Guideline for Concussion/Mild Traumatic Brain Injury ...

1 Healthcare Professional VersionAdults (18+ years of age)Complete VersionThird EditionGuideline for Concussion/Mild Traumatic Brain Injury & prolonged SymptomsThe project team would like to acknowledge the Ontario Neurotrauma Foundation (ONF), who initiated and funded the development of the original Guideline , as well as the current update. ONF is an applied health research organization with a focus on improving the quality of lives for people with an acquired Brain Injury or spinal cord Injury , and on preventing neurotrauma injuries from occurring in the first place. ONF uses strategic research funding activity embedded within a knowledge mobilization and implementation framework to build capacity within systems of care.

2 ONF works with numerous stakeholders and partners to achieve its objective of fostering, gathering and using research knowledge to improve care and quality of life for people who have sustained neurotrauma injuries, and to influence policy towards improved systems. The foundation receives its funding from the Ontario Government through the Ministry of Health and Long-Term note, the project team independently managed the development and production of the Guideline and, thus, editorial independence is retained. Ontario Neurotrauma Foundation 2018 Ontario Neurotrauma Foundation90 Eglinton EastToronto, ON, Canada M4P 2Y3 Tel.: 1 (416) 422-2228 Fax: 1 (416) 422-1240 Email: May 2018 COMPLETE VERSIONC over Photo Credit: Puzzle Image: recommendations and resources found within the Guideline for concussion /mTBI & prolonged Symptoms are intended to inform and instruct care providers and other stakeholders who deliver services to adults who have sustained or are suspected of having sustained a concussion /mTBI (mild Traumatic Brain Injury ).

3 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 may wish to bring their healthcare and other providers attention to this Guideline . The recommendations provided in this Guideline are informed by best available evidence at the time of publication, and relevant evidence published after this Guideline could in luence the recommendations made within. Clinicians should also consider their own clinical judgement, patient preferences and contextual factors such as resource availability in clinical decision-making 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 for concussion /mTBI and prolonged Symptoms: 3rd 1 2 3 4 5 6 7 8 9 10 11 12 Table of ContentsTable of ContentsINTRODUCTION.

4 1 KEY RECOMMENDATIONS ..8 Guideline 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 .. : Initial Diagnosis/Assessment of Adult mTBI .. : Initial Management of Symptoms Following mTBI.

5 : Management of Persistent Symptoms Following mTBI .. : Assessment and Management of Post- Traumatic Headache Following mTBI .. : Assessment and Management of Persistent Sleep-Wake Disturbances Following mTBI .. : Assessment and Management of Persistent Mental Health Disorders Following mTBI .. : Return-to-Work Considerations .. : Return-to-School (Post-Secondary) Considerations ..68 APPENDICESS ection 1: Diagnosis/Assessment of concussion /mTBI : Acute concussion Evaluation (ACE): Physician/Clinician Office Version ..78 : Abbreviated Westmead Post- Traumatic Amnesia Scale (A-WPTAS) ..80 : Brain Injury Advice Card (Long Version)..83 : Brain Injury Advice Cards (Short Versions) ..87 : Rivermead Post concussion Symptoms Questionnaire.

6 91 : Post concussion Symptom Scale ..92 Section 2: Management of concussion /mTBI : Specialized concussion Clinics/Centres in : The Parkwood Pacing Graphs ..100 Section 3: Sport-Related concussion /mTBI : Sport concussion Assessment Tool (SCAT5) ..103 : concussion Recognition Tool 5 (CRT5) ..111 : Buffalo concussion Treadmill Test (BCTT) ..112 : Important Components to Include in the Neurological and Musculoskeletal Exam ..115 Section 4: General Recommendations Regarding Diagnosis/Assessment and Persistent Symptoms : ICD-10 Definitions for Differential Diagnoses Related to mTBI ..116 Section 6: Post- Traumatic Headache : ICHD-III Beta: Acute Headache Attributed to Mild Traumatic Injury to the Head ..118 : ICHD-III Beta: Persistent Headache Attributed to Mild Traumatic Injury to the Head.

7 119 Guidelines for concussion /mTBI and prolonged Symptoms: 3rd 1 2 3 4 5 6 7 8 9 10 11 12 Table of Contents : Diagnostic Criteria for Selected Primary Headache Types from the ICHD-III Beta ..120 : Headache Diary ..123 : International Classification of Headache Disorders (ICHD-III Beta): Medication-Overuse Headache ..124 : Self-Regulated Intervention and Lifestyle Strategies to Minimize Headache Occurrence ..125 : Prophylactic Therapy ..127 Section 7: Sleep-Wake Disturbances : Brief Definitions of Sleep Disorders Most Frequently Reported Following mTBI ..128 : Short Clinical Interview for Sleep after Head Injury ..129 : Sleep and concussion Questionnaire ..130 : Sleep Hygiene Program ..133 : Behavioural Recommendations for Optimal Sleep.

8 134 : Sleep Diary ..135 : Limiting the Time Spent in Bed to Actual Sleep Time ..137 : Re-creating a Time and Place for Sleep ..140 Section 8: Mental Health Disorders : Patient Health Questionnaire 9-Item Scale (PHQ-9) for : Generalized Anxiety Disorder 7-Item Scale (GAD-7) ..145 : Primary Care Post- Traumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5) ..147 : Post- Traumatic Stress Disorder Checklist for DSM-5 (PCL-5) ..148 : CAGE and CAGE-AID 10: Vestibular (Balance/Dizziness) and Vision Dysfunction : Dizziness Handicap Inventory ..150 : Dix-Hallpike Manoeuvre ..152 : Particle Repositioning Manoeuvre (PRM)/Epley Manoeuvre ..153 : Screening Techniques for Vision Dysfunction ..154 Section 11: Fatigue : Barrow Neurological Institute (BNI) Fatigue Scale.

9 156 : List of Medications Associated with Fatigue, Asthenia, Somnolence and Lethargy from the MSC Guideline ..157 : Patient Advice Sheet on Coping Strategies for Fatigue ..159 : Gradually Increasing Physical Activity to Better Manage Fatigue ..161 Section 12: Return-to-Activity/Work/School Considerations Components of the Vocational Evaluation Following mTBI ..163 Example concussion /mTBI Accessibility Intake Package for Student services /Special Needs Department ..166 Greater Accommodations for Students with Persistent Symptoms following Managing Your Return to Post-Secondary Activities: Package Template and Activity Log ..177 Acute concussion Evaluation (ACE) Care Plan - Work Version ..181 Acute concussion Evaluation (ACE) Care Plan - School Version.

10 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 Con-sensus : Other Links/References for Resources to Consider ..205G: Results of the mTBI Systematic Review of the Literature (2012 May 2017) ..208 TABLESA: 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 ..74 Section 1: Diagnosis/Assessment of concussion /mTBI : Risk Factors Influencing Recovery Post mTBI.