Effectiveness of vestibular rehabilitation on concussion-induced vertigo: a systematic review

Digital health interventions for remote follow-up after mild traumatic brain injury

BACKGROUND

After a mild traumatic brain injury (mild TBI,) a significant number of patients may experience persistent symptoms and disabilities for months to years. Early identification and timely management of persistent symptoms may help to reduce the long-term impacts of mild TBIs. There is currently no formalised method for identifying patients with persistent symptoms after mild TBI once they are discharged from emergency department.

OBJECTIVE

Assess the feasibility of a remote monitoring tool for early identification of persistent symptoms after mild TBI in the outpatient setting using digital tools.

METHODS

Electronic surveys were sent to patients with mild TBI who presented to the emergency department at a Major Trauma Centre in England. The surveys were completed at three different timepoints (within days of injury (S1), 1 month (S2), and 3 months (S3) after injury). The indicators used to assess feasibility were engagement, number of eligible patients for follow-up evidence of need for the intervention, and consistency with the literature. Feedback was sought from participants.

RESULTS

Of the 200 people invited to participate, 134 (67.0%) completed S1, 115 (57.5%) completed S2, and 95 (47.5%) completed S3. The rates of persistent symptoms ranged from 17.9%-62.6% depending on the criteria used, and we found a significant proportion of the participants experienced morbidity 1 and 3 months after injury. The electronic follow-up tool was deemed an acceptable and user-friendly method for service delivery by participants.

CONCLUSION

Using digital tools to monitor and screen mild TBI patients for persistent symptoms is feasible. This could be a scalable, cost-effective, and convenient solution which could improve access to healthcare and reduce healthcare inequalities. This could enable early identification of patients with further medical needs and facilitate timely intervention to improve the clinical workflows, patient satisfaction, and health outcomes for people with persistent morbidities after mild TBIs.

The Efficacy of Vestibular Rehabilitation Therapy for Mild Traumatic Brain Injury: A Systematic Review and Meta-analysis

OBJECTIVE

Mild traumatic brain injury (mTBI) or concussion is a common yet undermanaged and underreported condition. This systematic review and meta-analysis aim to determine the efficacy of vestibular rehabilitation therapy (VRT) as a treatment option for mTBI.

METHOD

This review and meta-analysis was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. It included randomized controlled trials and pre-VRT/post-VRT retrospective chart reviews. Records meeting the inclusion criteria were extracted from the following databases: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL).

RESULTS

Eight articles met the inclusion criteria, from which 6 randomized controlled trials were included in the meta-analysis. VRT demonstrated significant improvement in decreasing perceived dizziness at the end of the intervention program as shown by Dizziness Handicap Inventory (DHI) scores (standardized mean difference [SMD] = -0.33, 95% confidence interval [CI]: -0.62 to -0.03, P = .03, I2 = 0%). However, no significant reduction in DHI was evident after 2 months of follow-up (SMD = 0.15, 95% CI: -0.23 to 0.52, P = .44, I2 = 0%). Quantitative analysis also depicted significant reduction in both Vestibular/Ocular Motor Screening (SMD = -0.40, 95% CI: -0.60 to -0.20, P < .0001, I2 = 0%) and Post-Concussion Symptom Scale (SMD= -0.39, 95% CI: -0.71 to -0.07, P = .02, I2 = 0%) following the intervention. Finally, there was no significant difference between intervention groups on Balance Error Scoring System scores (SMD = -31, 95% CI: -0.71 to 0.10, P = .14, I2 = 0%) and return to sport/function (95% CI: 0.32-30.80, P = .32, I2 = 82%).

CONCLUSIONS

Current evidence on the efficacy of VRT for mTBI is limited. This review and analysis provides evidence that supports the role of VRT in improving perceived symptoms following concussion. Although findings from this analysis suggest positive effects of VRT on included outcomes, the low certainty of evidence limits the conclusions drawn from this study. There is still a need for high-quality trials evaluating the benefit of VRT using a standardized approach.PROSPERO registration number: CRD42022342473.

Protocol for a living systematic review for the management of concussion in adults

INTRODUCTION

Concussion/mild traumatic brain injury (mTBI) often presents initially with disabling symptoms that resolve, but for an unfortunate minority some of these symptoms may become prolonged. Although research into diagnosis and interventions for concussion is increasing, study quality overall remains low. A living systematic review that is updated as evidence becomes available is the ideal research activity to inform a living guideline targeting clinicians and patients. The purpose of this paper is to present the protocol of an ongoing living systematic review for the management of adult concussion that will inform living guidelines building off the Guideline for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms: third Edition.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines were followed in the reporting of this systematic review protocol. We are including English peer-reviewed observational studies, trials, qualitative studies, systematic reviews and clinical practice guidelines related to diagnosis/assessment or treatment of adult concussion. Future searches will be conducted at minimum every 6 months using the following databases: MEDLINE ALL, EMBASE, Cochrane, PsycInfo and CINAHL. The data are managed in the Covidence website. Screening, data extraction and risk-of-bias assessments are being done through multiple raters working independently. Multiple validated tools are being used to assess risk of bias, and the tool applied matches the document or study design (eg, Downs and Black Scale for healthcare interventions). Many concussion experts in various clinical disciplines from across North America have volunteered to examine the evidence in order to make recommendations for the living guidelines.

ETHICS AND DISSEMINATION

No ethical approval is necessary because primary data are not collected. The results will be disseminated through peer-reviewed publications and on the living guidelines website once built.

PROSPERO REGISTRATION NUMBER

CRD42022301786.

Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation

IMPORTANCE

Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS.

OBJECTIVE

To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice.

DATA SOURCES

Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS.

STUDY SELECTION

A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury.

DATA EXTRACTION AND SYNTHESIS

Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework.

MAIN OUTCOMES AND MEASURES

All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention).

RESULTS

Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus.

CONCLUSIONS AND RELEVANCE

Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.

Do physical interventions improve outcomes following concussion: a systematic review and meta-analysis?

OBJECTIVE

To investigate the effect of physical interventions (subthreshold aerobic exercise, cervical, vestibular and/or oculomotor therapies) on days to recovery and symptom scores in the management of concussion.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Medline, CINAHL, Embase, SportDiscus, Cochrane library, Scopus and PEDro.

ELIGIBILITY CRITERIA

Randomised controlled trials of participants with concussion that evaluated the effect of subthreshold aerobic exercise, cervical, vestibular and/or oculomotor therapies on days to recovery/return to activity, symptom scores, balance, gait and/or exercise capacity.

RESULTS

Twelve trials met the inclusion criteria: 7 on subthreshold aerobic exercise, 1 on vestibular therapy, 1 on cervical therapy and 3 on individually tailored multimodal interventions. The trials were of fair to excellent quality on the PEDro scale. Eight trials were included in the quantitative analysis. Subthreshold aerobic exercise had a significant small to moderate effect in improving symptom scores (standardised mean difference (SMD)=0.43, 95% CI 0.18 to 0.67, p=0.001, I²=0%) but not in reducing days to symptom recovery in both acutely concussed individuals and those with persistent symptoms (SMD=0.19, 95% CI -0.54 to 0.93, p=0.61, I²=52%). There was limited evidence for stand-alone cervical, vestibular and oculomotor therapies. Concussed individuals with persistent symptoms (>2 weeks) were approximately 3 times more likely to have returned to sport by 8 weeks (relative risk=3.29, 95% CI 0.30 to 35.69, p=0.33, I²=83%) if they received individually tailored, presentation-specific multimodal interventions (cervical, vestibular and oculo-motor therapy). In addition, the multimodal interventions had a moderate effect in improving symptom scores (SMD=0.63, 95% CI 0.11 to 1.15, p=0.02, I²=0%) when compared with control.

CONCLUSIONS

Subthreshold aerobic exercise appears to lower symptom scores but not time to recovery in concussed individuals. Individually tailored multimodal interventions have a worthwhile effect in providing faster return to sport and clinical improvement, specifically in those with persistent symptoms.

PROSPERO REGISTRATION NUMBER

CRD42020108117.