Understanding and Improving Research in mTBI

Background

Concussion or mild traumatic brain injury (mTBI) is a highly prevalent topic in current research, as the recommendations for optimal rest and intervention have significantly changed over even the last decade.¹ Physical therapists are well suited to address the symptoms of concussion including but not limited to vestibular and cervical dysfunction, exertional intolerance, headache, and balance or functional mobility deficits.¹ There is a need for additional research in concussion to better understand the predisposing factors that lead to chronic symptoms known as Post-Concussive Syndrome, what interventions work best for which patients, as well as what clinical or subclinical deficits may linger at the end of treatment that could predispose the individual to subsequent injury.¹

I became interested in concussion during my rotation at UNC’s Center for Rehabilitation Care during the summer of 2018. My clinical instructor’s extensive understanding and knowledge of the complex symptom interactions as well as dedication to draw from the evidence in order to modify her treatment methods was an excellent example of evidence-based practice and presented a welcome challenge as I tried to develop my skills within this area.

Statement of Need

Due to the wide variety of symptoms related to concussion, there is a need for a new model of research able to manage the multiple comorbid symptoms and concurrent intervention strategies that occur in the treatment of these patients. Randomization, exclusion and blinding are often difficult, not applicable or unethical in rehabilitation research. The ORION project is based on a practice-based evidence model with the purpose of measuring and managing the diverse patient and treatment factors is necessary to move forward in our understanding of the effectiveness of mTBI intervention. The subset of my purpose within this need was to address the method of data collection and intervention factors relevant to physical therapy’s role within this multidisciplinary project.

As there is no formal evaluation tool for practice-based evidence, there was a need for a resource to provide a better understanding of the purpose and components of the PBE model for DPT students.

The Clinical Practice Guideline meets the need for a better understanding of the general categories of patient presentation and how a physical therapist may guide their interventions based on these symptoms. My role within this project was to assist with article review as there is ongoing innovative research necessary to incorporate into the guideline.

Project Overview and Purpose

I participated in two ongoing projects with Dr. Karen McCulloch, PT, PhD, MS, NCS. The first, the ORION project, is a large multi-center study following the “Practice Based Evidence” model investigating multidisciplinary interventions to treat mTBI in the military populations. Service members are a unique sub-population of those with mTBI as the mechanism of injury, immediate treatment abilities and high-level demands imposed when returning to service are different than those in the general public. Within this project, I partnered with Dr. McCulloch to organize the documentation coding for treatment diagnoses as well as develop an intake form for physical therapists to code their interventions. The practice-based evidence model demands a standardized treatment language for assessment, interventions and outcomes, so this form was an attempt at organizing the diverse treatments associated with mTBI that would accommodate interventions from the multiple sites. This taxonomy is based on the language of the treatment-based classification system, a proposed model to better define the “active ingredients” of treatment that not only assists with multicenter trials but also creates a structure of organization and purpose to clinical intervention linking techniques to the theoretical target deficit.³

The practice-based evidence model is a unique form of research designed to address the limited external and ecological validity of traditional research including randomized control trials and observational studies, but one with unique demands of data collection, management and appraisal. As it is emerging in prevalence, I created a voice thread for 2^nd Year Physical Therapy students in PHYT 784 & 785 to provide an overview of the purpose and value of this model.

Finally, I participated in article appraisal and developed an evidence table as a part of another project Dr. McCulloch is involved with, developing a Clinical Practice Guideline for Physical Therapists’ treatment of concussion. I reviewed articles related to dual-tasking and fatigue, submitting my appraisals to the data management software for systematic reviews to for later review and comparison with members of the project team. I submitted my evidence table as a summary of the interventions and components to the research team.

Overall, each project provided excellent exposure to the methods and involvement behind both the practice-based evidence model and a systematic review for the purposes of clinical practice guideline development.

Products

Intervention classification system proposal for PT within the ORION project

PBE Intervention Taxonomy mTBI

Practice Based Evidence: An Overview

VoiceThread

Evidence table of articles appraised for CPG

Evidence Table

Evaluation and Self Reflection

As a part of the ORION project I was able to participate in conference calls which focused on the need for a standardization of the treatment language, methods of data collection and organization of interventions in a way that would suit the multitude of therapists working on this project. The teams’ feedback on the form that Dr. McCulloch and I developed provided the tools to understand and revise the organization as well as insight into new treatment assessments in concussion and the shortfalls of this taxonomy in addressing those treatments. The team also discussed the design, purpose and format of the practice-based evidence model which advised my development of the voice thread as well as provided unique insight into the complexities of this model that required clarification for even the members of the project team. A subset of the feedback from this team and future revisions to this model are provided on the attached form.

As the intended audience of my voice thread on practice-based evidence is 2^nd year physical therapy students who have already completed their first Evidence Based Practice class, I used the resources on Sakai to optimize the efficiency of my message and ensure it clearly met the learning objectives revised by Dr. McCulloch. Completing a needs assessment, classifying my audience by learning category, and comparing my presentation to the Taxonomies of Educational Objectives by Plack et al. were each useful steps in revision.⁴ I’ve learned through the development and delivery of multiple presentations during this year that it is absolutely a honed skill and appreciate the feedback and purposeful review.

I used resources from the CPG team and Dr. McCulloch in order to complete my article appraisals and evidence table prior to submitting the data to the research team.

Self-Assessment

During third year, I often became frustrated by the lack of available research or its shortfalls in clinical applicability due to the narrow inclusion criteria of patients, use of interventions or treatment structures not feasible in every day practice, as well as the difficulty in drawing conclusions due to the widespread and varying opinions across concussion research. Therefore, it was exciting to be a part of two projects dedicated to addressing these issues head on.

These projects improved my knowledge of the wide variety of symptoms of concussion, the developing research related to fatigue and exertion related to reinjury risk, as well as complex dual tasking conditions especially relevant to high level athletes and service members which sparked great curiosity and hopefully an area of clinical specialty in my professional career. Concussion within these populations involves a unique combination of neurorehabilitation and high-performance athletics, which is well aligned with my background and interests within physical therapy so I hope to get the chance to pursue this clinical specialty further.

I certainly identified personal weaknesses during my work on these projects, including my pace with article appraisal, understanding the data management techniques and how this impacts bias and research quality, as well broadly organizing the detailed and frankly infinite number of specific treatment techniques into an efficient and non-redundant taxonomy of treatment. Feedback from the research teams and Dr. McCulloch clarified and refocused my attention to clinical relevancy and practicality of both my products and my considerations of research I reviewed.

Acknowledgements

I first would like to acknowledge Dr. Karen McCulloch, whose expertise and dedication to efficient, purposeful and clinically relevant research is an inspiring model in looking at the future of rehabilitation research. Her willingness to allow my involvement within these projects to further develop my clinical knowledge within this treatment specialty as well as exposure to the development side of research projects will serve me well as I pursue future professional goals. Her constant reminder to “get out of the weeds” is an ever-necessary lesson for me to step away from the details in order to more efficiently arrive at a useful and applicable solution.

I would like to thank the members of the ORION Project for allowing my participation in the early stages of this major project that will provide valuable insight to the methods and effectiveness of current rehabilitation for mTBI and an excellent basis for ongoing research. In particular the work of Susan Horn, PhD on the practice-based evidence model was the basis for my voice thread and an extremely valuable solution to the shortfalls of rehabilitation research.²

To the members of the Clinical Practice Guideline team, thank you for allowing my involvement with the project, support in using the online systematic review software as well as insight and examples of an effective evidence table for the purposes of a larger project.

Though not directly involved in this project, I would not have pursued dual task and visual stimulation in patients with concussion for my Critically Appraised Topic or the effects of cervical damage on Post Concussive Syndrome as my final project for my Orthopedic elective in the fall which both fed into my participation in these mTBI projects as my capstone had it not been for Catherine Hamilton, PT, DPT being such a patient and knowledgeable clinician in these areas, making vestibular rehabilitation not only accessible but exciting, so thank you for inspiring my interest!

Finally, I would like to acknowledge Anna Vermeulen, SPT as she was the primary student on the Clinical Practice Guideline project and provided a great deal of assistance as I joined in to use the systematic review software and evidence review, her organization and understanding of the project simplified my involvement immensely!

References

1. Ellis M, Leddy J, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Injury. 2015;29(2):238-248.
2. Horn S, DeJong G, Deutscher D. Practice-Based Evidence Research in Rehabilitation: An Alternative to Randomized Controlled Trials and Traditional Observational Studies. Archives of Physical Medicine and Rehabilitation. 2012; 93(2): 127-137.
3. Hart T, Tsaousides T, Zanca J, Whyte J, et al. Toward a Theory-Driven Classification of Rehabilitation Treatments. Archives of Physical Medicine and Rehabilitation. 2014; 95(1):S33-44.
4. Plack M, Driscoll M. CH 4 Systematic Effective Instruction: Keys to Designing an Effective Presentation. Teaching and Learning in Physical Therapy From Classroom to Clinic. P 67-115.
5. Whyte J. It’s More Than a Black Box; It’s a Russian Doll. American Journal of Physical Medicine and Rehabilitation  2003;82:639–652.
6. Swisher A. Practice-Based Evidence. Cardiopulmonary Physical Therapy Journal. 2010; 21(2): 4.
7. Ryser D, Egger M, Horn S, Handrahan D, Gandhi P, Bigler E. Measuring medical complexity during inpatient rehabilitation after traumatic brain injury. Arch Phys Med Rehabilitation.2005; 86:1108-17.
8. Image: Entities and Consciousness in Brain Damage Recovery. https://www.coasttocoastam.com/show/2015/07/25

Note: The references cited in the evidence table are not listed here, but can be found within that resource.