Guideline sources The following summarized guidelines for the evaluation and management of concussion are prepared by our editorial team based on guidelines from the Living Concussion Guidelines (LCG 2023; 2022; 2017), the American Academy of Ophthalmology (AAO/AAPOS/AACO/AAP 2022), the American College of Radiology (ACR 2021; 2020), the United States Department of Defense (DoD/VA 2021; 2016), the Center for Disease Control (CDC 2018), the American Academy of Pediatrics (AAP 2018), and the Eastern Association for the Surgery of Trauma (EAST 2012). 1 2 3 4 5 6 7 8 9 10 11 13 14 14 14 15 Definition Concussion is a mTBI induced by direct or indirect biomechanical force transmitted to the head that is characterized by reversible symptoms of dizziness, headache, nausea, imbalance, and loss of consciousness. 14 Epidemiology https://web.pathway.md/diseases/recKLNv0E5TL40GY0 1/14 6/23/23, 3:36 AM Concussion Pathway Concussion is caused by biomechanical force transmitted to the head in the setting of work environment, motor vehicle crashes, sports and recreation, and falls at home among elderly. 14 Disease course Clinical manifestations include dizziness, headache, nausea, imbalance, loss of consciousness, and on occasions malignant brain swelling. Repeated concussions may cause post-traumatic epilepsy, postconcussion syndrome, and delayed post-traumatic brain degeneration leading to dementia and movement disorders. 14 Prognosis and risk of recurrence Concussion is associated with increased mortality risk in the elderly with adjusted HR 1.25 (95% CI 1.16-1.34). 15 Calculator Calculator Calculator Canadian Assessment of Tomog Canadian CT head rule CCHR New Orlea Guidelines 1. Screening and diagnosis Terminology: consider using the terms "history of mTBI" or "concussion" and refraining from using the terms "brain damage" or "patients with mTBI" in communication with patients and the public. C 2. Diagnostic investigations History and physical examination: As per LCG 2022 guidelines, suspected concussion as soon as possible A and refer to a physician/nurse practitioner for diagnosis confirmation. B Show 2 more As per VA 2016 guidelines, evaluate patients presenting with symptoms or complaints potentially related to brain injury at initial presentation. A Diagnostic imaging, head CT: As per LCG 2022 guidelines, use the Canadian CT Head Rule to decide on the need for neuroimaging in acute presentation (within 24-48 hours post-injury), recognizing that anticoagulated patients and patients with bleeding disorders require extra consideration. B https://web.pathway.md/diseases/recKLNv0E5TL40GY0 2/14 6/23/23, 3:36 AM Concussion Pathway As per ACR 2021 guidelines, do not obtain diagnostic imaging in the initial evaluation of patients with mild acute head trauma (GCS 13-15) if not required by a clinical decision rule. Obtain non- contrast head CT when imaging is indicated by a clinical decision rule. D As per DoD/VA 2016 guidelines, avoid obtaining neuroimaging to establish the diagnosis of mTBI or direct the care in patients with a history of mTBI identified by post-deployment screening or presenting with symptoms or complaints potentially related to brain injury, except patients with indicators for immediate referral. D As per EAST 2012 guidelines: Obtain head CT, if available, in patients presenting with suspected brain injury in the acute setting. B Consider using a set of standardized criteria (such as the Canadian CT Head Rule and the New Orleans Criteria) to determine the need of CT in patients with mTBI in resource-limited settings. C Diagnostic imaging, other modalities: As per LCG 2022 guidelines: Obtain MRI in patients presenting at the post-acute phase (after 48 hours post-injury) of mTBI deemed to require neuroimaging. B Do not obtain plain skull X-rays in patients with a history of mTBI. D As per EAST 2012 guidelines, do not obtain routine MRI, PET, or nuclear magnetic resonance in patients with a history of mTBI. D Serum biomarkers: As per VA 2016 guidelines, avoid obtaining serum biomarkers (including S100B, GFAP, UCHL1, NSE, and AMPAR) to establish the diagnosis of mTBI or direct the care in patients with a history of mTBI identified by post-deployment screening or presenting with symptoms or complaints potentially related to brain injury, except patients with indicators for immediate referral. D As per EAST 2012 guidelines, do not obtain routine biochemical markers, such as S100, NSE, and serum tau, in patients with mTBI, except in the context of a research protocol. D Electroencephalogram: avoid obtaining an EEG to establish the diagnosis of mTBI or direct the care in patients with a history of mTBI identified by post-deployment screening or presenting with symptoms or complaints potentially related to brain injury, except patients with indicators for immediate referral. D Assessment of headache: elicit a comprehensive headache history to identify the headache subtype most closely resembling the patient's symptoms. B Perform neurological and musculoskeletal examinations, including the cervical spine and vestibular system. B Show 2 more Assessment of vision: obtain screening for vision changes after a concussion. Elicit an appropriate case history and perform a visual examination if vision symptoms are reported. E Assessment of cognitive difficulties: As per VA 2021 guidelines: https://web.pathway.md/diseases/recKLNv0E5TL40GY0 3/14 6/23/23, 3:36 AM Concussion Pathway Avoid obtaining comprehensive neuropsychological/cognitive testing during the first 30 days following mTBI. D Avoid using computerized post-concussive screening batteries for routine diagnosis and management of patients with symptoms attributed to mTBI. D As per LCG 2017 guidelines, assess for the presence of cognitive difficulties in patients with a history of concussion, taking into consideration the impact of such difficulties on functional areas, such as performance at work or school and completing tasks within the home and community. Consider conducting a focused clinical interview regarding symptoms and use a validated post-concussion questionnaire (such as the Rivermead Post-Concussion Symptoms, the Post-Concussion Symptom Scale, or the SCAT5) to assess and track symptoms. E As per VA 2016 guidelines, do not obtain comprehensive and focused neuropsychological testing (including automated neuropsychological assessment metrics, neurocognitive assessment tools, immediate post-concussion assessment, and cognitive testing) in the routine evaluation and management of patients with symptoms attributed to mTBI identified by post- deployment screening or presenting with symptoms or complaints potentially related to brain injury. D Assessment of mental health: As per LCG 2023 guidelines: Assess mental health symptoms following a concussion to determine whether the symptoms meet the criteria for a mental health disorder, including but not limited to depressive disorders, anxiety disorders, posttraumatic stress disorder and other trauma and stressor-related disorders, behavioral changes (such as lability, irritability), adjustment disorders, substance use disorders, and somatoform disorders. E Elicit a comprehensive history (including pre-morbid mental health symptoms and conditions, medical issues, and psychosocial issues), conduct a structured clinical interview, use self- report questionnaires, and obtain behavioral observation for mental health assessment. Include information from collateral sources if possible. E As per LCG 2022 guidelines, obtain routine monitoring for depression and anxiety after a concussion. B Consider referring to a mental health specialist if needed. B As per VA 2021 guidelines, consider evaluating patients with symptoms attributed to mTBI presenting with behavioral health conditions (including posttraumatic stress disorder, substance use disorders, and mood disorders) similar to patients without mTBI and according to current published evidence-based clinical practice guidelines. C As per VA 2016 guidelines: Obtain assessment for psychiatric symptoms and comorbid psychiatric disorders, including major depressive disorder, posttraumatic stress disorder, substance use disorders, and suicidality, in patients with symptoms attributed to mTBI. A Evaluate and manage psychological or behavioral symptoms following mTBI according to existing evidence-based clinical practice guidelines and based upon individual factors and the nature and severity of symptoms. A https://web.pathway.md/diseases/recKLNv0E5TL40GY0 4/14 6/23/23, 3:36 AM Concussion Pathway Assessment of sleep-wake disturbances: educate and reassure patients that sleep alterations are very common in the acute stages of concussion/mTBI. E Show 3 more Assessment of fatigue: Elicit a focused history and review the relevant items from obtained questionnaires to determine whether cognitive and/or physical fatigue is a significant symptom. E Characterize the dimensions of fatigue (such as physical, mental, impact on motivation) and assess for alternative or contributing treatable causes that may not be directly related to the injury. E 3. Respiratory support Hyperbaric oxygen therapy: As per LCG 2023 guidelines, do not offer hyperbaric oxygen therapy for the management of symptoms post-concussion. D As per VA 2021 guidelines, do not offer hyperbaric oxygen therapy in the treatment of patients with symptoms attributed to mTBI. D 4. Medical management Setting of care, initial management: As per DoD/VA 2016 guidelines, consider offering a primary care, symptom-driven approach for the evaluation and management of patients with a history of mTBI and persistent symptoms. C Show 2 more As per EAST 2012 guidelines, measure the INR level in patients taking warfarin presenting in the acute setting with mTBI. Admit anticoagulated patients with supratherapeutic INR values and a normal initial brain CT for a period of observation, as they remain at significant risk for interval development of ICH. B Setting of care, prolonged symptoms: As per LCG 2022 guidelines, consider referring patients with persistent symptoms of > 1 month to interdisciplinary concussion services/clinics. C As per DoD/VA 2016 guidelines, consider consulting and collaborating with a locally designated TBI or other applicable specialists in case of symptoms not resolving within 30-90 days, refractory to initial treatment in primary care, and significantly impacting activities of daily living. C Show 2 more Management of vestibular dysfunction, acute mTBI: As per LCG 2017 guidelines, perform the Dix-Hallpike maneuver for assessment of patients with symptoms of benign positional vertigo once the cervical spine has been cleared. E Show 3 more https://web.pathway.md/diseases/recKLNv0E5TL40GY0 5/14 6/23/23, 3:36 AM Concussion Pathway As per DoD/VA 2016 guidelines, consider offering a short-term trial of specific vestibular, visual, and proprioceptive therapeutic exercises to assess the individual patient's responsiveness to treatment in patients with a history of mTBI presenting with functional impairments due to dizziness, disequilibrium, and spatial disorientation symptoms. Avoid offering a prolonged course of therapy in the absence of patient improvement. C Show 2 more Management of vestibular dysfunction (post-acute mTBI): Consider offering a trial of specific vestibular rehabilitation and proprioceptive therapeutic exercise in patients with persistent symptoms of dizziness and imbalance attributed to mTBI. C Insufficient evidence to recommend for or against any particular modality for the treatment of tinnitus attributed to mTBI. I Management of visual symptoms: insufficient evidence to recommend for or against any particular modality for the treatment of visual symptoms attributed to mTBI, such as diplopia, accommodation or convergence deficits, visual tracking deficits, and/or photophobia. I Management of headache: As per LCG 2022 guidelines, identify personal, environmental, work-related, school-related, and physical factors (such as neck pain) and address them as potential headache contributors. B Show 7 more As per VA 2016 guidelines, consider individualizing and tailoring the treatment of headaches to the clinical features and patient preferences, including the following treatment options: headache education, including education about stimulus control, use of caffeine/tobacco/alcohol and other stimulants nonpharmacologic interventions, such as sleep hygiene education, dietary modifications, physical therapy, relaxation, and modification of the environment pharmacologic interventions as appropriate both for acute pain and prevention of headache attacks. C Management of neck pain: evaluate neck pain and other bodily pain significantly interfering with patient functioning and treat concurrently with other concussion-related symptoms. A Management of cognitive issues: As per VA 2021 guidelines: Consider referring patients with symptoms attributed to mTBI presenting with memory, attention, or executive function problems despite appropriate management of other contributing factors (such as sleep, pain, behavioral health, headache, and disequilibrium) for a short trial of clinician-directed cognitive rehabilitation services. C Avoid offering self-administered computer training programs for cognitive rehabilitation in patients with symptoms attributed to mTBI. D As per LCG 2017 guidelines, provide patients with education highlighting that cognitive symptoms may be intensified and prolonged by certain comorbidities (such as attention deficit hyperactivity disorder, learning disabilities, anxiety or mood disorders, pain, fatigue, sleep disturbance, neuroendocrine dysfunction, substance abuse, and existing medications). https://web.pathway.md/diseases/recKLNv0E5TL40GY0 6/14 6/23/23, 3:36 AM Concussion Pathway Show 4 more As per VA 2016 guidelines, consider referring patients with a history of mTBI reporting cognitive symptoms not resolving within 30-90 days and refractory to treatment for associated symptoms (such as sleep disturbance, headache) for a structured cognitive assessment or neuropsychological assessment as appropriate to determine functional limitations and guide treatment. C Show 2 more Management of mental health issues: As per LCG 2023 guidelines, manage mental health disorders (such as depressive disorder, GAD, posttraumatic stress disorder) in patients with a history of concussion according to current published evidence-based clinical practice guidelines. Show 5 more As per VA 2021 guidelines, consider managing behavioral health conditions (including posttraumatic stress disorder, substance use disorders, and mood disorders) in patients with symptoms attributed to mTBI similar to patients without mTBI and according to current published evidence-based clinical practice guidelines. C Management of sleep-wake disturbances: As per LCG 2017 guidelines, manage sleep-wake disturbances in patients with concussion/mTBI which may help with mood, anxiety, pain, fatigue, and cognitive problems. E Show 3 more As per VA 2016 guidelines: Consider individualizing and tailoring the treatment of sleep disturbance to the clinical features and patient preferences, including the assessment of sleep patterns, sleep hygiene, diet, physical activities, and sleep environment. C Consider offering the following in the treatment of sleep disturbance, in order of preference: sleep education, including education about sleep hygiene, stimulus control, use of caffeine/tobacco/alcohol and other stimulants nonpharmacologic interventions, such as CBT for insomnia, dietary modifications, physical activity, relaxation, and modification of the sleep environment pharmacologic interventions as appropriate to aid in sleep initiation and sleep maintenance. C Management of fatigue: Consider encouraging patients to become gradually and progressively more active as tolerated (activity level not bringing on or worsening symptoms) after a brief period of rest during the acute phase (24-48 hours) after injury. E Consider including the following for the management of persisting fatigue identified as a significant symptom: aim for a gradual increase in activity levels that will parallel improve energy levels, including exercise below symptom threshold C https://web.pathway.md/diseases/recKLNv0E5TL40GY0 7/14 6/23/23, 3:36 AM Concussion Pathway reinforce strategies of cognitive and physical activity pacing and fragmentation across the day to help achieve more without exceeding tolerance levels C encourage good sleep hygiene, especially regularity of sleep-wake schedule and avoidance of stimulants and alcohol, and proper relaxation times C use a notebook or a diary to plan meaningful goals, record activity achievement, and identify fatigue patterns C acknowledge that fatigue can be exacerbated by low mood or stress C provide patients with a pamphlet containing advice on coping strategies for fatigue. C Management of exertion-induced symptoms: insufficient evidence to recommend for or against treatments for exertion-induced symptoms/symptom clusters attributed to mTBI. I 5. Nonpharmacologic interventions Alternative and complementary therapies: Insufficient evidence to recommend for or against any of the following interventions in the treatment of patients with symptoms attributed to mTBI: acupuncture tai chi meditation mindfulness yoga massage chiropractic therapy cranial electrotherapy stimulation sensory deprivation tanks. I 6. Therapeutic procedures Transcranial magnetic stimulation: avoid offering repetitive transcranial magnetic stimulation in the treatment of patients with symptoms attributed to mTBI. D 7. Specific circumstances Pediatric patients (clinical assessment): use an age-appropriate, validated symptom rating scale as a component of the diagnostic evaluation in pediatric patients with acute mTBI. B Show 2 more Pediatric patients, diagnostic imaging: As per ACR 2020 guidelines, do not obtain diagnostic imaging in pediatric patients with minor acute blunt head trauma (excluding suspected abusive head trauma) with very low risk for clinically important brain injury per PECARN criteria. D https://web.pathway.md/diseases/recKLNv0E5TL40GY0 8/14 6/23/23, 3:36 AM Concussion Pathway Show 2 more As per CDC 2018 guidelines, do not obtain routine head CT for diagnostic purposes in pediatric patients with mTBI. D Show 5 more Pediatric patients (serum biomarkers): do not obtain biomarker measurements outside of a research setting for the diagnosis of pediatric patients with mTBI. D Pediatric patients, assessment of vision: As per AACO/AAPOS/AAO/AAP 2022 guidelines: Consider obtaining screening for vision problems following concussion to determine potential academic and activity modifications after injury in pediatric and adolescent patients. E Consider assessing for smooth pursuit, saccades, vestibulo-ocular reflex, convergence, and accommodation, in addition to visual acuity testing, to help identify these problems after a concussion. E As per AACO/AAPOS/AAO/AAP 2022 guidelines: Assess for signs of trauma to the ocular structures or visual system following a concussion. E Consider obtaining a careful assessment of the visual system, including visual acuity, visual fields, pupillary reactions, smooth pursuit, saccades, vestibulo-oculomotor reflex, monocular accommodation, and binocular convergence, to identify deficits following a concussion. E Pediatric patients (counseling): counsel patients and families that most (70-80%) pediatric patients with mTBI do not show significant difficulties lasting> 1-3 months after injury. B Show 5 more Pediatric patients (management of headache): obtain clinical observation and consider obtaining head CT in the emergency department in pediatric patients presenting with severe headaches, especially when associated with other risk factors and worsening headaches after mTBI, to evaluate for an intracranial injury requiring further management in accordance with validated clinical decision-making rules. B Show 4 more Pediatric patients (management of cognitive issues): attempt to determine the etiology of cognitive dysfunction within the context of other mTBI symptoms. B Show 2 more Pediatric patients (management of sleep disturbances): Provide guidance on proper sleep hygiene methods to facilitate recovery from mTBI. B Consider referring pediatric patients with mTBI to a sleep disorder specialist for further assessment if sleep problems emerge or continue despite appropriate sleep hygiene measures. C Pediatric patients (evaluation of persistent symptoms): Obtain close monitoring in pediatric patients with mTBI at high risk for persistent symptoms based on their premorbid history, demographics, and/or injury characteristics. B https://web.pathway.md/diseases/recKLNv0E5TL40GY0 9/14 6/23/23, 3:36 AM Concussion Pathway Provide or refer for appropriate assessments and/or interventions in pediatric patients with mTBI with symptoms not resolving as expected with standard care (within 4-6 weeks). B Pediatric patients (assessment of recovery): use a combination of tools to assess recovery in pediatric patients with mTBI. B Show 2 more Updated evidence: Effect of Screen Time on Recovery from Concussion In patients aged 12 to 25 years presenting to the emergency department within 24 hours of sustaining a concussion, screen time permitted was inferior to screen time abstinent with respect to median time until concussion recovery. Theodore Macnow et al. JAMA Pediatr. 2021 Nov 1. Pediatric patients (return to activity): counsel pediatric patients to observe more restrictive physical and cognitive activity during the first several days after mTBI. B Show 4 more Pediatric patients, return to school: As per AACO/AAPOS/AAO/AAP 2022 guidelines: Consider implementing academic accommodations for school accounting for possible vision problems after a concussion to help with recovery. E Consider referring selected pediatric patients with persistent visual issues after concussion to an appropriate specialist for treatment. E As per LCG 2022 guidelines: Offer immediate rest for 24-48 hours after concussion in students and advise avoiding participation in any sport or academic activities. A Implement an individualized return to school/studies strategy after 24-48 hours with the aim of progressing activity without provoking significant symptom exacerbation. B As per CDC 2018 guidelines, counsel the student and family by medical and school-based teams regarding the process of gradually increasing the duration and intensity of academic activities as tolerated with the goal of increasing participation without significantly exacerbating symptoms to assist returning to school after mTBI. B Show 5 more Pediatric patients (sport-related concussion, prevention): consider implementing strategies (including rule changes, educational programs, equipment design, and cervical strengthening programs) to reduce the risk of sport-related concussions. Focus prevention efforts on reducing the risk of long-term injury after a concussion. E Pediatric patients (sport-related concussion, cervical spine stabilization): suspect cervical spine injury in athletes remaining unconscious after a head injury. Perform appropriate stabilization of the cervical spine and transport the patient to an emergency facility for further evaluation. E https://web.pathway.md/diseases/recKLNv0E5TL40GY0 10/14 6/23/23, 3:36 AM Concussion Pathway Pediatric patients (sport-related concussion, evaluation of prolonged symptoms): evaluate athletes with prolonged symptoms after sport-related concussion for coexisting problems contributing to the lack of symptom resolution. Consider referring these patients to an appropriate healthcare provider able to evaluate and treat these problems. E Pediatric patients, sport-related concussion, return to sport: As per AAP 2018 guidelines, remove athletes with suspected sport-related concussion immediately from play and do not return to full sports participation until they have returned to their baseline level of symptoms and functioning and completed a full stepwise return-to-sport progression without a return of concussion symptoms. Offer a return to the full academic workload before a return to full sports participation if injury recovery occurs during the academic year. E Show 2 more Updated evidence: Sub-Threshold Exercise for SRC In adolescent athletes, aged 13-18 years, presenting within 10 days of sport-related concussion, aerobic exercise was superior to stretching exercise with respect to median recovery time. John J Leddy et al. JAMA Pediatr. 2019 Apr 1. As per CDC 2018 guidelines, consider obtaining balance testing to assess recovery in adolescent athletes with mTBI. C 8. Patient education General counseling, recovery: As per LCG 2023 guidelines: Counsel and reassure patients with symptoms persisting after 1 month that a symptom-based approach will facilitate recovery and most patients achieve symptom resolution. A Provide this education in written, verbal, and/or pictorial formats. B Counsel patients in a compassionate manner that involvement in litigation is associated with slower recovery. B As per LCG 2022 guidelines, counsel patients with a history of concussion that most patients typically experience a full recovery and return to usual activities within 1 month, while some patients may experience prolonged symptoms beyond this timeframe. Provide information and reassurance through both written and verbal education. B As per EAST 2012 guidelines, consider counseling patients that measurable deficits in cognition and memory usually resolve at 1 month, but post-concussion symptoms may persist for 3 months in 20-40% of cases. C General counseling (long-term effects): https://web.pathway.md/diseases/recKLNv0E5TL40GY0 11/14 6/23/23, 3:36 AM Concussion Pathway Counsel patients that there is insufficient evidence that single or repeated mTBI increases the risk of future neurocognitive decline. B Counsel patients that there is insufficient evidence that demographic, injury-related clinical, or management factors increase the risk of future neurocognitive decline in patients with symptoms attributed to single or repeated mTBI. B 9. Follow-up and surveillance Discharge from hospital: As per LCG 2022 guidelines, consider discharging patients presenting to the hospital/clinic acutely with a concussion for home observation if meeting the following clinical criteria: normal mental status (alertness/behavior/cognition) with clinically improving post-concussive symptoms no clinical risk factors indicating the need for CT or normal CT result if obtained because of the presence of risk factors. C Show 2 more As per EAST 2012 guidelines, consider discharging patients with an isolated mTBI and a negative brain CT from the emergency department in the absence of other injuries or issues requiring hospital admission. C Evaluation of prolonged symptoms: recognize that prolonged physical, cognitive, and/or psychological symptoms following concussion can be nonspecific and may overlap. Assess for differential diagnoses carefully and thoroughly, as similar symptoms (headache, pain, fatigue, concentration problems) are common in chronic pain, depression, anxiety disorders, sleep disorders, and other medical and psychiatric disorders. A Show 3 more Evaluation of delayed symptoms: consider obtaining symptom-specific evaluation for non-mTBI etiologies in patients with new symptoms developing > 30 days after mTBI. C Return to activity: encourage patients with a history of concussion to gradually resume normal activity (activities of daily living, work, school, duty, leisure) after a brief period of rest during the acute phase (24-48 hours) after injury, based upon their tolerance as long as the activity does not pose a risk for concussion. A Show 3 more Return to work: As per LCG 2022 guidelines: Encourage patients to return to some form of work so long as work does not place the person at risk of re-injury. Facilitate identification of necessary restrictions (where there is a risk of re- injury) and appropriate accommodations by clearly identifying patient symptoms and functional limitations (physical, cognitive, and emotional). B Consider introducing other meaningful activities to facilitate recovery when prolonged post- concussive symptoms pose a barrier to return to pre-injury employment. Consider advising https://web.pathway.md/diseases/recKLNv0E5TL40GY0 12/14 6/23/23, 3:36 AM Concussion Pathway other employment (full-time or part-time), educational activities, community roles, and activities promoting community integration (such as volunteer work) as an alternative focus for meaningful activities. C As per EAST 2012 guidelines, individualize the timing of returning to work in patients with mTBI. Consider obtaining formal neuropsychologic testing in some cases. B Return to driving: As per LCG 2022 guidelines, counsel patients that symptoms such as blurred vision, dizziness, fatigue, impaired cognition, and headache may impact their ability to drive. B Advise patients to resume driving following concussion only when their symptoms subside sufficiently to permit safe driving. B As per EAST 2012 guidelines, recognize that the ability to operate a motor vehicle safely may be impaired for a variable length of time in patients with mTBI. Individualize the timing of resumption of driving. B References 1. Expert Panel on Neurological Imaging, Robert Y Shih, Judah Burns et al. ACR Appropriateness Criteria Head Trauma: 2021 Update. J Am Coll Radiol. 2021 May;18 5S S13 S36. Open 2. No authors listed. Living Concussion Guidelines: Guideline for Concussion & Prolonged Symptoms for Adults 18 years of Age or Older: 2017 April Update. ConcussionsOntario. 2017 Apr. Open 3. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT AND REHABILITATION OF POST ACUTE MILD TRAUMATIC BRAIN INJURY. VA/DoD. 2021 Jun. Open 4. Angela Lumba-Brown, Keith Owen Yeates, Kelly Sarmiento et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr. 2018 Nov 1;172 11):e182853. Open 5. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF CONCUSSION MILD TRAUMATIC BRAIN INJURY. VA/DoD. 2016 Feb. Open 6. No authors listed. Living Concussion Guidelines: Guideline for Concussion & Prolonged Symptoms for Adults 18 years of Age or Older: 2022 August Update. ConcussionsOntario. 2022 Aug. Open 7. Ronald R Barbosa, Randeep Jawa, Jennifer M Watters et al. Evaluation and management of mild traumatic brain injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73 5 Suppl 4 S307 14. Open 8. No authors listed. Living Concussion Guidelines: Guideline for Concussion & Prolonged Symptoms for Adults 18 years of Age or Older: 2023 April Update. ConcussionsOntario. 2023 Apr. Open 9. Christina L Master, Darron Bacal, Matthew F Grady et al. Evaluation of the Visual System by the Primary Care Provider Following Concussion. Pediatrics. 2022 Aug 1;150 2):e2021056048. Open 10. Mark E Halstead, Kevin D Walter, Kody Moffatt et al. Sport-Related Concussion in Children and Adolescents. Pediatrics. 2018 Dec;142 6):e20183074. Open https://web.pathway.md/diseases/recKLNv0E5TL40GY0 13/14 6/23/23, 3:36 AM Concussion Pathway 11. Christina L Master, Darron Bacal, Matthew F Grady et al. Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment. Pediatrics. 2022 Aug 1;150 2):e2021056047. Open 12. Christopher C Giza, Jeffrey S Kutcher, Stephen Ashwal et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013 Jun 11;80 24 2250 7. Open 13. Expert Panel on Pediatric Imaging, Maura E Ryan, Sumit Pruthi et al. ACR Appropriateness Criteria Head Trauma-Child. J Am Coll Radiol. 2020 May;17 5S S125 S137. Open 14. Charles H. Tator. Concussions and their consequences: current diagnosis, management and prevention. CMAJ. 2013 Aug 6; 185 11 975 979. Open 15. Po-Liang Cheng, Hsin-Yi Lin, Yi-Kung Lee et al. Higher mortality rates among the elderly with mild traumatic brain injury: a nationwide cohort study. Scand J Trauma Resusc Emerg Med. 2014; 22 7. Open 16. American Medical Society for Sports Medicine. Choosing Wisely AMSSM recommendations. Choosing Wisely. 2014. Open 17. Gioia GA, Collins M, Isquith C et al. Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms. Ontario Neurotrauma Foundation. Open 18. Shawn Marshall, Mark Bayley, Scott McCullagh et al. Updated Clinical Practice Guidelines for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms. Brain Inj. 2015;29 6 688 700. Open 19. Dana Waltzman, Kelly Sarmiento. What the research says about concussion risk factors and prevention strategies for youth sports: A scoping review of six commonly played sports. J Safety Res. 2019 Feb;68 157 172. Open 20. Christian A Refakis, Christian D Turner, Patrick J Cahill. Sports-related Concussion in Children and Adolescents. Clin Spine Surg. 2017 Jun;30 5 191 196. Open 21. Christopher Giza, Tiffany Greco, Mayumi Lynn Prins. Concussion: pathophysiology and clinical translation. Handb Clin Neurol. 2018;158 51 61. Open 22. William T Jackson, Amaal J Starling. Concussion Evaluation and Management. Med Clin North Am. 2019 Mar;103 2 251 261. Open 23. John J Leddy, Mohammad N Haider, Michael J Ellis et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019 Apr 1;173 4 319 325. Open 24. Theodore Macnow, Tess Curran, Courtney Tolliday et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021 Nov 1;175 11 1124 1131. Open 25. John J Leddy, Christina L Master, Rebekah Mannix et al. Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial. Lancet Child Adolesc Health. 2021 Nov;5 11 792 799. Open https://web.pathway.md/diseases/recKLNv0E5TL40GY0 14/14