Concussion Clinical Practice Guideline

Background

Prior to beginning physical therapy school, I was employed as a rehabilitation technician at a level 1 trauma center in Charlotte, North Carolina. A few of the physical therapists specialized in treating individuals with traumatic brain injuries (TBI) and I became intrigued with the presentations of the patients and the treatment style. They quickly became my favorite patients to work with. Throughout my time in physical therapy school, I was always drawn to the TBI lectures and learning opportunities. During my third clinical, I had the amazing opportunity to work with Jen Meyer, PT, DPT, NCS, at Pi Beta Phi Rehabilitation Institute in Nashville, TN. This is where I was first exposed to physical therapy treatment of concussion in the outpatient clinic. I quickly fell in love with the patient population and treatment style and knew that I wanted to continue learning about and eventually work with this population as a future physical therapist. When it came time to select a Capstone topic, I knew I wanted to focus on the subject of concussion. When Dr. Karen McCulloch presented to me the opportunity to assist with the creation of the Concussion Clinical Practice Guideline, I could not turn it down. I have had the pleasure of working with this group of physical therapists devoted to creating a guide for concussion treatment in the general population.

 

Purpose and Overview of Concussion CPG

The Concussion Clinical Practice Guideline (CPG) was created by the Guideline Development Group, to be a comprehensive guide for physical therapists treating patients after a concussive event. The diagnosis and treatment of a concussive event is complex and can be challenging for any clinician. Current CPGs exist that focus on pediatrics, sports-related concussion, and military-related concussion, but there are none which currently address the breadth of physical therapy diagnosis, prognosis, evaluation and treatment of a concussion in the general population. This guideline aims to fill the gap in knowledge for treating concussions of all etiologies, all ages over 8 years old, at any time over the course of the injury, and in any physical therapy setting. The group’s intent was to review the best current evidence to address impairments related to concussion and associated musculoskeletal conditions. Additionally, the Guideline Development Group intends for this CPG to provide information to other health care professionals and stakeholders regarding the scope of physical therapy concussion management. The Concussion Clinical Practice Guideline is expected to be published in summer 2019 in the Journal of Orthopedic & Sports Physical Therapy (JOSPT).

 

Statement of Need

Around 3.8 million concussions occur in the United States each year from competitive sports or recreational activities.¹ But how many concussions occur during everyday activities, work-related activities, falls, or motor vehicle accidents? These data are less clear, and it is estimated that about 50% of concussions go unreported. Currently, the majority of research surrounding concussion is performed in the athletic population, focusing primarily on sideline evaluation and return-to-play, with few high-quality studies focused on the general population. This makes it difficult for physical therapists to find evidence to inform their evaluation and treatment procedures for individuals who present in the clinic. Additionally, the traditional recommendations of resting until symptom-free have been replaced with active intervention approaches to facilitate recovery. Therefore, physical therapists are beginning to see patients early into recovery and research is promoting interventions as early as the day of injury.^2,3 The Concussion Clinical Practice Guideline will provide a comprehensive summary of current evidence and expert opinion for the treatment of concussion for ages 8 and older in any practice setting, regardless of acuity.

My contributions will be incorporated into an appendix of the Clinical Practice Guideline and my VoiceThread will be provided as an adjunct reference for students and clinicians as an overview of the recommendations published in the Clinical Practice Guideline.

 

Products

Throughout the Capstone process, I participated in weekly conference calls with the Guideline Development Group to discuss the CPG. I assisted with the management of DistillerSR, an article appraisal manager, uploading and categorizing articles. I also completed article appraisals via DistillerSR that are intended for review and inclusion into the CPG. One product posted below includes an evidence table of articles covering topics of dizziness, balance, vision, cervical dysfunction, and exertional tolerance. Another product posted below is a VoiceThread that addresses and summarizes the key points and recommendations that can be found in the Concussion Clinical Practice Guideline.

Evidence Table (.xls)

VoiceThread: “Concussion Clinical Practice Guideline”

 

Evaluation

Throughout the process of creating my Capstone, I continuously integrated information about the CPG learned from the weekly meetings and through feedback from the Capstone Committee Members. I also watched the videos and read the articles placed on the Capstone site regarding resources for presentations. Additionally, I created an evaluation form that can be completed by anyone who views my Capstone VoiceThread.

Capstone Feedback Form (.docx)

 

Self-Assessment

My goals for this Capstone project were to expand my knowledge of current evidence-based practice for the treatment of concussion in the general population, provide valuable contributions to the CPG team, and produce a product that will present the Concussion Clinical Practice Guideline to students and clinicians who treat or are interested in treating those with a concussion. Through this process, I have gained experience of working with a team who lives all across the country and have learned how to appraise and synthesize a variety of research. I am proud of the products I was able to create this semester and grateful for all of the knowledge I have acquired.

 

Acknowledgments

I would like to thank my Capstone Mentor Dr. Karen McCulloch, my Capstone Committee Member Dr. Catherine Quatman-Yates, and the rest of the Guideline Development Group for the opportunity to be a part of the process of creating this Clinical Practice Guideline. I greatly appreciated their support and assistance throughout this process and admire their passion and knowledge of physical therapy and concussion.

 

References

1. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin. J. Sport Med. 2013;23(1):1-18. doi:10.1097/JSM.0b013e31827f5f93.
2. Lennon A, Hugentobler JA, Sroka MC, et al. An exploration of the impact of initial timing of physical therapy on safety and outcomes after concussion in adolescents. J Neurol Phys Ther 2018;42(3):123-131. doi:10.1097/NPT.0000000000000227.
3. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br. J. Sports Med. 2017;51(12):930-934. doi:10.1136/bjsports-2016-097475.