Background
I developed the passion and interest in Concussion from my first clinical rotation in 2020 and throughout the educational instruction from the UNC DPT program. Furthermore, my background in sports and manual skills helped mold this curiosity in me. Growing up, I played soccer and after performing few “headers” in practice, I quickly realized how it would give me a headache and I did not like it. From that point moving forward, I would try to avoid headers at all costs. I understand that I never sustained a concussion because of this habit, but I saw many of my peers sustain them in hindsight. The other part of this curiosity meshed my background of being a licensed massage therapist and my clinical instructor from my first clinical rotation. She always performed heavy manual with these patients to help with their symptoms, so naturally I become involved with their care. Based on this experience, I thought I could be extremely influential in their care because of my expertise in massage and relaxation technique. From that point forward, I kept reading and being inquisitive about concussion-based therapies and strategies to best treat this population. My education in UNC’s DPT program has led me to develop new ideas around the evaluation, evidence-based interventions, and return to sport/recreational activities clearance in patients who have sustained a concussion.
Statement of Need
The ability to understand concussion mechanisms and their implications on how they impact people is becoming more prominent in the physical therapy and other interdisciplinary realms. It’s been documented that 100-300/100,000 people a year consult emergency services for mTBI, which is mostly likely underestimated for the actual number that occur.1,2 Headaches is debates as the most common symptom after sustaining a mild traumatic brain injury (mTBI)/concussion.3 However, there is no clear protocol or guideline on how to best manage headaches secondary to sustaining a concussion. This lack of understand is partially due to scarcity of research specific to this population and more importantly the different types of mechanisms that can cause headaches. This can range from cervicogenic headaches, vestibulo-ocular induced headaches, exertional intolerances, and many more. Furthermore, these headaches can have disabling effects from neck pain, reduced concentration, depression or anxiety, inability to maintain a job, emotional irritability, and/or the overuse of medications.1 Therefore, we need to teach current clinicians how to best manage these headaches to allow them to progress to higher level activities and eventually returning to their preferred recreational/sport of choice. Thus my capstone aims at finding the most recent research about managing headaches in patients who have sustained a concussion or similarly a whiplash; these are two different pathologies, but there is a lot of overlap in research and pathophysiology. Secondly, I developed an extensive lesson about all things concussion that includes a wide variety of domains that are impacted in this population.
Purpose Statement
The purpose of this capstone project embraces two topics. First, I wanted to help update the clinical practice guidelines for concussion and specifically focus my efforts at finding the most recent (last few years) of research pertaining to headaches. Due to the inherent nature of updating a clinical practice guideline to take time and extensive collaboration between numerous members, I had to shift towards the second aspect of my project. A comprehensive PowerPoint that was initially developed to be presented in an in-service manner for practicing clinicians became much longer. The PowerPoint includes many signs and symptoms, interventions, and suggestions on evidence-based practice for clearing athletes to return to sport. Therefore, I decided to include all my research findings so others have these resources and consolidated research. In collaboration with my faculty member, we decided that the PowerPoint will be modified to best suit the needs of my fellow peers at the last clinical rotation, hopefully focusing on the headaches and cervical musculoskeletal components.
Presentation Assignments
Managing Concussion in the Clinic_Final
Literature Review
Research Question- How to Manage Headaches in Patients who suffer from PCS
Evaluation
Currently, my project has not been evaluated by clinicians. The project materials have been sent for evaluation, edits, and constructive criticism on how to improve the presented information from my committee members. I will use their guidance when I make a modified version to present in an in-service format. I developed a google survey that can utilized to get valuable feedback from clinicians and additionally made the same survey in a word document for those who prefer a hand-written assessment tool. The assessment information analyzed from clinicians will be pertinent to my success in the future to further develop my presenting skills. As well as, improve the PowerPoint to be more engaging, visually interesting, and helpful to maximize the audience’s learning.
Reflection
The scope of the project and different considerations from my initially thought process of how this project would go, drastically changed for a few reasons. Regarding the literature review for managing headaches secondary to concussion; I anticipated there be more quality research. There were a few systematic reviews and other higher quality articles, but not enough to give confidence on how to develop an evidence-based practice guideline. As I continued to find research, the data become heterogenous, inconclusive, and had many limitations to the studies which made it biased in nature. I did find that manual is just one strategy to manage headaches and it’s a great starting place to manage pain and symptoms, but ultimately it needs to be a multi-modal approach to maximize their therapy.
Regarding the presentation, I learned that I love the small details and over-estimated the amount of material one can teach in an in-service. I found myself researching and presenting about the smallest details to make sure my statements were supported appropriately. I learned an extensive amount about how to manage patients who have a concussion or whiplash associated disorder, which I will forever cherish. Not only did it grow my passion for this population, but this project taught me valuable lessons. It taught me how to do in-depth literature review, create a schedule to manage my workload, and understand the effort it goes into teaching. Furthermore, I look forward to the future because I will get to present this material to other clinicians to help support their growth and introduce them to the most current evidence about concussions. These attributes and skills I have learned will make me a better Physical Therapist and improve my critical thinking abilities to best serve my future patients.
Acknowledgement
Karen McCulloch, PT, PhD, MS, FAPTA, thank you for sharing your time and expertise as my capstone advisor. Your attentiveness and constructive feedback regarding my project were instrumental in providing me a worthy experience and developing the best materials possible to help other clinicians and myself.
Jon Hacke, PT, DPT, MA, ATRet, thank you for being a committee member and providing extensive suggestions on how to improve my different project materials. Your willingness to help me growth this project and provide feedback along the way were much appreciated.
Johnnie Sexton, Doctor of Audiology, Executive Director–The CARE Project, Inc., thank you for being a committee member and stepping in last minute to help with logistical issues. Your love for teaching and vast experience in developing presentations has been pertinent to my success.
- Landén Ludvigsson M, Peterson G, Widh S, Peolsson A. Exercise, headache, and factors associated with headache in chronic whiplash: Analysis of a randomized clinical trial. Medicine (Baltimore). 2019;98(48):e18130. doi:10.1097/MD.0000000000018130
- Gil C, Decq P. How similar are whiplash and mild traumatic brain injury? A systematic review. Neurochirurgie. 2021;67(3):238-243. doi:10.1016/j.neuchi.2021.01.016
- Patterson Gentile C, Shah R, Irwin SL, Greene K, Szperka CL. Acute and chronic management of posttraumatic headache in children: A systematic review. Headache. 2021;61(10):1475-1492. doi:10.1111/head.14236
2 Responses to “Concussion Research and Clinical Presentation”
Cam Hummel
Robbey,
I really appreciate all the work you have put into creating these materials! Your dedication to following the evidence (even if that meant identifying a lack thereof) gives credibility to the information you’ve presented here. I would have been very interested to be there when you presented this inservice. We learn the basics about assessing headaches in PT school but there’s nowhere near enough information to make me feel confident evaluating headaches in the clinic. While I would still need to observe the management of patients post-concussion firsthand in the clinic, you’ve provided a solid framework for understanding all of the considerations involved with this patient population. I’m especially appreciate how you’ve laid out the presentation to walk step by step through an evaluation (including decision trees, specific special tests, and other considerations). I will definitely be reaching out to you in the future if I see a tough patient case involving headaches!
Karen McCulloch
Nice job Robbey – I think you integrated the feedback that we discussed well in the final – I hope that you’ve been able to connect with your CI about this so that you further tailor the presentation so that it is a match for the interests of those that are in the clinic where you’ll be working and that you will also think carefully about how it might need further trimming to be able to fit into a usual “inservice” slot that often isn’t very long. I am with you on liking the details, so it is good that you dug deep in the development of the materials – that detail will serve you well in answering questions people might have….but you may not be able to share all of it in the actual presentation. This is a challenge for anyone who teaches content clinically or in the classroom to make sure that what is shared is what is most important and critical and what is “nice to know” for those who are really into a topic.
Look forward to hearing about how the inservice goes…AND expect that you may be hearing from Rob Landel/Katie Quatman-Yates about the cervical scoping review that the CPG group is planning. It sounds like there may be an opportunity for you to help contribute to the appraisal process for cervical assessments as part of the team that is putting that paper together. I hope that will serve to allow further application of your hard work to something that we anticipate will influence PT practice (although the timeline for the CPG revision stretches into 2025 – so not a quick process!!!).
kmac