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In 2015, the Department of Defense (DoD) reported 22,672 active duty service members were diagnosed with traumatic brain injury (TBI), 18,686 of which were reported as mild TBI (mTBI).1 Soldiers are at increased risk of sustaining head injuries due to blast and blunt trauma exposure in combat and in training exercises. The majority of mTBI and concussion symptoms resolve in 7-10 days, however in about 30% of cases symptoms may persist.3 During my clinical rotation at the Intrepid Spirit Center at Fort Bragg I had the unique opportunity to work with this patient population. I found great honor and fulfillment helping guide soldiers with mTBI in their quest to return to duty. However, in treating these patients I began to notice gaps and inconsistencies in care. I also saw a handful of patients who had unresolved symptoms after exhausting all medical options. I reviewed available evidence and found evidence that specific physical therapy intervention to address exertional headache and vestibular symptoms related to mTBI can be effective in this population.2,4,5 But I also found that there were no clinical practice guidelines for persistent mTBI/concussion and the available evidence was sparse. I felt as though I was doing the soldiers a disservice with the level of care I was able to provide and I had aspirations to work with population throughout my career. Consequently, I began devoting much of my academic efforts towards improving my understanding of the condition.

Specifically, I completed a critically appraised topic assignment (CAT) focusing on the inclusion of cerivcovestibular rehabilitation in combination with progressive aerobic exertion training to improve return to duty time but again found a lack of evidence supporting these interventions. There was a single randomized control trial (Schneider et al.)3 focusing on this particular topic and low-level evidence focusing on related topics.

My interest to improve the standard of care for this population did not waiver so when the opportunity arose to work with experts in the mTBI/concussion field to development Clinical Practice Guidelines for mTBI/concussion I was excited to contribute. The development of the guidelines will not only improve the standard of care for the population but will also highlight gaps that need to be addressed in the literature and drive future research efforts.

My involvement in the project has been to facilitate the efforts of the Core Working Group. I have highlighted my contributions to date and described my expected involvement moving forward. I have also included a link to access my completed products. A definitive timeline for the writing and expected completion of the Clinical Practice Guidelines has not been expressed to me and therefore I am currently unable to provide a definitive completion date for my capstone project.

Overview of Concussion CPG

The Clinical Practice Guidelines being developed by a Core Working Group of experts in the field of mTBI/concussion care and management will serve as a resource for healthcare professionals. The guidelines will clearly define mTBI/concussion, the timeframe associated with persistent symptoms, and the complex pathophysiologic symptoms associated with persistent symptoms. The guidelines will identify indications, benefits, and best practice recommendations within the scope of practice for physical therapists treating this population. The guidelines will also highlight gaps in literature that must be addressed in future research to improve the standard of care for the population. The expert recommendations in the Clinical Practice Guidelines will improve clinician’s ability to identify and address underlying impairments that cause persistent symptoms and limit activity and participation. The Clinical Practice Guidelines will include discussion in regards to the utilization of common screening measures for individuals with undiagnosed concussion and recommendations for appropriate referral.

Authors involved in the development of the Clinical Practice Guidelines include experts in the fields of cervicogenic disorders, vestibular dysfunction, sports concussion, military mTBI, pediatrics, orthopedics and neurology. Gaps in the literature will be addressed with the expert consensus of the Core Working Group.

Writing will commence in July 2017. When the initial draft is completed an external stakeholder review will be conducted and revisions will be made. An external expert review and public comment will then be conducted and final revisions will be made prior to submission.

Completed Products

I have completed numerous tasks in an effort to assist the Core Working Group in preparation to write Clinical Practice Guidelines for mTBI/concussion. The goal has been to prepare various documents that the Core Working Group will utilize during the writing process. Having these documents prepared ahead of time will ease their process. Thus far I have assisted in data extraction, constructed and organized evidence tables, attended a writing session at CSM, created a document to assist in the development of a definitive definition of “mTBI/concussion” to be used in the guidelines, created comprehensive lists of ICD-10 and ICF codes that relate to mTBI/concussion, constructed detailed psychometric charts for specific measures that will be included in the guidelines, created a short list of commonly used self-report measures and their psychometrics to facilitate a discussion amongst the authors regarding which of these measures should be included in the guidelines, and drafted a statement regarding the epidemiological data available for mTBI.

All of these products are working documents that will continue to evolve as the project moves forward, but as mentioned having these documents as a reference will aid the writing process.  Please visit the links listed below to view completed works with special emphasis on outcome measure charts.

Data Extraction Tables: EvidenceTable_DataExtraction (Has since been continued by the Core Working Group)
ICD-10 Codes: ICD10_Codes
ICF Codes: ICF_Codes_List+Description – ICFCodes_ExcelChart WorkingFile
Self Report Measures: SelfReportMeasure_WorkingFile
Outcome Measure Charts:OutcomeMeasureCharts_WorkingFile
Statement on Epidemiology: Epidemiology_ConcussionCPG

Moving Forward

My involvement will continue to evolve to meet the needs of the Core Working Group as the project progresses. I have discussed drafting an introduction for the guidelines and organizing an external expert review for the completed CPG. I will also be available to the Core Working Group to complete tasks that will facilitate the process as they arise.


My involvement in this project has helped me understand and appreciate the time and effort involved in constructing Clinical Practice Guidelines. It has also reinforced my appreciation for committed, flexible, capable colleagues. Members of the Core Working Group are spread all over the country and have numerous responsibilities unrelated to the Clinical Practice Guidelines; however they make time for weekly teleconferences, devote their valuable time to the project and are very understanding when other members have conflicts that delay their completion of tasks. It has been a pleasure to be involved with a group that worked so well together.

My involvement with the project also challenged my personal ability to be flexible and put my type B personality on display. The timeline of the project is not definite and expectations for contribution to the project were not clearly stated at the beginning of my involvement with the group. Rather, I would be assigned weekly tasks based on the needs of the Core Working Group to facilitate their efforts. At times I would have preferred a structured schedule to ease the stress of uncertainty but as I reflect now I realize how valuable my involvement in this project was for my personal and professional development. The opportunity to be present and offer input while a group of experts in the field that I aspire to focus my professional efforts towards discussed key aspects of the Clinical Practice Guidelines they were constructing was invaluable. I have immense gratitude to the group for allowing me that opportunity and all the other great learning experiences I have had throughout this process.


  1. Defense Veterans Brain Injury Center. DoD Worldwide Numbers for TBI. Washing- ton, DC.. Last updated Dec 8, 2016. Accessed Dec 9, 2016.
  2. Scherer MR, Schubert MC. Traumatic brain injury and vestibular pathology as a comorbidity after blast exposure. Phys Ther. 2009;89(9):980-92.
  3. Schneider KJ, Meeuwisse WH, Nettel-aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):1294-8.
  4. Leddy JJ, Willer B. Use of graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep. 2013;12(6):370-6.
  5. Leddy J, Hinds A, Sirica D, Willer B. The Role of Controlled Exercise in Concussion Management. PM R. 2016;8(3 Suppl):S91-S100.

4 Responses to “Assisting with PT Concussion/mTBI Clinical Practice Guidelines”

  1. Teddy Zabel

    Kmac – Thank you so much for allowing me to be involved with the project. It has been an amazing learning experience and I’m glad I was able to help!

    Carla – First, I think one of the most important things I would like my classmates to understand is the multivariate nature of persistent concussion symptoms. The interplay between systems and overlapping presentations can make diagnosing and choosing appropriate interventions difficult. A thorough multisystem evaluation is required to decrease the risk that we miss a piece of the puzzle. Diverse symptoms and impairments need to be identified but treating patients through a multisystem intervention approach rather than treating systems in isolation can help to improve outcomes.
    Secondly, the stigma of rest during the acute and symptomatic stage of concussion is being challenged in recent literature. I would urge my classmates to keep a finger on the pulse of this emerging research to provide the best care to their patients. The Collins paper that Tyler referenced in his comment alludes to this.
    Finally, I would like to stress the importance of patient, caregiver, coach, and community education. In recent years concussion awareness has skyrocketed due to happenings in college and professional sports, however there is still a long way to go. Concussions are a bit mysterious to the general public because there is no physical manifestation of injury. The mystery deepens when symptoms persist beyond the expected time course of recovery. Athletic and military populations have a tendency to “push through” in situations such as these and at times that attitude is encouraged by others who don’t understand the pathophysiology. We need to make a point to educate these patients that overextending themselves will result in setbacks, and as frustrating as the recovery process becomes they must be adherent to the process.

    Tyler-I had not read the Statements of Agreement from the TEAM meeting. Thank you for sharing. The CPG will make a statement in regards to their stance on rest during the acute stage of concussion however the focus of the CPG will be on the assessment and management of symptoms persisting beyond 2 weeks after the initial injury. To my knowledge the Collins paper is not included in the CPG. I believe the legislation has been modified (or is in the process of being modified) to grant physical therapists the authority to make return to play decisions in NC. I am not sure what the laws look like regarding return to play in other states.

  2. Tyler Shelton

    Ted, I really enjoyed reading about your capstone. This is also an area of personal interest for me, so I was excited to see someone expand on this topic. The impressive detail you put behind all documents will surely come in handy to the Core Working Group as they continue to establish clinical practice guidelines that can be used to benefit soldiers with mTBIs. I found the outcome measure charts particularly helpful, and appreciated the guidance for using these outcomes on athletes/soldiers with mTBIs. I was curious as to whether or not you have had a chance to read the Statements of Agreement from the TEAM meeting in Pittsburg last year, and whether or not you know if the Core Working Group plans to integrate agreements from this meeting into their CPGs? I came across the article while listening to a sports PT podcast discussing concussion, and learned that this group of concussion experts identified several common misconceptions about concussion and how it is currently being treated. Also, I recently learned during Advocacy Day that NC physical therapists are unable to clear athletes from a concussion protocol to return to play, and was wondering if this is a common theme in many states or if it is something that is only in NC? I thoroughly enjoyed learning from this capstone, and look forward to hearing of future CPGs released by the Core Working Group, thanks to your dedicated assistance.

  3. Carla Hill

    I know you are passionate about this patient population and rehabilitation topic. You’ve done a great job assisting the Core Working Group in the process of developing a CPG. Being around so many experts discussing the evidence must have been valuable to your learning. What are the top 3 things you want your classmates (and all PTs) to know about managing a patient with mTBI/concussion?

  4. KMac

    YAY Ted – thanks so much for all the work that you’ve done on this project – hopefully we’ll be able to continue to involve you over the summer b/c there is still more work to be done. I feel certain that the group will be appreciative for the pieces of the whole that you were able to carve off and take care of for us – there may be some edits that happen to your work, but having such great drafts to start with will be very helpful. Thanks again for your flexibility with all the craziness of my semester!


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