CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

BEST PRACTICE FOR CONCUSSION MANAGEMENT

Clinician Question & CAT Topic:

Clinical Question:

Clinical Bottom Line:

Refresh Date: 3/1/2019

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None
Key Findings
➢ Breadth of Literature:
o Since concussion management is a “hot topic” there is high quantity of available literature regarding concussions, including
sport-related concussions, motor vehicle accidents, acute recovery etc. This research readily addresses the use of balance training as an
intervention for individuals with mTBI.
➢ Research Quality:
o Due to the nature of literature reviews, the quality of research is low, especially as compared to the quantity.
o The most recently published systematic review, notes that original research regarding mTBA and balance training is of low quality,
due to the lack of consistency within balance intervention protocols and prescriptions.
➢ Level of Evidence:
o Systematic Review (Level 1).
o Literature reviews and Clinical Commentaries do not fall within any specified category of the Oxford levels of Evidence.
➢ General Limitations:
o Much of the available literature consists of literature reviews, which are a lower quality of evidence than systematic reviews or
meta-analyses. Often these reviews are summaries of other reviews, and the research itself is far-removed and recommendations
provided fail to offer parameters.
o The most current systematic review notes that a majority of the original research found was low-quality evidence, due to errors.
o The population specified by the research question:(patients with chronic oculomotor dysfunction following mTBI) allows for a high
level of variables prior to interventions which are implemented beyond the acute healing phase.
➢ Take-Home Findings:
o Current research supports the use of balance training for adults and children with delayed recovery from mTBI to reduce dizziness,
and facilitate improvements in gait and balance function
o Balance interventions should be implemented using a case-by-case prescription, to limit patient symptoms as they progress through
the standard phases of concussion recovery.
o In spite of the wide breadth of available literature, the quality of current research regarding mTBI and balance training is low, and
future research is necessary to determine appropriate parameters for balance training.
➢ Clinical relevance:
o Balance training is appropriate for patients presenting with delayed recovery from mTBI, who display deficits of balance.
o Since the literature does not directly assess use of oculomotor challenges (​saccades, smooth pursuits, cervical laser​) with balance
training, incorporation of these additional challenges should be used with each individual patient’s tolerance in mind.

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None
Search Methodology:​ (This section should include enough detail to make the search repeatable)
Search Resources Search Terms Limits # of Articles
Google Scholar concussion oculomotor dysfunction none set 14
intervention balance training with
1
oculomotor challenge (saccades,
smooth pursuits, cervical laser)
Google Scholar Vergence Dysfunction concussion none set 8
“delayed recovery” rehabilitation OR
2
treatment OR intervention "physical
therapy"
ClinicalKey concussion prolonged recovery Journal Articles, full text 5
3 vestibulo-ocular treatment Balance Filter by specialties: Physical
Intervention regimes medicine and rehabilitation
Cochrane Database of Systematic concussion AND Rehabilitation or none set 1
4
Reviews therapy or treatment
5 PubMed vergence disorder concussion None set 1
Google Scholar concussion meta analysis "balance since 2017 68
6
training" not citations or patents
Google Scholar concussion OR mTBI "systematic not citations or patents 190
7 review" "delayed recovery"
"balance training"

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None
Search Results Summary:
Results Reasons for Inclusion Reasons for Exclusion # of Articles
Included
1 Literature Review (Clinical None populaton: (neck pain excluding 1
Commentary) TBI), animal studies, focus on
1 Pre-Post Series examination, books
2 Case Study
1
1 Animal Study
2 Abstract
4 Book
2 Dissertation/theses
4 Literature review None population: (mild TBI, without 1
2 “Statement of Agreements” prolonged recovery), focus on early
2 1 Book intervention and management,
1 Litigation book, litigation, balance not
discussed as specific intervention
4 Literature Review None Balance interventions not included, 1
1 Index index, diagnosis as primary focus,
3
dual diagnosis with SCI, repeated
articles
4 1 Systematic review None Focus on hyperbaric oxygen 0
5 1 Abstract None Abstract 0
(Some) Meta-Analyses None not a meta-analysis, population: (no 0
(Many) Other concussion: vertigo, injuries to
6
extremities, disease process etc.),
prevention, not english
(Some) Systematic Review Most current systematic review not a systematic review, population 1
7 (Many) Other (no concussion/mTBI), past search
page 3 (decreasing relevance)

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None
Research Participant and Study Characteristics:
Reference Participant Key Clinical Control Intervention Experimental Intervention Level of
Characteristics (frequency/duration) (frequency/duration) Evidence
N/A N/A N/A N/A N/A

Outcomes:
Reference Event/Outcome Time to Mean (SD) ES &/or NNT
(may have more than one per Event Control Group Experimental Group
reference)
N/A N/A N/A N/A N/A N/A

Systematic Review/Meta-Analysis Characteristics

Reference Data Sources/Author Search Inclusion/Exclusion Criteria Number of Studies Reviewed and
Processes Included (Data Extraction in Meta
Analysis)
Leddy, 2016 None specified Inclusion: TBI, vestibular dysfunction 104 (total referenced)
(vestibular therapy section only) 9 ​(vestibular section of review)
Lundbald, 2017 None specified Inclusion: protracted recovery following 124 (total referenced)
a sports related concussion
Phillips, 2016 None specified Inclusion: Prolonged concussion/PCS 153 (total referenced)
diagnosis 16 ​(Vestibular/vision section of
review)
Schneider et al, -Databases searched: MEDLINE Inclusion: (1) original research 5,711 (screened)
2017 (OVID), CINAHL (Ebsco- (2) reported sport-related concussion 41 (reviewed)
Host), PsycInfo (OVID), Cochrane (SRC) as the diagnosis 19 ​(active treatment, met inclusion
Central Register of Controlled Trials (3) evaluated the effect of rest or active criteria)
(OVID), SPORTDiscus (Ebsco- treatment/rehabilitation.
Host), EMBASE (OVID), Proquest Exclusion: Review articles, Abstracts
Dissertations and Theses Global
(Proquest).
-The search run by expert librarian,
exported for review for the author group

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None
 (including articles published until 17
October 2016) Duplicates were
removed.
-References of papers and systematic
reviews searched for additional
references
-Authors were asked to share any
additional references that met the
inclusion criteria.
-Article title and abstract article
independently reviewed by 2 authors
-3rd reviewer to resolve discrepancies,
full-text manuscripts were retrieved to
determine
eligibility for inclusion

Systematic Review/Meta-Analysis Outcomes:

Reference Author Conclusions (Data Synthesis in Meta- Analysis) Limitations
Leddy, 2016 -Vestibular rehabilitation (gaze stabilization exercises w/ fixed gaze position -Specific parameters not provided, further
while turning the head from side to side in sitting and standing positions, research required
standing balance with feet apart and feet together -Not a systematic review
on foam with eyes open and closed, walking with balance challenge: head
turns, tandem walking, obstacle avoidance)can result in reduced dizziness as
well as improvements in gait and balance function after concussion in
children and adults
-Patients with persistent symptoms following sport related concussion (SRC)
are more likely to be medically
cleared to return to sport ≤ 8 weeks of initiating treatment with combined
vestibular and cervical PT
-Patients after concussion can safely engage in controlled physical activity
below their individual symptom threshold
-Controlled activity including balance training may be beneficial to recovery

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None
Lundbald, 2017 -Provides a conceptual model/timeline of progression of treatments for -Provides a broad overview of existing
patients with concussions: Relative Rest, Symptom Management, literature for concussion recovery and
Neuroplasticity , Complex Functional Activities, Guided Return to Sports. treatment timelines, without specification of
-Timelines are individualized, and transition to the next phase is dependent parameters or specific intervention
upon completion of the previous (ie symptoms managed before techniques.
neuroplasticity) -Not a systematic review
-The treatment progression correlates to 3 phases of recovery: Protection,
Deficit Management, Return to Sport
-The neuroplasticity portion of the progression of treatment is focused on
addressing impairments, neuroplasticity, and normalizing full function, and
is directly in the center of the deficit management phase.
-Vestibular-Ocular Interventions should primarily be incorporated at an
appropriate level based on the phase of recovery a patient is currently within.
Phillips, 2016 -Principles of vestibular rehabilitation include recalibration of depth and -Specific parameters not provided, further
spatial perception under static and dynamic conditions by reestablishing research required
efficient integration of the vestibular,visual, and somatosensory subsystems -Not a systematic review
-Vestibular treatment programs improve function of the vestibulo-ocular
reflex, cervico-ocular reflex, depth perception, somatosensory retraining,
dynamic gait, and aerobic training, all beneficial for recovery.
Schneider et al, -Vestibular rehabilitation is supported for individuals with persisting -Most studies included were biased by
2017 dizziness, cervical spine pain and headaches). systematic errors and were of low
-Closely monitored active rehabilitation programmes involving subsymptom methodological quality.
threshold and submaximal exercise are safe and may facilitate recovery. -Review may be subject to publication bias.
-Language bias (English)
-Other treatments of potential benefit may
have been evaluated in this population,
outside of inclusion criteria.

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None
References:
1. Leddy JJ, Baker JG, Willer B. Active Rehabilitation of Concussion and Post-concussion Syndrome. ​Physical Medicine and

Rehabilitation Clinics of North America​. 2016;27(2):437-454. doi:10.1016/j.pmr.2015.12.003.

2. Lundblad M. A Conceptual Model for Physical Therapists Treating Athletes with Protracted Recovery Following a

Concussion. ​The International Journal of Sports Physical Therapy​. 2017;12(2):286-296.

3. Phillips MM, Reddy CC. Managing Patients with Prolonged Recovery Following Concussion. ​Physical Medicine and

Rehabilitation Clinics of North America​. 2016;27(2):455-474. doi:10.1016/j.pmr.2015.12.005.

4. Schneider KJ, Leddy JJ, Guskiewicz KM, et al.​ ​Br J Sports Med Published Online First: 2017;0:1-7.

doi:10.1136/ bjsports-2016-097475

Author(s): Corianne Strupp Date Created: 3/1/2018

Reviewer(s): None Date Updated: None