Guideline For Concussion/Mild Traumatic Brain Injury & Prolonged Symptoms
GuidelineforConcussion/MildTraumaticGuideline for Concussion/Mild TraumaticBrainInjury&ProlongedSymptomsBrain Injury & Persistent SymptomsHealthcare Professional VersionThird EditionAdults (18 years of age)Complete Version
COMPLETE VERSIONThe project team would like to acknowledge the Ontario Neurotrauma Foundation (ONF), who initiated andfunded the development of the original guideline, as well as the current update. ONF is an applied healthresearch organization with a focus on improving the quality of lives for people with an acquired brain injury orspinal cord injury, and on preventing neurotrauma injuries from occurring in the first place. ONF uses strategicresearch funding activity embedded within a knowledge mobilization and implementation framework to buildcapacity within systems of care. ONF works with numerous stakeholders and partners to achieve its objectiveof fostering, gathering and using research knowledge to improve care and quality of life for people who havesustained neurotrauma injuries, and to influence policy towards improved systems. The foundation receives itsfunding from the Ontario Government through the Ministry of Health and Long-Term Care.Please note, the project team independently managed the development and production of the guideline and,thus, editorial independence is retained. Ontario Neurotrauma Foundation 2018Ontario Neurotrauma Foundation90 Eglinton EastToronto, ON, Canada M4P 2Y3Tel.: 1 (416) 422-2228Fax: 1 (416) 422-1240Email: info@onf.orgwww.onf.orgPublished May 2018Cover Photo Credit: Puzzle Image: wallpaperwide.com
The recommendations and resources found within the Guideline for Concussion/mTBI & Prolonged Symptoms are intended to inform and instruct care providers andother stakeholders who deliver services to adults who have sustained or aresuspected of having sustained a concussion/mTBI (mild traumatic brain injury). Thisguideline is not intended for use with patients or clients under the age of 18 years.This guideline is not intended for use by people who have sustained or are suspectedof having sustained a concussion/mTBI for any self-diagnosis or treatment. Patientsmay wish to bring their healthcare and other providers’ attention to this guideline.The recommendations provided in this guideline are informed by best available evidenceat the time of publication, and relevant evidence published after this guidelinecould in luence the recommendations made within. Clinicians should alsoconsider their own clinical judgement, patient preferences and contextual factorssuch as resource availability in clinical decision-making processes.The developers, contributors and supporting partners shall not be liable for any damages,claims, liabilities, costs or obligations arising from the use or misuse of this material,including loss or damage arising from any claims made by a third party.
Table of ContentsINTRODUCTION.1KEY RECOMMENDATIONS.8GUIDELINE RECOMMENDATIONS1. Diagnosis/Assessment of Concussion/mTBI.122. Initial Management of Concussion/mTBI.183. Sport-Related Concussion/mTBI.224.General Recommendations Regarding Diagnosis/Assessment of Prolonged Symptoms .275.General Recommendations Regarding Management of Prolonged Symptoms .296. Post-Traumatic Headache.337. Persistent Sleep-Wake Disturbances.388. Persistent Mental Health Disorders.439. Persistent Cognitive Difficulties.5010. Persistent Vestibular (Balance/Dizziness) and Vision Dysfunction.5311. Persistent Fatigue.5612. Return-To-Activity/Work/School Considerations.59ALGORITHMS1.1: Initial Diagnosis/Assessment of Adult mTBI.162.1: Initial Management of Symptoms Following mTBI.215.1: Management of Persistent Symptoms Following mTBI.326.1: Assessment and Management of Post-Traumatic Headache Following mTBI.377.1: Assessment and Management of Persistent Sleep-Wake Disturbances Following mTBI.428.1: Assessment and Management of Persistent Mental Health Disorders Following mTBI.4912.1: Return-to-Work Considerations.6712.2: Return-to-School (Post-Secondary) Considerations.68APPENDICESSection 1: Diagnosis/Assessment of Concussion/mTBI1.1: Acute Concussion Evaluation (ACE): Physician/Clinician Office Version.781.2: Abbreviated Westmead Post-Traumatic Amnesia Scale (A-WPTAS).801.3: Brain Injury Advice Card (Long Version).831.4: Brain Injury Advice Cards (Short Versions).871.5: Rivermead Post Concussion Symptoms Questionnaire.911.6: Post Concussion Symptom Scale.92Section 2: Management of Concussion/mTBI2.1: Specialized Concussion Clinics/Centres in Ontario.932.2: The Parkwood Pacing Graphs .100Section 3: Sport-Related Concussion/mTBI3.1: Sport Concussion Assessment Tool (SCAT5).1033.2: Concussion Recognition Tool 5 (CRT5). 1113.3: Buffalo Concussion Treadmill Test (BCTT). 1123.4: Important Components to Include in the Neurological and Musculoskeletal Exam. 115Section 4: General Recommendations Regarding Diagnosis/Assessment and Persistent Symptoms4.1: ICD-10 Definitions for Differential Diagnoses Related to mTBI. 116Section 6: Post-Traumatic Headache6.1: ICHD-III Beta: Acute Headache Attributed to Mild Traumatic Injury to the Head. 1186.2: ICHD-III Beta: Persistent Headache Attributed to Mild Traumatic Injury to the Head. 119Table of ContentsSection 1 2 3 4 5 6 7 8 9 10 11 12Guidelines for Concussion/mTBI and Prolonged Symptoms: 3rd Ed.I
Table of Contents6.3: Diagnostic Criteria for Selected Primary Headache Types from the ICHD-III Beta.1206.4: Headache Diary.1236.5: International Classification of Headache Disorders (ICHD-III Beta): Medication-Overuse Headache.1246.6: Self-Regulated Intervention and Lifestyle Strategies to Minimize Headache Occurrence.1256.7: Prophylactic Therapy.127Section 7: Sleep-Wake Disturbances7.1: Brief Definitions of Sleep Disorders Most Frequently Reported Following mTBI.1287.2: Short Clinical Interview for Sleep after Head Injury.1297.3: Sleep and Concussion Questionnaire.1307.4: Sleep Hygiene Program.1337.5: Behavioural Recommendations for Optimal Sleep.1347.6: Sleep Diary.1357.7: Limiting the Time Spent in Bed to Actual Sleep Time.1377.8: Re-creating a Time and Place for Sleep.140Section 8: Mental Health Disorders8.1: Patient Health Questionnaire 9-Item Scale (PHQ-9) for Depression.1438.2: Generalized Anxiety Disorder 7-Item Scale (GAD-7).1458.3: Primary Care Post-Traumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5).1478.4: Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5).1488.5: CAGE and CAGE-AID Questionnaire.149Section 10: Vestibular (Balance/Dizziness) and Vision Dysfunction10.1: Dizziness Handicap Inventory.15010.2: Dix-Hallpike Manoeuvre.15210.3: Particle Repositioning Manoeuvre (PRM)/Epley Manoeuvre.15310.4: Screening Techniques for Vision Dysfunction.154Section 11: Fatigue11.1: Barrow Neurological Institute (BNI) Fatigue Scale.15611.2: List of Medications Associated with Fatigue, Asthenia, Somnolence and Lethargy from the MSC Guideline.15711.3: Patient Advice Sheet on Coping Strategies for Fatigue.15911.4: Gradually Increasing Physical Activity to Better Manage Fatigue.161Section 12: Return-to-Activity/Work/School Considerations12.1 Components of the Vocational Evaluation Following mTBI.16312.2 Example Concussion/mTBI Accessibility Intake Package for Student Services/Special Needs Department.16612.3 Greater Accommodations for Students with Persistent Symptoms following mTBI.17512.4 Managing Your Return to Post-Secondary Activities: Package Template and Activity Log.17712.5 Acute Concussion Evaluation (ACE) Care Plan - Work Version.18112.6 Acute Concussion Evaluation (ACE) Care Plan - School Version.183A: Project Members.185B: Formal Schema Used in the Establishment of the mTBI Expert Consensus Group.187C: Conflicts of Interest.190D: Database Search Strategies.198E: Example Summary Spreadsheet of New Evidence and Guidance Provided to the Working Groups at the Expert Consensus Conference.200F: Other Links/References for Resources to Consider.205G: Results of the mTBI Systematic Review of the Literature (2012–May 2017).208TABLESA: Common Symptoms of mTBI.2B: Diagnostic Criteria for Concussion/mTBI.2C: Symptom Treatment Hierarchy.6D: Existing TBI Guidelines Evaluated in the Process of Developing the Current Guideline.70E: Levels of Evidence.74Section 1: Diagnosis/Assessment of Concussion/mTBI1.1: Risk Factors Influencing Recovery Post mTBI.131.2: Key Features of mTBI Assessment in an Emergency Department or Doctor’s Office.13Section 3: Sport-Related Concussion/mTBI3.1: Concussion Modifiers.233.2: Graduated Return-to-Sport Strategy.24Table of ContentsSection 1 2 3 4 5 6 7 8 9 10 11 12Guidelines for Concussion/mTBI and Prolonged Symptoms: 3rd Ed.II
Table of ContentsSection 4: General Recommendations Regarding Diagnosis/Assessment of Prolonged Symptoms4.1: Differential Diagnoses Related to mTBI.27Section 6: Post-Traumatic Headache6.1: Important Components to Include in the Focused Headache History.33Section 7: Persistent Sleep-Wake Disturbances7.1: Important Components to Include in the Sleep-Wake Disturbances Screen.39Section 8: Persistent Mental Health Disorders8.1: General Considerations Regarding Pharmacotherapy after mTBI.46Section 11: Persistent Fatigue11.1: Fatigue: Assessment and Management Factors for Consideration.57Section 12: Return-to-Activity/Work/School Considerations12.1: Factors Associated with Poor Functional Outcomes.6012.2: Stepwise Approach to Return-to-Work Planning for Patients with Concussion/mTBI.61FIGURESSection 1: Diagnosis/Assessment of Concussion/mTBI1.1: Canadian CT Head Rule.12A: Practice Guidelines Evaluation and Adaptation Cycle.69B: PRISMA Flow Diagram: Results from the Systematic Review of the Literature (2012–May 2017) .71C: Guideline Recommendation Review .76Unique Features and Symbols in the Current GuidelineHyperlinksTo improve ease of use, the current guideline has embedded hyperlinks to improve navigation between sections, appendices,and so on. For example, by clicking any heading in the table of contents above, you will be taken directly to that particularsection in the current PDF document. Also, anytime there is mention of a particular table, figure, appendix, or section, youcan simply click on it (e.g., click “Table 6.1”) to go directly to that item.SymbolsThe key symbol has been placed to the left of each guideline recommendation that should beprioritized for implementation. This was determined by expert consensus members during theendorsement/prioritization process, where experts were allowed to provide 20 prioritization votes(see Methodology). Guideline recommendations with a summed prioritization score greater than30 are key clinical practice guideline recommendations for implementation.For sections that did not include a Key Recommendation as above, a star has been placed nextto the highest prioritization score recommendation in that section. The reason for this is that whilea recommendation may not be a priority it is helpful to note the most important step in any area ofsymptom treatment.Levels of EvidenceRecommendations have been colour coded to indicate the level of evidenceLEVEL A: At least one randomized controlled trial, meta-analysis or systematic reviewLEVEL B: At least one cohort comparison, case studies or other types of experimental studyLEVEL C: Expert opinion, experience or consensus panelAt the bottom of each page there is a hyperlinked footer that can be used to return to any particular section or the table ofcontents as desired. Also, clicking “Return to Last Page” will take you back to the previously viewed page. (Note: Whenscrolling through the pages, the “Return to Last Page” button will only return to the last page that was scrolled through.)Table of ContentsSection 1 2 3 4 5 6 7 8 9 10 11 12Guidelines for Concussion/mTBI and Prolonged Symptoms: 3rd Ed.III
IntroductionBackground Information on Concussion/ Mild TBI and Prolonged SymptomsConcussion/Mild Traumatic Brain InjuryConcusson/Mild traumatic brain injury (mTBI) is a significant c ause o f m orbidity a nd mortality, w ith m any s urvivors ofconcussion/mTBI dealing with persisting difficulties for years post-injury.1-3 Over the years, various terms have been usedsynonymously with mild traumatic brain injury, such as mild head injury and concussion. It is important to note that allconcussions are considered to be a mTBI however mTBI is distinguished from concussion when there is evidenceof intracranial injury on conventional neuroimaging or there is persistent neurologic deficit.Definition of Concussion/mTBIConcussion/mTBI denotes the acute neurophysiological event related to blunt impact or other mechanical energy applied tothe head, neck or body (with transmitting forces to the brain), such as from sudden acceleration, deceleration or rotationalforces. Concussion can be sustained from a motor vehicle crash, sport or recreational injury, falls, workplace injury, assaultor incident in the community.Clinical signs of concussion immediately following the injury include any of the following:1. Any period of loss of or a decreased level of consciousness less than 30 min.2. Any lack of memory for events immediately before or after the injury (post-traumatic amnesia) less than 24 hours.3. Any alteration in mental state at the time of the injury (e.g., confusion, disorientation, slowed thinking, alteration ofconsciousness/mental state).4. Physical Symptoms (e.g., vestibular, headache, weakness, loss of balance, change in vision, auditory sensitivity,dizziness).5. Note: No evidence of Intracranial lesion on standard imaging (if present, suggestive of more severe brain injury)Clinical symptoms most commonly experienced following concussion are listed in Table A.Concussion is a traumatic brain injury at the beginning of the brain injury spectrum ranging from mild to severe brain injury.Mild TBI is among the most common neurological conditions with an estimated annual incidence of 500/100,000 in theUnited States.6 One Canadian study examining both hospital-treated cases as well as those presenting to a family physiciancalculated the incidence of mTBI in Ontario to lie between 493/100,000 and 653/100,000, depending on whether diagnosiswas made by primary care physicians or a secondary reviewer.7There has been much research in the role of structural imaging in diagnosing concussion/mTBI and prolongedsymptoms, however studies have yet to find a consistent pattern in structural brain changes to diagnose concussion/mTBIand further research is needed.8-10 Computed Tomography (CT) and conventional Magnetic Resonance Imaging (MRI)usually fail to detect evidence of structural brain abnormalities in mTBI. Research in Diffusion Tensor Imaging (DTI) todetect white matter changes post-concussion/mTBI has detected structural changes acutely following, but results havenot been shown to be consistent across groups, the resolution does not get at the submillimeter level and is only detectingmacroscopic changes, therefore these tests are unable to accurately diagnose concussion/mTBI.11-13 DTI has also beenresearched in people with chronic prolonged symptoms14-16 however more research is needed as the association withprolonged symptoms has not been established. Reviews of recent advances in the biomechanical modeling of mTBI inhumans and animals conclude that mTBI leads to functional neuronal disruption, and at times structural damage.4,17-19There are several criteria commonly used to index severity of traumatic brain injuries. One of the most commonly used isthe Glasgow Coma Scale (GCS),20 which assesses a patient’s level of consciousness. GCS scores can range from 3 to 15;mTBI is defined as a GCS score of 13-15, typically measured at 30 minutes post-injury or “on admission.” Post-traumaticamnesia (PTA), measured as the time from when the trauma occurred until the patient regains continuous memory, isanother criterion used to define injury severity, and the cut-off for mild injuries is usually placed at 24 hours or less. Finally, aloss of consciousness of less than 30 minutes has also served as an index of mTBI.21 However, it should be noted that mTBIcan occur in the absence of any loss of consciousness. The acute symptoms that may follow mTBI are often categorizedaccording to the following domains: 1) physical, 2) behavioural/emotional and 3) cognitive. Some of the more commonrepresentatives of each symptom category are presented in Table A.Table of ContentsSection 1 2 3 4 5 6 7 8 9 10 11 12Guidelines for Concussion/mTBI and Prolonged Symptoms: 3rd Ed.1
IntroductionTable A. Common Symptoms of iveHeadacheNauseaVomitingBlurred or double visionSeeing stars or lightsBalance problemsDizzinessSensitivity to light or tabilityDepressionAnxietySleeping more than usualDifficulty falling asleepFeeling “slowed down”Feeling “in a fog” or “dazed”Difficulty concentratingDifficulty rememberingAdapted from Willer B, Leddy JJ. Management of concussion and post-concussion syndrome. Current Treatment Options in Neurology.2006;8:415-426; with kind permission from Springer Science and Business Media.Disparities exist in the definitions used for mTBI, and several organizations have created formal diagnostic criteria in order to try toovercome inconsistencies. Due to this fact the Expert Consensus Group (see Methodology) established a sub-committee to reviewthe diagnostic criteria of concussion/mTBI. Experts reviewed recent definitions of concussion/mTBI as published by established mTBIconsensus groups (sport, military) and from clinical practice guidelines. Depending on the population studied the literature would suggestthat minimally 15% of persons with concussion may experience persisting symptoms beyond the typical 3 month time frame.22 Theconsequences for these individuals may include reduced functional ability, heightened emotional distress, and delayed return to work23or school.5 In a Canadian longitudinal study, they found that only 27% of patients diagnosed with concussion and with symptoms lastinggreater than 3 months at clinic presentation eventually recovered and 67% of those who recovered did so within the first year. They alsofound that no patient recovered who had post-concussion syndrome lasting 3 years or longer.24 When symptoms persist beyond thetypical recovery period of three months, the term post-concussion syndrome or disorder may be applied.Prolonged SymptomsJust as there is confusion surrounding the definition of mTBI, this is also the case with the definition of post-concussion syndrome. Therehas been debate as to whether prolonged symptoms are best attributed to biological or psychological factors. It now appears thata variety of interacting neuropathological and psychological contributors both underlie and maintain post-concussive symptoms.25,26One source of controversy has been the observation that the symptoms found to persist following mTBI are not specific to this condition.They may also occur in other diagnostic groups, including those with chronic pain,27-29 depression 30 and post-traumatic stressdisorder,31 and are observed to varying extent among healthy individuals.32-34 For the purposes of this guideline prolonged symptomsrefer to: A variety of physical, cognitive, emotional and behavioural symptoms that may endure for weeks or months following aconcussion.35Overall approach to treatment:Phase of recovery should be considered in regards to treatment approaches: Acute: (0-4 weeks): Emphasis should be placed on facilitation of recovery including education, reassurance, subsymptom thresholdtraining and non-pharmacological interventions. Post-Acute: (4-12 weeks): If patient not improving or symptoms worsening, then referral to an interdisciplinary clinic should bemade. Focus should be placed on managing symptoms of sleep impairment, headache, mood, fatigue and memory/attention. Thefocus is on a graduated return to activity which may include work and school. Persistent: (3 mo. ): If symptoms persist for more than 3 months, patients require an interdisciplinary team for symptommanagement using an individualized management approach with focus on returning to pre-injury activities.Another area of controversy is the potential influence of related litigation and financial compensation on the presentation and outcomefor persons who have sustained mTBI. While there is consistent evidence of an association between seeking/receiving financialcompensation (i.e., via disability benefits or litigation) and the persistence of post-concussive symptoms, this relationship is complex andthe mechanisms through which litigation/financial compensation issues affect rate of reco
suspected of having sustained a concussion/mTBI (mild traumatic brain injury). This guideline is not intended for use with patients or clients under the age of 18 years. This guideline is not intended for use by people who have sustained or are suspected of having sustained a concussion/mTBI for any self-diagnosis or treatment. Patients
Brain Injury and Persistent Symptoms 3rd Edition - for adults, 18 years of age Patient Version This guideline has been created to help with management of concussion/mild traumatic brain injury (mTBI). It is only for management for adults over 18 years of age. The guideline can be used by patients when speaking with healthcare providers
concussion test is a tool or device used to check a What is a concussion test? person's level of functioning after a suspected concussion. There are several types of concussion tests, including neurocognitive, balance, vestibular ocular, motion sensors, and more. These tests do not diagnose concussion, but rather note deficits in
3. onsite medical assessment 14 4. medical assessment 16 5. concussion management 17 6. multidisciplinary concussion care 20 7. return to sport 21. canadian sport concussion pathway 23 guideline development process . evidence stakeholder consultation updates to this guideline. appendix: documen
The risk of concussion is 4 times higher in a previously concussed player than in a player who has never sustained a concussion. Concussion (Mild Traumatic Brain Injury) Structural damage with loss of brain cells does occur with some concussions Repeated concussions additive – slower/ less complete recovery Second Impact Syndrome – 100%
Jan 01, 2008 · VA/DoD Clinical Practice Guideline for the Management of Concussion -mild Traumatic Brain Injury . February 2016 Page . 5. of . 133. I. Introduction . The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Working Group (EBPWG) was established
This policy is aligned with the Canadian Guideline on Concussion in Sport. . the 5th International conference on concussion in sport held in Berlin, Oct 2016. British Journal of Sports Medicine 2017 0:1-10. This policy is aligned with the Canadian Guideline on Concussion in Sport. . medical
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The external evaluation of the National Plan on Drugs and Drug Addiction 2005-2012 is taking place now and the final report will be presented in December 2012, which will include recommendations for the next policy cycle. The final report of the internal evaluation of both Plans (Drugs and Alcohol) will be presented by the end of 2012 for approval of the Inter-ministerial Council. Drug use in .
