Developing a Comprehensive, Interdisciplinary Concussion Program

Multidisciplinary care for patients with persistent symptoms following concussion: a systematic review

PURPOSE

To systematically characterize and assess the effectiveness of multidisciplinary care for patients with persistent post-concussion symptoms (PPCS).

MATERIALS AND METHODS

Only studies describing multidisciplinary treatment, defined as intervention provided by no less than 2 healthcare disciplines, each with independent scopes of practice, for patients with PPCS were considered.

RESULTS

A total of 8 of the 1357 studies identified were included. The studies were comprised of heterogenous patient populations, care delivery systems, healthcare providers, treatment approaches, and outcomes.

CONCLUSIONS

Findings suggest multidisciplinary care, using a needs-based approach with individual- or group-based interventions, may be more beneficial than usual care to; 1) immediately reduce concussion-related symptom complaints and improve mood and quality of life in adolescents following sports-related concussion (SRC) and, 2) may produce immediate and lasting improvements in symptom complaints of young, primarily female, adults following a non-SRC. Future studies should clearly describe the decision-making processes used to deliver care through a needs-based approach and prioritize the inclusion of objective, performance-based measures to assess outcomes.

Experienced Clinical Decision-Making in Physical Therapist Management of Concussion: A Qualitative Study

OBJECTIVE

The recent publication of the Physical Therapy Evaluation and Treatment After Concussion Clinical Practice Guideline is intended to assist clinicians in their decision-making specific to evaluation and intervention. Clinical practice guidelines are supported by best available evidence, though it is unknown what other factors drive clinical decision-making in the realm of concussion management. The purpose of this study was to explore factors related to the process of clinical decision-making of experienced physical therapists who treat individuals with concussion.

METHODS

This grounded theory approach used semi-structured interviews of physical therapists who have practiced concussion management ≥3 years and have treated ≥15 individuals for postconcussion symptoms in the last year. Following the inductive approach, deductive qualitative methodology was used to explore alignment with recent guidelines. Member checking was used to ensure trustworthiness.

RESULTS

Ten therapists' experience in treating concussion ranged from 5 to 20 years. Four overarching themes were identified that contribute to clinical decision-making: expert practice behaviors through use of reflection in action, clinical reasoning, collaboration, and evidenced informed practice; therapeutic alliance building using individualized education, reassurance, and relationship building; adaptability in prioritizing, assessing, and responding to patients' needs; and listening and observing. Clinician decision-making statements showed alignment with clinical practice guideline recommendations.

CONCLUSION

Experienced therapists demonstrate a consistent approach that parallels the current clinical practice guideline while building off clinical experience to tailor individualized care focusing on patient centeredness. These factors may assist more novice clinicians to develop and improve their management strategies for optimal outcomes.

IMPACT

Identified themes may broaden frameworks and guidelines for the management of individuals postconcussion specific to the field of physical therapy.

Examining the interdisciplinary approach for treatment of persistent post-concussion symptoms in adults: a systematic review

BACKGROUND

The objective of this review is to examine the evidence for the interdisciplinary approach in treatment of persistent post-concussion symptoms in adults.

METHODS

This systematic literature search was undertaken according to the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) guidelines. Five electronic databases were searched: CINAHL, Informit, ProQuest, PubMed and Scopus. After screening and quality assessment, the review included six studies published in English and peer-reviewed journals, between 2011 and 2021 to return contemporary evidence.

RESULTS

The results revealed that there was significant variation between measures used and the timing of the pre- and post-treatment assessment. The studies found an interdisciplinary approach to be beneficial, however, the challenges of inherent heterogeneity, lack of clarity for definitions and diagnosis, and mixed results were apparent. The interdisciplinary interventions applied in all identified studies were found to reduce post-concussion symptoms across the symptom subtypes: headache/migraine, vestibular, cognitive, ocular motor and anxiety/mood.

CONCLUSIONS

The results demonstrated evidence for a reduction in persistent post-concussion symptoms following interdisciplinary intervention. This evidence will inform health services, clinicians, sports administrators and researchers with regard to concussion clinic and rehabilitation team design and service delivery.

Service Delivery Models for the Management of Pediatric and Adolescent Concussion: A Systematic Review

Objective

To examine the current peer-reviewed literature on pediatric concussion and mild traumatic brain injury (mTBI) service delivery models (SDMs) and relevant cost analyses.

Data Sources

PubMed, Embase (Elsevier), CINAHL Plus (EBSCO), APA PsycINFO (EBSCO), and Web of Science Core Collection, limited to human trials published in English from January 1, 2001, to January 10, 2022.

Study Selection

Included articles that (1) were peer-reviewed; (2) were evidence-based; (3) described service delivery and/or associated health care costs; and (4) focused on mTBI, concussion, or postconcussion symptoms of children and adolescents. Studies describing emergency department-based interventions, adults, and moderate to severe brain injuries were excluded.

Data Extraction

The initial search resulted in 1668 articles. Using Rayyan software, 2 reviewers independently completed title and abstract screening followed by a full-text screening of potentially included articles. A third blinded reviewer resolved inclusion/exclusion conflicts among the other reviewers. This resulted in 28 articles included.

Data Synthesis

Each of the 28 articles were grouped into 1 of the following 3 categories: generalist-based services (7), specialist-based services (12), and web/telemedicine services (6). One article discussed both generalists and specialists. It was clear that specialists are more proactive in their treatment of concussion than generalists. Most of the research on generalists emphasized the need for education and training. Four studies discussed costs relevant to SDMs.

Conclusions

This review highlights the need for more discussion and formalized evaluation of SDMs to better understand concussion management. Overall there is more literature on specialist-based services than generalist-based services. Specialists and generalists have overarching similarities but differ often in their approach to pediatric concussion management. Cost analysis data are sparse and more research is needed.

Phybrata Sensors and Machine Learning for Enhanced Neurophysiological Diagnosis and Treatment

Concussion injuries remain a significant public health challenge. A significant unmet clinical need remains for tools that allow related physiological impairments and longer-term health risks to be identified earlier, better quantified, and more easily monitored over time. We address this challenge by combining a head-mounted wearable inertial motion unit (IMU)-based physiological vibration acceleration (“phybrata”) sensor and several candidate machine learning (ML) models. The performance of this solution is assessed for both binary classification of concussion patients and multiclass predictions of specific concussion-related neurophysiological impairments. Results are compared with previously reported approaches to ML-based concussion diagnostics. Using phybrata data from a previously reported concussion study population, four different machine learning models (Support Vector Machine, Random Forest Classifier, Extreme Gradient Boost, and Convolutional Neural Network) are first investigated for binary classification of the test population as healthy vs. concussion (Use Case 1). Results are compared for two different data preprocessing pipelines, Time-Series Averaging (TSA) and Non-Time-Series Feature Extraction (NTS). Next, the three best-performing NTS models are compared in terms of their multiclass prediction performance for specific concussion-related impairments: vestibular, neurological, both (Use Case 2). For Use Case 1, the NTS model approach outperformed the TSA approach, with the two best algorithms achieving an F1 score of 0.94. For Use Case 2, the NTS Random Forest model achieved the best performance in the testing set, with an F1 score of 0.90, and identified a wider range of relevant phybrata signal features that contributed to impairment classification compared with manual feature inspection and statistical data analysis. The overall classification performance achieved in the present work exceeds previously reported approaches to ML-based concussion diagnostics using other data sources and ML models. This study also demonstrates the first combination of a wearable IMU-based sensor and ML model that enables both binary classification of concussion patients and multiclass predictions of specific concussion-related neurophysiological impairments.

Baseline concussion assessment performance of community-based senior rugby players: a cross-sectional study

OBJECTIVE

To report pre-season baseline concussion assessment performance among senior rugby players and explore associations between assessment performance and player demographics.

DESIGN

A cross-sectional study using the New Zealand Rugby Concussion Assessments (NZRCA), comprising symptom, cognitive and dynamic coordination assessments was conducted in the 2018-2019 season.

METHODS

Players' baseline assessments were characterised using descriptive statistics; effect sizes (ES) and t-tests were used to explore associations between player demographic characteristics and NZRCA performance.

RESULTS

A total of 733 players (11.4% female) aged between 16 and 52 years completed the NZRCA. The median (range) value for symptom severity, endorsed symptoms and "percentage normal" was respectively, 5 (0-40), 5 (0-21) and 90% (30-100%). A perfect standardised assessment of concussion score was achieved by one participant; seven achieved ≥27/30 for immediate recall, and 22 achieved a perfect delayed recall score. Most participants (n = 674, 92%) passed the tandem gait test. Associations between NZRCA performance and gender, concussion history, and Pasifika ethnicity were observed with effect sizes ranging from small (0.18) to large (0.70). Six hundred and twenty-three (85%) participants reported at least one symptom.

CONCLUSIONS

The results from this study could help support decision-making by clinicians, improving the management of concussions in the community setting.

Improving Outcomes for Work-Related Concussions: A Mental Health Screening and Brief Therapy Model

OBJECTIVE

This study assessed the efficacy of a neurocognitive screening evaluation and brief therapy model to improve RTW outcomes for workers who experienced mild head injuries.

METHODS

Patients referred were evaluated using a neurocognitive and psychological screening battery. Work-focused cognitive behavioral therapy was provided when appropriate, addressing the role of negative emotional adjustment and functional sleep disturbance in prolonging recovery.

RESULTS

Average time to RTW was 7 weeks post-evaluation, despite workers being off an average of 10 months between injury and referral dates. Overall, 99% were released to full-duty work without restrictions or accommodations.

CONCLUSIONS

This study demonstrates the favorable outcomes achieved via a structured, clinically driven program for workers who experience head-involved injuries, validating previous research on the importance of recognizing the role of psychological factors in prolonging concussion recovery.

Concussion symptoms experienced during driving may influence driving habits

Objective: To examine the symptoms experienced and the change in driving habits in individuals with concussion.Materials and methods: A survey was created by a team of rehabilitation professionals who see persons with concussion in their clinics. The survey captured demographics, mechanism of injury, date of injury, symptoms experienced during driving, if drivers felt safe when driving, and changes in driving habits since the concussion. Non-parametric tests were used to compare symptoms experienced and driving habits across three groups which were created based on time since injury.Results: Of the 140 participants, 74% (104/140) had resumed driving after concussion; of these 27% (28/104) reported that they felt unsafe while driving. Forty-four per cent (46/104) experienced symptoms while driving, of which headache, and difficulty concentrating were the most common symptoms experienced throughout the concussion spectrum (acute to chronic phase). Most drivers (78/104, 75%) with concussion had changed their driving habits by driving less often and shorter distances, and by avoiding nighttime driving and heavy traffic areas.Conclusions: Headache and concentration problems were experienced by drivers regardless of the time since injury. Most drivers had made changes to their driving habits. Clinicians should consider the symptom burden patients experience and discuss driving restrictions to ensure driving safety.