Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms

Abstract

Objective: To introduce a set of revised guidelines for the management of mild traumatic brain injury (mTBI) and persistent symptoms following concussive injuries.

Quality of evidence: The Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms were made available in March 2011 based on literature and information up to 2008. A search for new clinical practice guidelines addressing mTBI and a systematic review of the literature evaluating treatment of persistent symptoms was conducted. Healthcare professionals representing a range of disciplines from Canada and abroad attended a consensus conference to revise the original guidelines in light of new evidence.

Main message: A modified Delphi process was used to create 96 recommendations addressing the diagnosis and management of mTBI and persistent symptoms, including post-traumatic headache, sleep disturbances, mental health disorders, cognitive difficulties, vestibular and vision dysfunction, fatigue and return to activity/work/school. Numerous resources, tools and treatment algorithms were also included to aid implementation of the recommendations.

Conclusion: The revised clinical practice guideline reflects the most current evidence and is recommended for use by clinicians who provide care to people who experience PPCS following mTBI.

• Concussion
• diagnosis
• guideline recommendations
• management
• mild traumatic brain injury
• persistent post-concussive symptoms

Acknowledgements

We thank the mTBI Expert Consensus Group (Robert Brison, MD, MPH, FRCP; Carol Cancelliere, DC, MPH; Angela Colantonio, PhD, OT; Victor Coronado, MD, MPH; Nora Cullen, MD, MSc, FRCPC; Lisa Fischer, MD, CCFP, DipSportMed; Anne Forrest, PhD; Bryan Garber, MD; Jonathan Gladstone, MD, FRCPC; Wayne Gordon, PhD, ABPP/Cn; Robin Green, PhD, CPsych; Grant Iverson, PhD, RPsych; Corinne Kagan, BA, BPS Cert; Vicki Kristman, PhD; Andrea Laborde, MD; Patricia McCord, DC; Willie Miller, MD, FRCPC; Gregory O’Shanick, MD; Marie-Christine Ouellet, PhD; Angela Peddle, OD, FCOVD; Laura Rees, PhD, CPsych; Wendy Shama, MSW, RSW; Mary Stergiou-Kita, PhD; Rob van Reekum, MD, FRCPC; and Catherine Wiseman-Hakes, PhD, Reg CASLPO) and the external reviewers (Markus Besemann, LCol, BSc, MD, FRCP, DipSportMed; Pierre Côté, DC, PhD; David Cifu, MD; Mark Rapoport, MD, FRCPC; Noah Silverberg, PhD, RPsych, ABPP; Bonnie Swaine, PT, PhD; and Charles Tator, PhD, MD). We would also like to thank our stakeholders/auditors for their contributions during the guideline development process (Humberto Laranjo, Emergency Nurses Association of Ontario; Ruth Wilcock, Ontario Brain Injury Association; Roger Zemek, Children’s Hospital of Eastern Ontario; and injury claims managers from the property and casualty insurance industry). Finally, we would also like to thank our student research assistants (Andrew Bayne, BSc candidate; Natalie Fersht, BSocSc candidate; Hayley MacLeay, BA & BSc candidate; Chantal Rockwell, BA Hons; and Kelsey Scheier, BSc candidate).

Declaration of interest

The authors report no conflicts of interest. The Ontario Neurotrauma Foundation initiated and funded the development of the original and updated guidelines. The project team independently managed the development and production of the guideline and, thus, editorial independence is retained.