Abstract
Keywords
List of abbreviations:
AMS (altered mental status), CT (computed tomography), mTBI (mild traumatic brain injury), SCAT5 (Sport Concussion Assessment Tool–5th Edition), TBI (traumatic brain injury)Ontario Neurotrauma Foundation standards for post-concussion care. 2019. Available at: http://onf.org/documents/standards-for-post-concussion-care. Accessed June 11, 2018.
Ontario Neurotrauma Foundation standards for post-concussion care. 2019. Available at: http://onf.org/documents/standards-for-post-concussion-care. Accessed June 11, 2018.
Methods
Ontario Neurotrauma Foundation standards for post-concussion care. 2019. Available at: http://onf.org/documents/standards-for-post-concussion-care. Accessed June 11, 2018.
Variable | ONF | CDC | VA/DoD | CISG |
---|---|---|---|---|
Prompt diagnostic evaluation | 1.1 (A) | C | 2 (Strong) | Pg. 3-4 |
No routine neuroimaging | 1.3 (A) | 1A/1B, 2 (B) | 3 (Weak) | C |
No clinical use of serum biomarkers | C | 6 (R) | 3 (Weak) | Pg. 5 |
Advice to rest for 1-3 d post injury | 3.4 (A) | 13A (B) | C † Detailed recommendations for clinicians regarding rest and return to activity in an active duty military setting are covered in the Defense and Veterans Brain Injury Center’s (2014) Progressive Return to Activity Following Acute Concussion/Mild TBI (accessed May 2, 2019: https://dvbic.dcoe.mil/material/progressive-return-activity-following-acute-concussionmild-tbi-clinical-suite). | Pg. 5 |
Guidance on gradual stepwise return to preinjury activities | 3.4 (A), 12.3 (A) | 13B, 13D (B) | C † Detailed recommendations for clinicians regarding rest and return to activity in an active duty military setting are covered in the Defense and Veterans Brain Injury Center’s (2014) Progressive Return to Activity Following Acute Concussion/Mild TBI (accessed May 2, 2019: https://dvbic.dcoe.mil/material/progressive-return-activity-following-acute-concussionmild-tbi-clinical-suite). | Pg. 5, 7 |
Early education for patient/family | 2.3 (A), 2.6 (A) | 7A/7B (B), 12 (A) | 11, 15, 22 (Weak) | C |
Use validated symptom scales for initial assessment and to track recovery | 4.1 (C) | 5A, 10B (B) | C | Pg. 3, 4, 7 |
Neuropsychological assessment to investigate persistent (>30d) cognitive symptoms | 9.4 (A) | 19C (C) | 17 (Weak) | C |
Referral to specialist or higher level of care for slow to recover patients (>10-14d for adult athletes, >30d for others) | 2.4 (C) | 11B/15F (B) | 21 (Weak) | Pg. 5 |
Discussion
Pathophysiology
Clinical presentation and diagnosis


Centers for Disease Control and Prevention Report to Congress on Mild Traumatic Brain Injury in the United States: steps to prevent a serious public health problem; 2003. Available at: https://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf. Accessed June 11, 2018.
Prognosis
Treatment
Early clinical management. Ruling out medical emergencies

Education
Ontario Neurotrauma Foundation standards for post-concussion care. 2019. Available at: http://onf.org/documents/standards-for-post-concussion-care. Accessed June 11, 2018.

Return to activity advice
Stage | Aim | Activity | Goal of Each Step |
---|---|---|---|
1 | Symptom-limited activity | Usual daily activities that do not provoke symptoms | Gradual reintroduction to school and work |
2 | Light aerobic exercise | Walking or stationary biking at slow to medium pace without resistance. | Increase heart rate |
3 | Sport-specific exercise | Aerobic exercises such as running, sprinting, skating. Sport-specific warm-up and light drills. No head impact activities | Increase motion |
4 | Noncontact training drills | More intense training drills. May start progressive resistance training and weight lifting | Assess coordination, fitness, and concentration |
5 | Full contact practice | Participate in normal training activities including scrimmaging | Restore confidence and assess functional skills by coaching staff |
6 | Return to sport | Normal game play |
Symptom | Manifestation | Possible Accommodations |
---|---|---|
Decreased attention/poor concentration | Has trouble focusing during lessons and assignments. | Advise a lighter work load with shorter/modified assignments. Provide written notes of lessons. |
Trouble remembering | Struggles holding instructions in mind, retaining information, and accessing new concepts. Trouble with reading comprehension and math calculations. | Provide written instructions, shorter reading assignments, and offer smaller amounts of new material to learn. |
Decreased processing speed | Struggles to keep up with work demands and processes information at a slower rate. | Provide increased time for tests and/or assignments. |
Cognitive fatigue | Decreased arousal. | Provide breaks throughout day as needed. |
Emotional symptoms (eg, anxiety or depression) | Increased social isolation or lack of interest in participating in usual activities (eg, sports, clubs). | Provide encouragement to engage in social activities at school and outside of school. Suggest an appointment with a school counselor. |
Headaches | Interferes with ability to concentrate and perform school work. | Breaks as needed in a quiet environment. |
Light or noise sensitivity | Symptoms may worsen with screen time or in loud environments. | Offer written assignments vs computer-based assignments. Avoid loud settings, such as cafeteria or assemblies. |
Symptom sensitivity | Symptoms worsen with cognitive and/or physical exertion. | Reduce cognitive or physical demands by providing rest breaks and completing work in small sections (ie, working to a point that does not elicit symptoms). |
Follow-up care for patients with persistent symptoms
Ontario Neurotrauma Foundation standards for post-concussion care. 2019. Available at: http://onf.org/documents/standards-for-post-concussion-care. Accessed June 11, 2018.
Investigations
Ontario Neurotrauma Foundation standards for post-concussion care. 2019. Available at: http://onf.org/documents/standards-for-post-concussion-care. Accessed June 11, 2018.
Symptom management: general approach
Headaches
Sleep disturbance
Psychological distress
Exercise as treatment
Referral to a specialty clinic
Ontario Neurotrauma Foundation standards for post-concussion care. 2019. Available at: http://onf.org/documents/standards-for-post-concussion-care. Accessed June 11, 2018.
Pediatric considerations
Study limitations
Conclusions
Acknowledgments
Supplementary data
- Supplemental Appendix S1
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