Physiological or exercise-induced headaches.
  • Headaches associated with prolonged visual stimulation.
  • Occipital neuralgia.

* “Reproduced with permission of International Headache Society”.

6.2

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

6.2a

Advise on non-pharmacological strategies to minimize headaches including sleep hygiene, activity modifications, limiting triggers, and information on screen time. 

Level of Evidence:  

6.2b

Encourage patients with headaches to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation threshold. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   Physical activity. Cognitive activity.

See Recommendation 2.3.

See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

6.2c

Consider suggesting the use of a headache and medication diary in order to monitor symptoms and medications taken. Use clinical judgment and an individualized approach on use or duration of this strategy. 

Level of Evidence:  

Link: Headache and Medication Diary (Boston Children’s Hospital)

6.2d

Over-the-counter medications such as acetaminophen and ibuprofen may be recommended to treat acute headache. Advise on limiting the use of these medications to less than 15 days a month and avoiding “around-the-clock” dosing to prevent overuse or rebound headaches. I.e., advise that children/adolescents avoid using over the counter medications at regular scheduled times throughout the day.

Level of Evidence:  

6.3

Refer patients who have prolonged post-concussion headaches for more than 4 weeks to an interdisciplinary concussion team or to a sub-specialist for further evaluation and management.

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.

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

References

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

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

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

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

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.

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

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

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

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

Additional references that helped to inform the domain recommendations:

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

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

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

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

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

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

icon imgDomain 7: Sleep

Introduction:

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

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

Tool 7.1: Managing post-concussion sleep disturbances algorithm.

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

Recommendations

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

7.1

Perform a repeat medical assessment on all patients presenting with post-concussion sleep disturbances 1-2 weeks following acute injury. 

Level of Evidence:  

Include a focused history, physical examination, and consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Screen for factors that may influence the child/adolescent’s sleep/wake cycle and for sleep-wake disturbances such as insomnia or excessive daytime sleepiness.

7.2

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

Level of Evidence:  

7.2a

Continue to encourage patients with sleep disturbances to engage in sub-symptom threshold cognitive activities and physical activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) as soon as tolerated. 

Level of Evidence:   Gradual return to physical activity. Gradual return to cognitive activity.

See Recommendation 2.3.

See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

7.3

Consider managing patients who experience sleep-wake disturbances for more than 4 weeks with cognitive behavioural therapy, treat with daily supplements, and/or refer to an interdisciplinary concussion team.

Level of Evidence:  

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).

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.

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.

7.4

Refer patients with prolonged post-concussion sleep disturbances (more than 6 weeks) to a sleep specialist or an interdisciplinary concussion team if the interventions introduced at 4 weeks have been unsuccessful and sleep issues persist.

Level of Evidence:  

If sleep issues persist for more than 6 weeks post-acute injury, sleep hygiene can’t be optimized, and if poor sleep quality is impacting the ability to return-to-school or ability to recondition:

  • Refer to a sleep specialist who has experience with concussion and polysomnography or to an interdisciplinary concussion team that has the expertise to understand sleep disturbances in the context of concussion-related symptoms.

Consider ordering sleep tests to rule out possible sleep-related breathing disorders, nocturnal seizures, periodic limb movements, or narcolepsy.

  • Examples of sleep tests include Sleep Study, Multiple Sleep Latency Test, and the Maintenance of Wakefulness Test.

7.5

Consider prescribing medication on a short-term basis if sleep has not improved after 6 weeks following the acute injury. 

Level of Evidence:  

Ensure that medications do not result in dependency and that the patient has minimal adverse effects. The aim is to establish a more routine sleep pattern.

If sleep disturbances persist after pharmacological treatment refer to a pediatric sleep specialist ideally with experience with concussion and polysomnography. 

7.6

Recommend a medical follow-up to reassess clinical status if sleep disturbances persist. Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (before 4 weeks) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence: Medical follow-up.  Early referral in the presence of modifiers that may delay recovery.

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

References

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

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

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

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

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

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

Additional references that helped to inform the domain recommendations:

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

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

Meng, X., Li, Y., Li, S., Zhou, Y., Gan, R. Y., Xu, D. P., & Li, H. B. (2017). Dietary Sources and Bioactivities of Melatonin. Nutrients9(4), 367. https://doi.org/10.3390/nu9040367

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

icon imgDomain 8: Mental Health

Introduction:

There is evidence that early identification of common mental health disorders and risk factors for mental health disorders may prevent/mitigate additional problems such as learning and behavior problems, school avoidance and exacerbation of pre-existing problems. Having a mental health disorder prior to concussion is a critical risk factor for a post-concussion mental health disorder.

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

It is important to:

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

Tool 8.1: Post-Concussion Mental Health Considerations Algorithm.

Tool 8.2: Management of Prolonged Mental Health Disorders Algorithm.

Recommendations

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

8.1

Assess existing and new mental health symptoms and disorders. 

Level of Evidence:

Experienced and trained healthcare professionals should use appropriate screening tools to assess the child/adolescent. These assessments should be considered for children/adolescents with a history of mental health problems or with prolonged post-concussive symptoms. 

Use Tool 8.1: Post-concussion mental health considerations algorithm and refer to a mental health specialist using clinical judgment.

Assessment screening tools to consider (direct website links):

8.2

Assess the child/adolescent’s broader environment, including family and caregiver function, mental health, and social connections. 

Level of Evidence:   

  • Ask about socioeconomic status (caregiver education, family income, occupation).
  • Ask about social impacts and life stressors (school setting, friends, teammates).
  • Ask the child/adolescent and parents and/or caregivers to complete the following, as appropriate:

8.3

Treat mental health symptoms or refer to a specialist in pediatric mental health. 

Level of Evidence:   

Base the mental health treatment on individual factors, patient preferences, the severity of symptoms, and co-morbidities.

Tools to assist healthcare professionals to make treatment decisions:

Consider referring to a local healthcare professional, specialized pediatric concussion program or to a specialist with experience in pediatric mental health if child/adolescent has prolonged or urgent mental health symptoms. Provide the name of a specialist with experience in pediatric mental health.

For deciding when to refer a child/adolescent to a specialist, use Tool 8.1: Post-Concussion Mental Health Considerations Algorithm

Tools and Resources

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

References

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

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

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

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

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

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

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

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

icon imgDomain 9: Cognition

Introduction:

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

Recommendations

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

9.1

Evaluate a child/adolescent for cognitive symptoms that interfere with daily functioning following the acute injury. 

Level of Evidence:   

For symptoms that interfere with daily functioning for more than 4 weeks following acute injury, further evaluation by experienced professionals to assess cognitive problems may be required. 

Depending on the nature of the cognitive symptoms, examples of professionals may include:

  • Experienced educational professionals.
  • Pediatric neuropsychologists.
  • Occupational therapists.
  • Speech language pathologists.

Other assessments may be required to determine the underlying cause(s) and any pre-existing contributing factors that can be managed:

9.2

Manage cognitive symptoms that interfere with daily functioning for more than 4 weeks following acute injury.

Level of Evidence:   

See Domain 3: Medical Follow-up and Management of Prolonged Symptoms.

See Domain 12: Return-to-School and Work for suggestions to guide an initial discussion about the best pathways for the student in school, employment, sports, social, and home environments. Tools and tests should be used in conjunction with an examination of previous school records such as marks and teacher observations.

Tools and Resources
References

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

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

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

icon imgDomain 10: Vision, Vestibular and Oculomotor Function

Introduction:

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

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

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

Oculomotor or Vision Deficits

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

Benign Paroxysmal Positional Vertigo 

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

Vestibulo-Ocular Deficits

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

Recommendations

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

10.1

Perform a repeat medical assessment on all patients presenting with dizziness, blurred or double vision, vertigo, difficulty reading, postural imbalance, or headaches elicited by prolonged visual or vestibular stimulation 1-2 weeks following acute injury.

Level of Evidence:   

Depending on the nature of the symptoms, the medical assessment should include a focused history, focused physical examination, and consideration for the need for diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Tool 10.1: Post-Concussion Vision, Vestibular, and Oculomotor Disturbances Algorithm.

Tool 2.1: Physical examination.

Recommendation 2.1d: When to consider diagnostic brain or cervical spine imaging.

10.2

Screen for oculomotor or vision deficits.

Level of Evidence:  

Perform an assessment of visual acuity, pupillary function, visual fields, fundoscopy, and extra-ocular movements.

  • With appropriate experience, consider an objective assessment of convergence, accommodation, saccades and smooth pursuits.
  • Consider additional tests such as automated visual field testing, formal vestibular testing or diagnostic imaging.

Consider referral to an interdisciplinary concussion team or neuro-ophthalmologist, neuro-optometrist, developmental optometrist, occupational therapist, or physiotherapist with competency-based training in vestibular rehabilitation to assess for impairments in convergence, accommodation, saccades and other visual oculomotor disorders.

Online instructional video to consider:

10.3

Screen for benign paroxysmal positional vertigo (BPPV) if the patient reports vertigo or dizziness that occurs for seconds following position changes and consider targeted particle re-positioning manoeuvres.

Level of Evidence:  

After completing a neurological screen and clearing the cervical spine to move into the test position, perform the Dix-Hallpike Test. If positive for BPPV (i.e., reproduction of vertigo, typically for seconds, in addition to a characteristic pattern of nystagmus for the canal that is being assessed), a Particle Repositioning Manoeuvre may be appropriate.

Consider the Epley Manoeuvre which can be used to treat the anterior and posterior canals in the case of a canalithiasis. There are many subtypes of BPPV that may require further assessment or alternate canalith repositioning manoeuvres and referral to a healthcare professional (often a physiotherapist with competency-based training in vestibular rehabilitation) for treatment.  If symptoms are provoked by pressure (i.e., val salva) or accompanied by a change in hearing, referral to an otolaryngologist or neuro-otologist is warranted.    

In patients who continue to experience prolonged vertigo or dizziness despite 3 particle repositioning maneouvers, consider referral to an interdisciplinary concussion team or neuro-otologist or physiotherapist with competency-based training in vestibular rehabilitation. These experienced healthcare professionals should rule out alternative peripheral and central vestibular disorders (e.g., superior semi-circular canal dehiscence (SSCD), vestibular hypofunction) and initiate active management with rehabilitation or referral as appropriate.  

Online instructional videos to consider:

10.4

Screen for vestibulo-ocular deficits.

Level of Evidence:   

With appropriate experience, perform an assessment of the vestibulo-ocular reflex (VOR) such as the head thrust test and dynamic visual acuity.

Consider referral to a physiotherapist with competency-based training in vestibular rehabilitation.

Online instructional videos to consider:

10.5

Screen for balance deficits.

Level of Evidence:  

Assess for prolonged balance deficits and determine which systems (visual reflexes, inner ear, musculoskeletal, nervous system or brain) might be contributing to dizziness, headaches, and balance problems. Vestibular rehabilitation may improve balance and dizziness. If prolonged impairment is identified, refer to a specialist immediately.

Perform assessment of postural stability and balance.

  • Standing balance test (eyes open/closed, tandem stance, single leg stance), Balance Error Scoring System.
  • Dynamic balance: Consider the Functional Gait Assessment and BOT (Bruininks-Oseretsky Test of Motor Proficiency) tests.

Consider referral to an interdisciplinary concussion team or physiotherapist with competency-based training in vestibular rehabilitation.

Online instructional videos to consider:

10.6

Screen for and consider underlying psychosocial causes of vestibular, vision, and oculomotor dysfunction.

Level of Evidence:  

Domain 8: Mental Health.

10.7

Provide general post-concussion education that outlines symptoms of concussion, provides suggestions regarding activity modification and includes academic accommodations to manage visual, vestibular and oculomotor symptoms. 

Level of Evidence:  

Guidance about how to make a gradual return-to-school, cognitive activities, and physical activities:

10.8

Encourage patients with post-concussion vestibular, visual, or oculomotor symptoms to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation thresholds. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   Gradual return to physical activity. Gradual return to cognitive activity.

See Recommendation 2.3.

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.

Tool 10.1: Post-Concussion Vision, Vestibular, and Oculomotor Disturbances Algorithm

Assessment by an interdisciplinary concussion team can assist in identifying the type of management that is required, along with the medical and health professions on the interdisciplinary concussion team or external to this team who can provide the required management. Not all children/adolescents will require care from all members of the interdisciplinary concussion team and care should be targeted based on identified symptoms and patient needs.

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

10.10

Recommend a medical follow-up to reassess clinical status if vestibular functioning, balance or visual dysfunction symptoms persist. Recommend an immediate medical follow-up in the presence of any deterioration.  

Level of Evidence:  

Tools and Resources

Online videos to consider:

References

Alberts, J. L., Thota, A., Hirsch, J., Ozinga, S., Dey, T., Schindler, D. D., … Linder, S. M. (2015). Quantification of the Balance Error Scoring System with Mobile Technology. Medicine and Science in Sports and Exercise, 47(10), 2233–2240. https://doi.org/10.1249/MSS.0000000000000656

Alsalaheen, B. A., Haines, J., Yorke, A., Stockdale, K., & Broglio, S. P. (2015). Reliability and concurrent validity of instrumented balance error scoring system using a portable force plate system. Physician and Sportsmedicine, 43(3), 221–226. https://doi.org/10.1080/00913847.2015.1040717

Alsalaheen, B. A., Whitney, S. L., Marchetti, G. F., Furman, J. M., Kontos, A. P., Collins, M. W., & Sparto, P. J. (2016). Relationship between cognitive assessment and balance measures in adolescents referred for vestibular physical therapy after concussion. Clinical Journal of Sport Medicine, 26(1), 46–52. https://doi.org/10.1097/JSM.0000000000000185

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

Anzalone, A. J., Blueitt, D., Case, T., McGuffin, T., Pollard, K., Garrison, J. C., … Oliver, J. M. (2017). A Positive Vestibular/Ocular Motor Screening (VOMS) Is Associated with Increased Recovery Time after Sports-Related Concussion in Youth and Adolescent Athletes. American Journal of Sports Medicine, 45(2), 474–479. https://doi.org/10.1177/0363546516668624

Conder, R. L., Conder, A. A., Register-Mihalik, J., Conder, L. H., & Newton, S. (2015). Preliminary Normative Data on the Penn State University Symbol Cancellation Task With Nonconcussed Adolescents. Applied Neuropsychology: Child, 4(3), 141–147. https://doi.org/10.1080/21622965.2013.816849

Corwin, D. J., Wiebe, D. J., Zonfrillo, M. R., Grady, M. F., Robinson, R. L., Goodman, A. M., & Master, C. L. (2015). Vestibular deficits following youth concussion. Journal of Pediatrics, 166(5), 1221–1225. https://doi.org/10.1016/j.jpeds.2015.01.039

Cossette, I., Gagné, M.-È., Ouellet, M.-C., Fait, P., Gagnon, I., Sirois, K., … McFadyen, B. J. (2016). Executive dysfunction following a mild traumatic brain injury revealed in early adolescence with locomotor-cognitive dual-tasks. Brain Injury, 30(13–14), 1648–1655. https://doi.org/10.1080/02699052.2016.1200143

Dematteo, 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

Dorman, J. C., Valentine, V. D., Munce, T. A., Tjarks, B. J., Thompson, P. A., & Bergeron, M. F. (2015). Tracking postural stability of young concussion patients using dual-task interference. Journal of Science and Medicine in Sport, 18(1), 2–7. https://doi.org/10.1016/j.jsams.2013.11.010

Ellis, M. J., Cordingley, D. M., Vis, S., Reimer, K. M., Leiter, J., & Russell, K. (2017). Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics, 19(1), 38–45. https://doi.org/10.3171/2016.7.PEDS16310

Ellis, M. J., Cordingley, D., Vis, S., Reimer, K., Leiter, J., & Russell, K. (2015). Vestibulo-ocular dysfunction in pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics, 16(3), 248–255. https://doi.org/10.3171/2015.1.PEDS14524

Fabri, T. L., Wilson, K. E., Holland, N., Hickling, A., Murphy, J., Fait, P., & Reed, N. (2017). Using a dual-task protocol to investigate motor and cognitive performance in healthy children and youth. Gait and Posture, 54, 154–159. https://doi.org/10.1016/j.gaitpost.2017.03.002

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

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

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

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

Hansen, C., Cushman, D., Anderson, N., Chen, W., Cheng, C., Hon, S. D., & Hung, M. (2016). A Normative Dataset of the Balance Error Scoring System in Children Aged between 5 and 14. Clinical Journal of Sport Medicine, 26(6), 497–501. https://doi.org/10.1097/JSM.0000000000000285

Hansen, C., Cushman, D., Chen, W., Bounsanga, J., & Hung, M. (2017). Reliability testing of the balance error scoring system in children between the ages of 5 and 14. Clinical Journal of Sport Medicine, 27(1), 64–68. https://doi.org/10.1097/JSM.0000000000000293

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

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

Howell, D. R., Brilliant, A., Berkstresser, B., Wang, F., Fraser, J., & Meehan, W. P. (2017). The Association between Dual-Task Gait after Concussion and Prolonged Symptom Duration. Journal of Neurotrauma, 34(23), 3288–3294. https://doi.org/10.1089/neu.2017.5191

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

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

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

Howell, D. R., Osternig, L. R., & Chou, L. S. (2015). Adolescents demonstrate greater gait balance control deficits after concussion than young adults. American Journal of Sports Medicine, 43(3), 625–632. https://doi.org/10.1177/0363546514560994

Howell, D. R., Osternig, L. R., & Chou, L. S. (2015). Return to activity after concussion affects dual-task gait balance control recovery. Medicine and Science in Sports and Exercise, 47(4), 673–680. https://doi.org/10.1249/MSS.0000000000000462

Howell, D. R., Osternig, L. R., & Chou, L. S. (2016). Consistency and cost of dual-task gait balance measure in healthy adolescents and young adults. Gait and Posture, 49, 176–180. https://doi.org/10.1016/j.gaitpost.2016.07.008

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

Howell, D. R., Osternig, L. R., Koester, M. C., & Chou, L.-S. (2014). The effect of cognitive task complexity on gait stability in adolescents following concussion. Experimental Brain Research, 232(6), 1773–1782. https://doi.org/10.1007/s00221-014-3869-1

Howell, D. R., Shore, B. J., Hanson, E., & Meehan, W. P. (2016). Evaluation of postural stability in youth athletes: the relationship between two rating systems. Physician and Sportsmedicine, 44(3), 304–310. https://doi.org/10.1080/00913847.2016.1197763

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

Hugentobler, J. A., Gupta, R., Slater, R., Paterno, M. V., Riley, M. A., & Quatman-Yates, C. (2016). Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment. Clinical Journal of Sport Medicine, 26(6), 510–517. https://doi.org/10.1097/JSM.0000000000000286

King, L. A., Horak, F. B., Mancini, M., Pierce, D., Priest, K. C., Chesnutt, J., … Chapman, J. C. (2014). Instrumenting the balance error scoring system for use with patients reporting persistent balance problems after mild traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 95(2), 353–359. https://doi.org/10.1016/j.apmr.2013.10.015

Königs, M., Weeda, W. D., Van Heurn, L. W. E., Vermeulen, R. J., Goslings, J. C., Luitse, J. S. K., … Oosterlaan, J. (2015). Impaired Visual Integration in Children with Traumatic Brain Injury: An Observational Study. PLoS ONE, 10(12), 1–15. https://doi.org/10.1371/journal.pone.0144395

Lynch, J. M., Anderson, M., Benton, B., & Green, S. S. (2015). The gaming of concussions: A unique intervention in postconcussion syndrome. Journal of Athletic Training, 50(3), 270–276. https://doi.org/10.4085/1062-6050-49.3.78

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

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

Murray, N. G., Ambati, V. N. P., Contreras, M. M., Salvatore, A. P., & Reed-Jones, R. J. (2014). Assessment of oculomotor control and balance post-concussion: A preliminary study for a novel approach to concussion management. Brain Injury, 28(4), 496–503. https://doi.org/10.3109/02699052.2014.887144

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

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

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

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

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

Rhine, T., Quatman-Yates, C., & Clark, R. A. (2017). A longitudinal examination of postural impairments in children with mild traumatic brain injury: Implications for acute testing. Journal of Head Trauma Rehabilitation, 32(2), E18–E23. https://doi.org/10.1097/HTR.0000000000000192

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

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

Sambasivan, K., Grilli, L., & Gagnon, I. (2015). Balance and mobility in clinically recovered children and adolescents after a mild traumatic brain injury. Journal of Pediatric Rehabilitation Medicine, 8(4), 335–344. https://doi.org/10.3233/PRM-150351

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

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

icon imgDomain 11: Fatigue

Introduction:

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

Recommendations

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

11.1

Perform a repeat medical assessment on all patients presenting with post-concussion fatigue 1-2 weeks following acute injury. 

Level of Evidence:  

The medical assessment should include a clinical history of symptoms, physical examination, and screen for other causes of fatigue (e.g., mononucleosis, anemia, thyroid dysfunction, mood disorders, pregnancy, etc.).

11.2

Provide patients with post-concussion fatigue with general education and guidance that outlines non-pharmacological strategies to help cope with fatigue symptoms and set expectations. 

Level of Evidence:  

Strategies and post-concussion education guidance related to fatigue:

11.3

Encourage patients with post-concussion fatigue to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation thresholds. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence: Gradual return to physical activity. Gradual return to cognitive activity. 

See Recommendation 2.3.

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.

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

References

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

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

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

icon imgDomain 12: Return-to-school and Work

Introduction:

Parents and/or caregivers need to be made aware that most youth will experience symptom resolution and full return to daily activities following a concussion; however this is highly variable and individual. It is reasonable for a child/adolescent to miss some school after a concussion, regardless of symptoms. However, it is also important not to allow or encourage the child/adolescent to “settle into the habit” of missing school. The school setting provides beneficial contact with peers and social support. A gradual return-to-school and activity is the best way to make sure that the child/adolescent remains symptom-free when he or she fully engages in school and related activities.

Overview:

  • The return-to-school process should be coordinated by the school’s concussion management team and/or a point person in the school (e.g., guidance counsellor, principal/vice principal, teacher, etc.).
  • A key to the initial management of concussion is a gradual return-to-school and activities as symptoms are improving.
  • Manage the gradual return to school/activity/sport on a case-by-case basis.
  • Making short-term changes to a student’s school workload and schedule can help the child/adolescent get back to their regular school routine. Accommodations can be modified as symptoms resolve.
  • Recommend an additional assessment or referral to an interdisciplinary concussion team if symptoms worsen or fail to improve 2-4 weeks following the acute injury.

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

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

Recommend a stepwise return-to-school plan and monitor once the student is ready to start a graduated return-to-school. Include temporary accommodations based on symptoms and recommendations from the healthcare professional.  Modify the return-to-school plan based on ongoing assessment of symptoms.  

Level of Evidence:   

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

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

12.2

Assess for school difficulties using clinical judgment.

Level of Evidence:   

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

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

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

12.3

Manage school difficulties. 

Level of Evidence:  

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

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

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

Summary of tools to consider:

12.4

Encourage patients with school difficulties to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation thresholds. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   Gradual return to physical activity. Gradual return to cognitive activity.

See Recommendation 2.3

12.5

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

Level of Evidence:  

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

12.6

Prioritize return-to-school before return to work.

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

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

References

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

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Section A:

Concussion Recognition, Initial Medical Assessment, Management

Section C:

Biomarkers