[State of knowledge: mild traumatic brain injury, knowledge update in preparation for the revision of the ministerial orientations for mild traumatic brain injury (2005-2010)]

Truchon C, Guérin F, Ulysse MA, Martin G
Record ID 32018001017
Original Title: État des connaissances: traumatisme craniocérébral léger - mise à jour des connaissances en préparation de la révision des orientations ministérielles pour le traumatisme craniocérébral léger (2005-2010)
Authors' objectives: Mild traumatic brain injury (mTBI) is the mildest subcategory of the large family of traumatic brain injuries (TBIs). It is the most common type of TBI in adults and children and generates a large number of medical and hospital visits. To structure the organization of services and support the implementation of services offered to victims of mTBI, the Ministère de la Santé et des Services sociaux (MSSS) published, in 2005, ministerial orientations concerning mTBIs. As these orientations date back more than 10 years, the MSSS asked the Institut national d’excellence en santé et en services sociaux (INESSS) to shed some scientific light on mTBI to guide the work of the committee that will be in charge of updating the ministerial orientations. This knowledge update presents an analysis of the literature and of the trends identified in different guidance documents since the publication of the ministerial orientations in 2005. It examines the main components of the scientific and clinical framework of the ministerial orientations, namely, the definition of mTBI, the screening criteria, the diagnostic criteria, the criteria for assessing the risk of severe complications, the criteria for assessing the risk of developing functional complications, and the main principles guiding its clinical management. In addition, it analyzes and compares the implication of the criteria used to define sports-related concussion, a concept often used synonymously with mTBI.
Authors' results and conclusions: RESULTS: The literature analysis puts into perspective the changes in knowledge and in the position of a number of organizations regarding several aspects of mTBI/concussion since the publication of the ministerial orientations in 2005. In the past decade, there have been a large number of publications and position statements in the specific area of sports-related concussion. This very influential trend is prompting questions and challenging the definition and characterization of mTBI, the screening criteria and the ensuing diagnostic criteria. Specifically, this perspective promotes the recognition of various and often more subtle physiological and functional disturbances, thus leading to a less narrow and generally more interventional screening, diagnostic and intervention framework. This new paradigm has the advantage, according to many, of recognizing and legitimizing the presence of mTBI in a certain proportion of individuals who are excluded from the diagnostic framework recommended in the current Québec model. If it was to influence Québec’s orientations, this model could have a considerable impact on the number of cases of mTBI detected or suspected and the use of the health and social services system’s resources. Two important elements dictate clinical management following mTBI: the risk, during the acute phase, of developing serious medical complications due to active brain lesions, and the risk of developing functional complications during the post-acute phase. Having undergone two official revisions since the 2005 publication, the decision algorithm for assessing the risk of serious medical complications in adults (2011 version), which is based on the Canadian CT Head Rule criteria, is well supported by the literature and therefore still seems quite appropriate in the Québec context. However, it may prove necessary to reevaluate certain criteria for transferring patients within the trauma care network and to revise the pediatric algorithm, given data showing the Pediatric Emergency Care Applied Research Network (PECARN) tool’s superior metric qualities compared to those of the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) tool, on which the 2011 Québec algorithm is based. As for assessing the risk of developing persistent symptoms during the post-acute phase, the recent literature places more emphasis than do the ministerial orientations on the fact that mTBI/concussion can, in fact, cause an entire array of signs and symptoms in a significant number of individuals. The approach aimed at quickly providing preventive information and reassurance is still strongly emphasized, but the latest guidelines and position statements tend to recommend certain symptom mitigation measures closer in time to the traumatic event. In this regard, the literature offers different intervention tools and frameworks to support clinicians in the evaluation and clinical intervention process. Very specific guidelines regarding instructions for resuming intellectual and sports activities are presently the subject of strong awareness and dissemination initiatives by numerous organizations, especially in the areas of education and sports. These initiatives are currently guiding the processs of revising information pamphlets that might be incorporated into the new ministerial orientations. The knowledge update and the analysis of the schools of thought currently prevailing in the sectors concerned about mTBI/concussion will help elucidate and guide the process of revising the ministerial orientations. Several avenues of discussion and areas requiring updates are proposed. They will need to be contextualized and enriched with the experience of the Québec network that has been serving this population for many years. Special attention will have to be given to harmonization, consistency and continuity in relation to the other frames of reference currently in effect as well as other existing tools
Authors' methods: Given our objective, the literature review was conducted using a rapid review method and specifically focused on clinical practice and other guidelines, consensus statements, and position statements of professional associations and other learned societies in Canada and elsewhere. These are based on syntheses of primary studies and, in several cases, on a consensus process involving clinical and scientific experts.
Project Status: Completed
Year Published: 2018
Requestor: Minister of Health
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
Province: Quebec
MeSH Terms
  • Brain Injuries, Traumatic
  • Brain Concussion
  • Head Injuries, Closed
  • Practice Guidelines as Topic
  • Diagnosis
  • Mild traumatic brain injury
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: Gouvernement du Québec
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