Physical Therapy Management of Pediatric Patients Post-Concussion
A Learning Module and Evidence Table
By: Sage Stout, SPT
Coming into UNC’s DPT program, I knew I had an interest in pediatrics, but I was surprised to learn – through courses with Drs. Karen McCulloch and Vicki Mercer – that I had an equally strong interest in neurology. Specifically, I was interested in how physical therapy interventions can set the stage for rehabilitation following brain injury.
My initial interest in management of pediatric patients following concussion emerged during my first clinical rotation, when I was exposed to an adolescent with post-concussion symptoms who had been prescribed a program of complete cognitive and physical rest. This patient interaction became the starting point for a Critically Appraised Topic (CAT) project exploring the efficacy of physical therapy versus complete rest for management of post-concussion symptoms in adolescents. This project exposed me to research on the role of various physical therapy interventions in management of patients with persistent post-concussion symptoms.
Part of what initially drew me to the profession of physical therapy was the mantra “movement is medicine,” which one of my early PT mentors – Jette Goldman – taught me while I observed her pediatric practice. In researching the management of post-concussion symptoms I discovered an arena in which this mantra rings especially true.
Concussion is a form of mild traumatic brain injury (mTBI) that occurs when forces acting on the head cause neuronal injury, which sets off a neurometabolic cascade that results in energy deficits and unorganized neurotransmission within the brain.1–4 These energy deficits and issues of neurotransmission result in many of the symptoms commonly associated with concussion.1–4 Additionally, axillary structures such as cervical musculature or peripheral aspects of the vestibular system may also be damaged during concussive injuries, resulting in a variety of patient complaints.1–3,5 Children aged birth to four and twelve to eighteen years old make up two of the three groups in which concussion is most prevalent, with the third group being adults over 65 years old.6–8
While most individuals recover relatively quickly following concussion, roughly 10-15% will experience persistent post-concussion symptoms (often termed “post-concussion syndrome” or “PCS”).1 Common PCS symptoms include headache, cervical pain, balance impairments, dizziness, and exertional intolerance.1,9,10 Current research shows that a variety of physical therapy interventions are effective in the management of post-concussion symptoms in both children and adults.1–3,10–13
The learning module and associated evidence table which make up my capstone project are meant to familiarize DPT students with post-concussion syndrome and its clinical management within the scope of physical therapy. And while my project focuses on pediatric patients, much of the content is applicable to patients across the lifespan.
Statement of Need
Conversations with Dr. McCulloch pointed to a need for additional content addressing concussion within UNC’s DPT curriculum, specifically in Dr. McCulloch’s Traumatic Brain Injury unit during the third year PHYT 820: Advanced Patient Management I course.
Rising public awareness of concussion has led to an increase in the number of children and adolescents for whom medical treatment is sought after a possible concussive injury.14 As more evidence emerges supporting the utility of various physical therapy interventions in the management of patients with persistent post-concussion symptoms, it is likely that physical therapists will encounter more of these patients in clinic. “The Physical Therapist’s Role in Management of the Person with Concussion: HOD P06-12-12-10,” a recent position statement from the American Physical Therapy Association (APTA), envisions physical therapists as participating in a wide range of concussion prevention and management activities, including evaluation, diagnosis, treatment, return to participation decisions, and preventative education.15
These factors mean that it is important for entry-level PT students to gain exposure to educational content that addresses concussions in pediatric populations.
The products which makeup this capstone project include the following:
A series of case study videos were filmed by members of my capstone committee and written descriptions of those videos were provided to me by those committee members. I edited the Case Study Video Descriptions so they can serve as a tool for fostering the skills of clinical observation in students during this module.
Below, I present a mock-up of how my capstone materials might appear when viewed by students through the PHYT 820 course site. Due to privacy considerations, the case study videos for this project will only be available via the password protected Sakai course site and therefore I do not link to them in this mock-up.
Mock Course Outline
This week you’ll be exploring PT management of patients with post-concussion symptoms. Please complete the following steps:
Step 3: Complete “Patient Assessment” and “Intervention” activities
For this activity, you will explore the process of initially evaluating a patient referred to PT for post-concussion symptoms by viewing the attached Case Study Initial Evaluation PowerPoint, which details patient B’s initial evaluation. As you read through the description of B’s initial evaluation, think back to your readings and the VoiceThread for this unit. Are there other evaluations you might want to include?
The attached videos show B approximately 20 sessions (roughly 3 months) into his course of care. While B’s plan of care involved a number of different intervention strategies that aren’t included in these videos, they illustrate some options for vestibular exercises you might use in clinic. Please reference the attached Case Study Video Descriptions while watching these because the videos might be a bit confusing if you’ve never seen these exercises performed. We know not all post-concussion patients will require vestibular intervention, so make sure to look over the readings by Leddy et al and Cheever et al to get a sense of other potential intervention strategies for this population.
Step 4: Complete Discussion Board Post & Response
Select one of the following as the focus of your original post. Respond to a post with a different focus for your response. For each post, please cite at least two sources (not the VoiceThread). Make an effort to draw on recent additions to the research literature. As we discussed, this is an evolving field, so it is important to search the literature for recent work.
Which additional assessments might be appropriate for use during “B’s” initial evaluation and why?
Based on the information we have regarding B’s balance, vestibulocochlear function, and strength, as well as his primary complaints and stated goals, discuss which interventions you might utilize – and why. Create 2 short-term and 2 long-term goals for B based on this initial evaluation and your newly acquired clinical knowledge of post-concussion patient management.
After viewing the case videos, suggest ways that at least two of the demonstrated exercises could be simplified, as well as how they could be progressed. Explain your rationale for each. Make sure to read over the case video descriptions before answering this question.
In video 8903 we see B using the NeuroCom® inVision system. Describe this system, its use, and how we might utilize it to track patient outcomes across a course of care. The inVision system is most commonly utilized in research settings (versus clinical ones) so students interested in clinical research might want to look into this.
Identify one recent research study (published within the last 5 years) that deals with rehabilitation strategies for patients with post-concussion symptoms, but is not focused on concussion in sport. Describe the study’s design, participants, interventions, outcomes, and why or why not you would feel comfortable utilizing this intervention approach in clinic. Why is it important to address non-sports related concussions in clinical research?
The evaluation of these products occurred through ongoing feedback from my capstone committee: Dr. McCulloch, Catherine (CJ) Hamilton, PT, and Elizabeth (Dietra) Buxton, PT, DPT.
Additionally, I had the opportunity to present the VoiceThread component of this project to a group of approximately 30 first and third year DPT students. The Feedback collected following this presentation provided an important source of information regarding the accessibility of the content to students with variable levels of interest in neurology and/or pediatrics.
I would like to thank Dr. McCulloch for her support of this project, and her contagious enthusiasm for physical therapy in the neurologic sphere. Through the capstone process and her Advanced Neurology course, I have been exposed to tools that will serve me well throughout my clinical practice.
I would also like to extend my sincere gratitude to both Catherine (CJ) Hamilton, PT, and Elizabeth (Dietra) Buxton, PT, DPT, for their valuable feedback during the capstone process, as well as their assistance with getting a case study for the project. I was fortunate to have committee members who brought both clinical knowledge and enthusiasm to this project.
Finally I would like to thank the patient (“B”) who provided a case study for this project. It was incredibly generous of you to share your experience and this project is much richer because of it.
Ontario Neurotrauma Foundation. Guidelines for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms, 2nd edition. 2013. Available at: http://onf.org/system/attachments/60/original/Guidelines_for_Mild_Traumatic_Brain_Injury_and_Persistent_Symptoms.pdf. Accessed November 7, 2017.
McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51(11):838-847. doi:10.1136/bjsports-2017-097699.
Marshall S, Bayley M, McCullagh S, et al. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Inj 2015;29(6):688-700. doi:10.3109/02699052.2015.1004755.
Shrey DW, Griesbach GS, Giza CC. The pathophysiology of concussions in youth. Phys Med Rehabil Clin N Am 2011;22(4):577-602, vii. doi:10.1016/j.pmr.2011.08.002.
Cheever K, Kawata K, Tierney R, Galgon A. Cervical injury assessments for concussion evaluation: A review. J Athl Train 2016;51(12):1037-1044. doi:10.4085/1062-6050-51.12.15.
Parachute Canada. Concussion: the basics. Concussion Resources. Available at: http://www.parachutecanada.org/downloads/resources/Concussion_Basics.pdf. Accessed February 25, 2018.
Centers for Disease Control. Get the Stats on Traumatic Brain Injury’ ‘ in the United States. Available at: https://www.cdc.gov/traumaticbraininjury/pdf/bluebook_factsheet-a.pdf. Accessed February 21, 2018.
Centers for Disease Control. Fact Sheet: Facts about Concussion and Brain Injury [PDF]. Available at: https://www.cdc.gov/traumaticbraininjury/pdf/Fact_Sheet_ConcussTBI-a.pdf. Accessed February 21, 2018.
Winkler R, Taylor NF. Do children and adolescents with mild traumatic brain injury and persistent symptoms benefit from treatment? A systematic review. J Head Trauma Rehabil 2015;30(5):324-333. doi:10.1097/HTR.0000000000000114.
Imhoff S, Fait P, Carrier-Toutant F, Boulard G. Efficiency of an Active Rehabilitation Intervention in a Slow-to-Recover Paediatric Population following Mild Traumatic Brain Injury: A Pilot Study. J Sports Med (Hindawi Publ Corp) 2016;2016:5127374. doi:10.1155/2016/5127374.
Gagnon I, Galli C, Friedman D, Grilli L, Iverson GL. Active rehabilitation for children who are slow to recover following sport-related concussion. Brain Inj 2009;23(12):956-964. doi:10.3109/02699050903373477.
Leddy J, Hinds A, Sirica D, Willer B. The role of controlled exercise in concussion management. PM R 2016;8(3 Suppl):S91-S100. doi:10.1016/j.pmrj.2015.10.017.
Hugentobler JA, Vegh M, Janiszewski B, Quatman-Yates C. Physical therapy intervention strategies for patients with prolonged mild traumatic brain injury symptoms: a case series. Int. J. Sports Phys. Ther. 2015;10(5):676-689.
Centers for Disease Control and Prevention. Traumatic Brain Injury In the United States: Epidemiology and Rehabilitation. Atlanta, GA: National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention; 2015.
The Physical Therapist’s Role in Management of the Person with Concussion: HOD P06 -12- 12 -10. 2012. Available at: https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/ManagementConcussion.pdf.Accessed August 31, 2017.