ER doc spearheads 'living guideline' for concussion

There are no blood or picture tests to help doctors determine whether a patient has a concussion or not. This Ottawa doctor is hoping to help others recognize it

Joanne Laucius, Ottawa Citizen 5 minute read January 9, 2020

Dr. Roger Zemek, an emergency room physician at CHEO, is one of the new authors of "living guidelines" - an online guide that offers a series of recommendations to help children and adolescents get back to everyday life after suffering a concussion. Julie Oliver / Postmedia

A CHEO emergency room physician is one of the researchers behind a “living guideline” to help prevent, recognize and treat concussions in children and youth.

The living guideline for pediatric concussion is the first of its kind in the world. It will be maintained and developed through a continuous process of review, evaluation and revision of research by a group of more than 50 physicians, nurses, diagnosticians and rehabilitation specialists who will be combing through scientific papers from around the world and deciding whether new information warrants being included.

That’s important because research is being published at a brisk pace, said Dr. Roger Zemek, who is also a senior scientist at the CHEO Research Institute and a professor at the University of Ottawa.

“It’s essential that professional providers have the latest and greatest evidence.”

In the past year, there were about 1,000 visits to the CHEO emergency room for suspected concussions.

People are much more aware of concussion.Visits have increased four-fold in emergency rooms and family physicians offices over 10 years

“People are much more aware of concussion. My own work has shown that visits have increased four-fold in emergency rooms and family physicians offices over 10 years,” said Zemek, who led the project with Dr. Nick Reed, an adjunct scientist with the Holland Bloorview Kids Rehabilitation Hospital in Toronto.

“All of the other protocols get stale and have to be revised,” said Judy Gargaro, acquired brain injury program director with the Ontario Neurotrauma Foundation, which funded the project and facilitated the expert panel.

The foundation’s previous 2014 guideline already has a global reach, with a lot of online traffic coming not just from Canada, but also the U.S., U.K., France, Australia and New Zealand.

“We want to harmonize the messages so it doesn’t matter where you are injured, people will be getting the same messages,” said Gargaro.

We talked to Zemek and about pediatric concussions and how a living guideline will help kids get the best treatment.

Your research found a four-fold increase in visits to emergency rooms and doctors’ offices in a decade. Are more children really getting more concussions?

I don’t think so. People are more aware, and they’re recognizing the potential dangers. I can only anticipate that more awareness will lead to better care. Prevention is the best way to improve outcomes. We’re not seeing a world where kids don’t do sports. Exercise and healthy living are good preventatives.

Why create a living guideline for pediatric concussion?

Knowledge is increasing on a multiplicative scale. When we did the first guideline in 2014, we looked at papers that went back to the 1940s and 1930s. There have been more papers in the past four years than there were in all the years before that. And it looks like the rate of new knowledge and publications will continue on that trajectory. If we were to wait four more years to update the guideline, it wouldn’t be the go-to document. We need something that would be adaptable and comprehensive. If you’re a family doctor working in a small community, you need to know it all. Concussion is very common problem. This is a one-stop shop.

There is no blood test or picture test I can do to come to a definitive conclusion that a patient has a concussion.

What makes this a “living” document?

There are still so many questions that we have to answer. Better ways to improve recovery after concussion, better ways to return to learning, for example. That’s why this is so exciting. We have over 50 international panel members. This is beyond Ontario and beyond Canada. We wanted something that will be dynamic. Every month, we can look at what has been published, and we have that team of 50 experts. Because it’s a website, within hours the guidelines can reflect new information.

Can you give an example of a recommendation that has been turned upside down by recent research?

In the 2014 guideline, the recommendations said that if you have a concussion, you should not do any physical activity until you’re symptom-free. “When in doubt, sit it out.” Some of that was with safety in mind. But research showed that one in three kids had symptoms that lasted a month or more. Now, exercise is used as a treatment. It leads to better recovery. We no longer recommend that kids just sit and do nothing. We can permit safe activities like walking and jogging, under medical supervision, as long as there is no colliding or falling. Families were interpreting treatment as jail time and kids were feeling isolated. We will continue to evolve as soon as evidence is published.

Why are physicians so cautious?

Part of the reason is because there are long-term consequences to concussion. There is no blood test or picture test I can do to come to a definitive conclusion that a patient has a concussion. Until we can develop that holy grail of a test, we have to base decisions on judgment and self-reporting.

How will you spread the word about the new guideline?

It’s not a sprint, it’s a marathon. We’ll be talking to Pediatric Emergency Research Canada, which is  a network of health-care researchers at children’s hospitals. We’ll be talking to family medicine groups and we’ll be talking at conferences.

Can anyone read the guideline?

Sure. There’s information for parents, teachers and coaches. The more people are aware, the better. Visit

(This interview has been edited for clarity and brevity.)