Wednesday, September 05, 2018 New Pediatric mTBI Guidelines from CDC Take Comprehensive Approach In light of what it describes as a "significant public health concern," the US Centers for Disease Control and Prevention (CDC) has issued what it says are the first-ever comprehensive clinical guidelines for the diagnosis and management of mild traumatic brain injury (mTBI) in children. The 19 sets of recommendations address the condition from diagnosis through management and treatment, and cover settings including primary care, outpatient settings, inpatient care, schools, and emergency departments. The resource, published in JAMA Pediatrics and available for free, is organized into 3 main areas—diagnostic recommendations, prognostic recommendations, and recommendations related to management and treatment—with each area containing several recommendations based on extensive literature reviews. The 46 discrete recommendations are organized into 19 topic areas, and include do's and don'ts that cover the gamut from the use of serum testing to diagnose mTBI to the best approaches for talking with families about the injury. APTA members John DeWitt, PT, DPT, ATC; and Anne Mucha, PT, DPT, MS, were members of the CDC Pediatric Mild Traumatic Brain Injury Workgroup responsible for development of the recommendations, which are published in JAMA Pediatrics. Additionally, APTA submitted extensive comments on the guidelines during the public comment period during fall of 2017. A number of issues highlighted by APTA were included or addressed in the final version. Among the highlights from each broad area: Diagnostic recommendations: imaging is (mostly) not necessary, but rating scales and testing are crucial. Authors of the guidelines acknowledge that while assessing for intracranial injury (ICI) is important, the use of head computed tomography (CT) should not be routine and that providers should rely more heavily on clinical decision rules including those related to the Glasgow Coma Scale (GCS). The guidelines also caution against the routine use of magnetic resonance imaging (MRI), single photon emission CT, and skull radiographs, but they stress the importance of age-appropriate rating scales and cognitive testing. Authors warn, however, that clinicians shouldn't rely solely on the Standardized Assessment of Concussion to diagnose mTBI in children ages 6 to 18. Also not recommended: the use of "biomarkers" to establish the presence of mTBI "outside of a research setting." Prognostic recommendations: providers need to be sensitive to factors that can lead to variation in recovery. The guidelines support the idea that providers should help patients and families understand that for 70%-80% of children with mTBI, significant difficulties don't persist past 1 to 3 months after the injury and that "recovery from mTBI is unique and will follow its own trajectory." However, authors also advise providers to evaluate any factors that were present in a child before the mTBI that are linked to delayed recovery, such as learning difficulties, the presence of a neurologic disorder, or a history of previous mTBI. Providers should also assess for any risk factors not related to premorbid health or functional conditions, including socioeconomic factors and the severity of the presenting injury. Management and treatment recommendations: the keys are education, continued assessment of progress, and understanding when to refer for specialized care. The authors stress the importance of patient and family education around what to look for during recovery from mTBI, including warning signs of more serious injury and management of physical and cognitive activity. The guidelines also provide detailed recommendations on returning to activity and school, and stress the importance of careful monitoring in the classroom and provision of educational supports if necessary. Also included in this section are guidelines around headache management and treatment, and the importance of providers' understanding of when to refer a patient for additional treatment, particularly in the areas of vestibule-oculomotor dysfunction, disordered sleep, and cognitive impairment. The CDC is accompanying release of the guidelines with an educational push to promote consistent implementation. In addition to the guidelines themselves, providers can also download resources that include screening tools, online trainings, and fact sheets in support of the recommendations. According to authors, the guidelines arrive at a time when pediatric mTBI is on the rise, with more than 2 million outpatient visits and just under 3 million emergency department visits for mTBI in children taking place between 2005 and 2009. The CDC believes its resource is the first comprehensive set of mTBI guidelines focused exclusively on children in the US. Physical therapists (PTs) play an important role in the treatment of individuals who have suffered concussions. Get the latest information on these injuries and what’s being done to reduce them at the APTA traumatic brain injury webpage (look under the "Concussion or mTBI" header). Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.