Table 1.
The CDC Pediatric Mild Traumatic Brain Injury Guideline Summary and Relationship to the NATA Position Statement on Sport Concussion Continued on Next Page
| Topic (Recommendation[s]) |
Summary of CDC Recommendations1 |
Level of Confidence |
Action Levela |
Corresponding NATA Position Statement Recommendation(s)15 |
| Imaging (1–4) | • No routine use of CT or MRI for diagnosis | Moderate | B | NA: ATs cannot order imaging, but they can assist in educating the patient and family about the role and value of imaging in diagnosis |
| • Use decision rules to determine use of CT | Moderate | B | ||
| • Do not use skull radiographs or SPECT for acute evaluation or diagnosis | Moderate | B | ||
| Assessment (5, 6) | • Use age-appropriate, validated measures (eg, symptom scales, cognitive tests) | Symptom scales: moderate | B | 31: ATs should use age-appropriate, validated concussion-assessment tools in younger populations 32: ATs should assess postconcussion symptoms in pediatric patients using age-validated, standardized symptom scales and formal input from supervising adults 15: ATs should diagnose concussions through clinical evaluations supported by assessment tools 16: If a rapid concussion assessment is needed, ATs can use the SAC with a motor-control and symptom-scale evaluation |
| Cognitive tests: moderate | C | |||
| • Do not use the SAC as the sole diagnostic tool | Moderate | B | ||
| • Do not use biomarkers for diagnosis outside of research applications | High | R | NA: ATs cannot conduct blood or cerebrospinal fluid testing but can use this information to educate and inform stakeholders and families regarding the insufficient clinical utility of these markers | |
| Patient and family education (7) | • Counsel patients and families that most children do not have difficulty beyond 1–3 mo after mTBI | Moderate | B | 2: ATs should ensure appropriate parental and coach education on key aspects of concussion management (eg, prevention, mechanism, recognition, referral, physical and cognitive restrictions, appropriate return to sport, and ramifications of improper management) |
| 7: ATs should document the athletes' and parents' understanding of concussion signs and symptoms and the athlete's responsibility to report | ||||
| Determining the risk for prolonged recovery (8, 9) | • Complete premorbid history assessment preinjury or as soon as possible postinjury | Moderate | B | 3: ATs should document any potential modifying factors that could delay normal return to play postconcussion |
| 10: ATs should complete baseline examinations with athletes at high risk for concussion before the competitive season | ||||
| 12: Baseline examinations should include a variety of clinical assessments: in particular, clinical history and symptom checklist | ||||
| • Counsel families of children with certain comorbidities that recovery may be delayed | Moderate | B | 15: ATs should diagnose concussions through clinical evaluations supported by assessment tools and consider the results when predicting mTBI prognosis | |
| • Screen for risk factors for persistent symptoms | Moderate | B | ||
| • May use validated decision rules for emergency department patient counseling | High | C | ||
| Return to activity (10–14) | • Use a combination of tools: eg, validated symptom scales, cognitive tests, and balance tests to assess recovery | Combined tools: moderate | B | 17: ATs should administer a daily focused examination to monitor the concussion recovery 12: Baseline examinations should consist of a variety of clinical assessments, including a clinical history and symptom checklist 15: ATs should diagnose concussions through clinical evaluations supported by assessment tools 32: ATs should assess postconcussion symptoms in pediatric patients using age-appropriate, standardized symptom scales and formal input from supervising adults 3: ATs should document any potential modifying factors that could delay normal return to play after concussion. Although not specifically cited, premorbid medical history, demographics, and injury history should be considered. |
| Symptom scales: moderate | B | |||
| Cognitive testing: moderate | C | |||
| Balance testing: moderate | C | |||
| • Monitor children at risk for persistent symptoms and refer if symptoms do not resolve as expected with standard care | Monitor: high | B | 23: ATs should carefully monitor athletes with persistent symptoms that do not resolve in a normal progression and who may benefit from other therapies | |
| Refer: moderate | B | |||
| • Educate patients and families about warning signs, prevention, and key management strategies for physical activity and rest, return to play, and follow-up | High | A | 2: ATs should ensure appropriate parent and coach education on key aspects of concussion management (eg, prevention, mechanism, recognition, referral, physical and cognitive restriction, appropriate return to participation, and ramifications of improper management) | |
| • Provide information regarding initial rest followed by gradual reintegration into activities and offer an active rehabilitation program | Initial rest: moderate | B | 9: ATs should properly document all aspects of concussion management, including evaluations, treatments, return-to-play progression, and physician communications 39: ATs should instruct patients to avoid physical or mental exertion that exacerbates symptoms during the acute stage of concussion injury 40: ATs should ensure that concussed athletes are excused from physically demanding team activities and any activity requiring physical exertion until full medical clearance is obtained | |
| Gradual activity: moderate | B | |||
| Active rehabilitation: high | B | |||
| • Inform patients and families that return to full activities should only be allowed when clinical assessment performance is at premorbid levels and patients are symptom free at rest and exertion | Moderate | B | 22: ATs should only begin the physical-exertion progression after the athlete demonstrates a normal clinical examination, concussion-related symptom resolution, and preinjury scores on motor-control and neurocognitive function tests | |
| • Assess social support | Moderate | C | ||
| Return to learn (15) | • Counsel patients and families about gradual return to school | Moderate | B | 8: ATs should maintain regular communication with the managing physician regarding the athlete's status after concussion 34: ATs should work with administrators and teachers to construct and approve appropriate academic accommodations as part of the concussion-management plan |
| • Customize protocols to symptom severity and as jointly determined by the medical and school-based teams | Moderate | B | 39: ATs should instruct patients to avoid physical or mental exertion that exacerbates symptoms during the acute stage of concussion injury | |
| • Assess needs of patients with prolonged symptoms for educational supports | High | B | 41: School administrators, counselors, and teachers should be made aware of an athlete's injury and academic accommodations during recovery | |
| • Monitor postconcussion symptoms and academic progress | High | B | ||
| • Support should be adjusted as needed on an ongoing basis and children with persistent symptoms and academic difficulties despite an active treatment approach should be referred for a formal evaluation by a pediatric TBI specialist | Adjust supports: moderate | B | ||
| Refer: moderate | B | |||
| Severe or persistent dysfunction (16–19) | • Observe and consider head CT in children presenting with severe headache associated with other risk factors for more severe TBI in accordance with validated clinical decision rules | High | B | 23: ATs cannot order imaging, but they should carefully monitor and appropriately refer patients with persistent symptoms that do not resolve in a normal progression 21: ATs should review each patient's medical history after injury; patients with multiple previous concussions, developmental disorder, or psychiatric disorder may benefit from referral to a neuropsychologist |
| • Use emergent neuroimaging for patients under observation for headache with acutely worsening symptoms | High | B | ||
| • Offer nonopioid analgesia for patients with painful headache and counsel patients and families about overuse | Moderate | B | 36: ATs should instruct patients to avoid medications other than acetaminophen after an acute concussion, and all current medications should be reviewed by a physician | |
| • Do not administer 3% hypertonic saline for headache outside the research setting | Moderate | R | ||
| • Refer patients with chronic headache to a headache specialist | High | B | ||
| • Refer patients with persistent vestibulo-oculomotor dysfunction to a vestibular-therapy program | Moderate | C | ||
| • Provide patient guidance on sleep hygiene to facilitate recovery | Moderate | B | 38: ATs should inform patients and families that there is typically no need to wake the patient during the night unless instructed by a physician, because rest is currently the best practice for concussion recovery | |
| • Refer patients with persistent sleep problems to a sleep disorder specialist | Moderate | C | ||
| • Attempt to determine the cause of cognitive dysfunction and refer for a formal cognitive evaluation | Determine cause: moderate | B | ||
| Evaluate and treat: high | C |
Abbreviations: AT, athletic trainer; CDC, Centers for Disease Control and Prevention; CT, computed tomography; MRI, magnetic resonance imaging; mTBI, mild traumatic brain injury; NA, not applicable; NATA, National Athletic Trainers' Association; SAC, Standardized Assessment of Concussion; SPECT, single-photon emission computed tomography; TBI, traumatic brain injury.
a
Through the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) process, the CDC assigned an action level to each recommendation: Level A: (Must do) Almost all patients in almost all circumstances would want the recommendation followed; Level B: (Should do) Most patients in most circumstances would want the recommendation followed; Level C: (May do) Some patients in some circumstances would want the recommendation followed; Level R: Do only in a research setting. The level of confidence was based on the workgroup's assessment of the cogency of the rationale supporting each recommendation and was assigned on the basis of 5 domains: rationale is logical, evidence statements are accurate, axioms are true, related evidence is strong and applicable, and internal inferences logically follow. Levels are high, moderate, low, or very low.