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Galgon AK, Bliss RA. Experienced Clinical Decision-Making in Physical Therapist Management of Concussion: A Qualitative Study. Phys Ther 2024; 104:pzae027. [PMID: 38386996 DOI: 10.1093/ptj/pzae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/02/2023] [Accepted: 02/21/2024] [Indexed: 02/24/2024]
Abstract
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.
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Affiliation(s)
- Anne K Galgon
- Physical Therapy Department, Saint Joseph's University, Philadelphia, Pennsylvania, USA
| | - Rebecca A Bliss
- Department of Physical Therapy, University of Missouri, Columbia, Missouri, USA
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Cecchini AS, Prim J, Zhang W, Harrison CH, McCulloch KL. The Portable Warrior Test of Tactical Agility: A Novel Functional Assessment That Discriminates Service Members Diagnosed With Concussion From Controls. Mil Med 2023; 188:e703-e710. [PMID: 34414438 PMCID: PMC10026616 DOI: 10.1093/milmed/usab346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Return-to-duty (RTD) readiness assessment for service members (SM) following concussion requires complex clinical considerations. The Portable Warrior Test of Tactical Agility (POWAR-TOTAL) is a functional assessment which improves on previous laboratory-based RTD assessments. METHODS Sixty-four SM diagnosed with concussion and 60 healthy control (HC) SM participated in this study. Group differences were analyzed to validate the POWAR-TOTAL. The High-level Mobility Assessment Test (HiMAT) was used to examine concurrent construct validity. An exploratory logistic regression analysis examined predictive validity. RESULTS The groups were demographically well-matched except for educational level. POWAR-TOTAL measures were statistically significantly different between the groups with moderate to large effect sizes. Concussed participants were less likely to be able to complete all trials of the POWAR-TOTAL. Motor scores correlated highly with HiMAT scores. POWAR-TOTAL motor task performance and membership in the control group was significantly associated with self-reported physical readiness to deploy. CONCLUSION The POWAR-TOTAL is a clinically feasible, military relevant assessment that is sensitive to differences between concussed and HC SM. This analysis supports the discriminant and construct validity of the POWAR-TOTAL, and may be useful for medical providers evaluating RTD readiness for SM who have sustained a concussion.
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Affiliation(s)
- Amy Seal Cecchini
- Geneva Foundation, Ft. Bragg Intrepid Spirit Center, Womack Army Medical Center, Fayetteville, NC 28310, USA
| | - Julianna Prim
- Division of Physical Therapy and Curriculum in Human Movement Science, Department of Allied Health Sciences, School of Medicine UNC-Chapel Hill, Chapel Hill, NC 27599-7135, USA
| | - Wanqing Zhang
- Office of Research, Department of Allied Health Sciences, School of Medicine UNC-Chapel Hill, Chapel Hill, NC 27599-7120, USA
| | - Courtney H Harrison
- Division of Physical Therapy and Curriculum in Human Movement Science, Department of Allied Health Sciences, School of Medicine UNC-Chapel Hill, Chapel Hill, NC 27599-7135, USA
| | - Karen L McCulloch
- Division of Physical Therapy and Curriculum in Human Movement Science, Department of Allied Health Sciences, School of Medicine UNC-Chapel Hill, Chapel Hill, NC 27599-7135, USA
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Powell DRL, Petrie FJ, Docherty PD, Arora H, Williams EMP. Development of a Head Acceleration Event Classification Algorithm for Female Rugby Union. Ann Biomed Eng 2023; 51:1322-1330. [PMID: 36757631 PMCID: PMC10172216 DOI: 10.1007/s10439-023-03138-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/25/2022] [Indexed: 02/10/2023]
Abstract
Instrumented mouthguards have been used to detect head accelerations and record kinematic data in numerous sports. Each recording requires validation through time-consuming video verification. Classification algorithms have been posed to automatically categorise head acceleration events and spurious events. However, classification algorithms must be designed and/or validated for each combination of sport, sex and mouthguard system. This study provides the first algorithm to classify head acceleration data from exclusively female rugby union players. Mouthguards instrumented with kinematic sensors were given to 25 participants for six competitive rugby union matches in an inter-university league. Across all instrumented players, 214 impacts were recorded from 460 match-minutes. Matches were video recorded to enable retrospective labelling of genuine and spurious events. Four machine learning algorithms were trained on five matches to predict these labels, then tested on the sixth match. Of the four classifiers, the support vector machine achieved the best results, with area under the receiver operator curve (AUROC) and area under the precision recall curve (AUPRC) scores of 0.92 and 0.85 respectively, on the test data. These findings represent an important development for head impact telemetry in female sport, contributing to the safer participation and improving the reliability of head impact data collection within female contact sport.
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Affiliation(s)
- David R L Powell
- ZCCE, Faculty of Science and Engineering, Swansea University, Wales, UK.,Applied Sports, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University, Wales, UK
| | - Freja J Petrie
- Applied Sports, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University, Wales, UK
| | - Paul D Docherty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.,Institute for Technical Medicine (ITeM), Furtwangen University, Villingen Schwenningen, Germany
| | - Hari Arora
- ZCCE, Faculty of Science and Engineering, Swansea University, Wales, UK
| | - Elisabeth M P Williams
- Applied Sports, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University, Wales, UK.
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Acute Effects of Concussion in Adolescent Athletes With High Preseason Anxiety. Clin J Sport Med 2022; 32:361-368. [PMID: 35762865 DOI: 10.1097/jsm.0000000000000963] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 07/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine associations between pre-existing anxiety symptoms, and symptoms and cognitive functioning acutely following a suspected concussion. DESIGN Nested case-control study. SETTING High schools in Maine, USA. PARTICIPANTS Participants were identified from a dataset of 46 920 student athletes ages 13 to 18 who received baseline preseason testing. A subset of 4732 underwent testing following a suspected concussion. Of those, 517 were assessed within 72 hours after their suspected concussion and met other inclusion criteria. Nineteen injured athletes endorsed anxiety-like symptoms on the Post-Concussion Symptom Scale (PCSS) during baseline testing and were placed in the high anxiety group. Each athlete was matched to 2 injured athletes who did not endorse high levels of anxiety-like symptoms (N = 57). MAIN OUTCOME MEASURES Immediate Post-Concussion Assessment and Cognitive Testing cognitive composite scores, PCSS total score, and symptom endorsement. RESULTS Cognitive composite scores were similar between groups across testing times ( = 0.004-0.032). The high anxiety group endorsed a greater number of symptoms than the low anxiety group ( = 0.452) and rated symptoms as more severe ( = 0.555) across testing times. Using a modified symptom score that excluded anxiety-like symptoms, a mixed analysis of variance indicated a group by injury interaction ( = 0.079); the high anxiety group reported greater increases in overall symptom severity following injury. CONCLUSIONS Adolescent athletes who have an anxious profile at baseline are likely to experience greater symptom burden following injury. Consideration of pre-injury anxiety may inform clinical concussion management by tailoring intervention strategies (eg, incorporating mental health treatments) to facilitate concussion recovery.
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Factor Structure for the Sport Concussion Assessment Tool Symptom Scale in Adolescents After Concussion. Clin J Sport Med 2022; 32:400-407. [PMID: 34342297 DOI: 10.1097/jsm.0000000000000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the factor structure of the Sport Concussion Assessment Tool-5 (SCAT5) symptom scale in adolescents on their initial presentation to a concussion clinic within the typical recovery period after concussion (ie, <30 days). We hypothesize that the SCAT5 symptoms represent various clinically meaningful groups. A secondary purpose was to examine the effects of sex on the factor structure of the SCAT5 symptom scale. STUDY DESIGN Retrospective cross-sectional analysis. SETTING Tertiary, institutional. PATIENTS Nine hundred eighty-one adolescents (45% women) aged between 13 and 18 years. INDEPENDENT VARIABLES Adolescents completed the SCAT5 symptom scale. MAIN OUTCOME MEASURES The factor structure of SCAT5 examined using a principal axis factor analysis. RESULTS A 5-factor structure model explained 61% of the variance in symptoms. These 5 factors are identified as Energy (17%), Mental Health (13%), Migrainous (13%), Cognitive (9%), and Vestibulo-Ocular (9%). A similar 5-factor model emerged for each sex, and the proportion of variance in symptoms explained by the 5-factor model was comparable between the sexes. CONCLUSIONS The findings of this report indicate that the SCAT5 symptoms aggregated into 5 delineated factors, and these factors were largely consistent across the sexes. The delineation of symptoms into 5 factors provides preliminary validation for the presence of different concussion phenotypes. Confirmatory factor analysis is warranted to examine the applicability and clinical utility of the use of the 5-factor structure in a clinical setting.
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Concurrent validity of the Vestibular/Ocular Motor Screening (VOMS) tool with the Dizziness Handicap Inventory (DHI) among adolescents with vestibular symptoms/impairment following concussion. Phys Ther Sport 2021; 53:34-39. [PMID: 34785482 DOI: 10.1016/j.ptsp.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine whether the Vestibular/Ocular Motor Screening (VOMS) tool demonstrates concurrent validity with the Dizziness Handicap Inventory (DHI) in a sample of concussed athletes referred for vestibular therapy and whether DHI items were predictive of VOMS outcomes. DESIGN Cross-sectional cohort study. SETTING Concussion specialty/vestibular therapy clinic. METHODS Adolescents (n = 55; 15.4 ± 1.6 years) with diagnosed sport-related concussion (SRC) with vestibular symptoms and/or impairment between October 2018-February 2020. Patients completed VOMS and DHI at initial visit. Seven individual VOMS and twenty-five DHI items, VOMS and DHI total score and three DHI sub-scales, were compared with Spearman correlations. Three backwards linear regression (LR) models were built to predict 1. VOMS vestibular symptoms, 2. VOMS ocular symptoms, and 3. near-point of convergence-distance (NPC-distance) using individual DHI items as predictors. RESULTS Spearman correlations (p) identified DHI items with moderate to strong associations for VOMS items. DHI sub-scales demonstrated moderate-to-strong correlations with VOMS items (p = 0.30-0.59). Total DHI score demonstrated a moderate-to-strong association with HSAC (p = 0.30), VSAC (p = 0.32), and SP (p = 0.61). Results from the LRs predicting VOMS ocular symptoms (R (Alsalaheen et al., 2010) = 0.56; p < 0.001), and VOMS vestibular symptoms (R (Alsalaheen et al., 2010) = 0.23; p = 0.01), and NPC-distance (R (Alsalaheen et al., 2010) = 0.56; p < 0.001) included significant DHI predictors. CONCLUSIONS There was moderate-to-strong associations between VOMS and 56% of DHI items (i.e., p > 0.30).
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Helminski JO, Keller S, Suckow M, Stein A, Grieco L, Lintakas R, Reinders C. Reliability of two dissociating tests of phoria in artificially created phoria in normal adults. Laryngoscope Investig Otolaryngol 2021; 6:1142-1150. [PMID: 34667859 PMCID: PMC8513437 DOI: 10.1002/lio2.653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The ability of physical therapists (PTs) to accurately identify and reliably measure phoria/tropia is critical in the differential diagnosis of individuals with acute vestibular syndrome and concussion/mild traumatic brain injury. OBJECTIVES To determine if PTs may reliably measure phoria and to determine the reliability of two dissociating tests of phoria, the prism neutralized Maddox rod test and modified Thorington method, in normal adults with artificially created phoria. METHODS Thirty adults (mean age 24.87 ± 4.74 years) were randomly assigned to wear trial lenses (1, 2, 4, or 6 pd prism left, plain glass right) to create phoria. In sitting and supine, phoria was measured using prism neutralized Maddox rod test and modified Thorington method. Mean, SD, and range of first neutral endpoint were calculated for each examiner. Percentage of trials in agreement (≤ 2 and 4 pd); comparisons within the linear mixed effects regression model; and inter-rater reliability between examiners was calculated with the intra-class correlation coefficient (ICC). RESULTS Participants underwent 20 measurements by each examiner. Trial agreement between examiners was 74% (range 13%-100%) in horizontal and 91% (range 63%-100%) in vertical plane. Maddox rod test had significantly different means between two examiners (P < .05). Modified Thorington test had no significant difference. The Maddox rod test had a significant examiner main effect, examiner 2 always scored lower. Inter-rater correlation coefficient for each test was significant at level of P < .01 (ICC ≥ 0.67 ≤ 0.94) except for modified Thorington test in supine, horizontal plane with P < .05 (ICC ≥ 0.38). CONCLUSION PTs may reliably measure artificially created phorias using prism neutralized Maddox rod test and modified Thorington method.
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Affiliation(s)
- Janet O. Helminski
- Physical Therapy Program, College of Health SciencesMidwestern UniversityDowners GroveIllinoisUSA
| | - Sarah Keller
- Physical Therapy Program, College of Health SciencesMidwestern UniversityDowners GroveIllinoisUSA
| | - Melissa Suckow
- College of OptometryMidwestern UniversityDowners GroveIllinoisUSA
| | - Amy Stein
- Office of Research Sponsored ProgramsMidwestern UniversityDowners GroveIllinoisUSA
| | - Lauren Grieco
- Physical Therapy Program, College of Health SciencesMidwestern UniversityDowners GroveIllinoisUSA
| | - Rima Lintakas
- Physical Therapy Program, College of Health SciencesMidwestern UniversityDowners GroveIllinoisUSA
| | - Caroline Reinders
- Physical Therapy Program, College of Health SciencesMidwestern UniversityDowners GroveIllinoisUSA
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Alsalaheen B, Almeida A, Eckner J, Freeman J, Ichesco I, Popovich M, Streicher N, Lorincz M. Do male and female adolescents report symptoms differently after concussion? Brain Inj 2021; 35:698-704. [PMID: 33689531 DOI: 10.1080/02699052.2021.1896034] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We investigated sex-based differences in the presence and severity of aggregated symptom indicators as well as individual concussion symptoms.Materials and Methods: A cross-sectional examination of sex differences in symptoms reported by adolescents upon initial concussion evaluation at a concussion clinic. Nine hundred and eighty-six adolescents completed the Sport Concussion Assessment Tool (SCAT5) symptom checklist. Chi-square and Mann-Whitney U tests were used for differences in the presence and severity of symptoms, respectively. Sex differences in global indices of symptom distress were compared.Results: Females endorsed more symptoms (Female: Median (M)=15, Interquartile range (IQR):9-18 vs. Male: M=11, IQR: 6-15, p<0.001) and a greater total symptom score (Female: M=37, IQR:16-45 vs. Male: M=20, IQR:8-39). After False Discovery Rate (FDR) adjustment, females endorsed the presence of 21 of 22 individual symptoms more frequently than males (p≤ 0.039), with greater symptom severity for 20 of 22 individual symptoms (p≤0.036). Moderate ESs were observed for sex-based differences in the total symptom score and the global severity index. Small ESs was observed for differences in most individual symptoms.Conclusions: The greater frequency and severity of concussion symptoms reported by female adolescents highlights the importance of considering sex as a modifier for the management of concussion.
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Affiliation(s)
- Bara Alsalaheen
- Department of Physical Therapy, University of Michigan-Flint, USA
| | - Andrea Almeida
- Department of Neurology, University of Michigan, Ann Arbor, USA
| | | | | | - Ingrid Ichesco
- Department of Pediatrics, University of Michigan, Ann Arbor, USA
| | | | | | - Matthew Lorincz
- Department of Neurology, University of Michigan, Ann Arbor, USA
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Changes in Vestibular/Ocular-Motor Screen Scores in Adolescents Treated With Vestibular Therapy After Concussion. Pediatr Phys Ther 2020; 32:331-337. [PMID: 32773522 DOI: 10.1097/pep.0000000000000729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To examine interrelationships among Vestibular/Ocular-Motor Screen (VOMS) items and to characterize the recovery of VOMS performance in a sample of adolescents treated with vestibular physical therapy (VPT) after concussion. METHODS Seventy-seven patients with concussion and 77 participants without concussion completed the study. Adolescents with concussion received an individualized VPT intervention consisting of targeted exercises for gaze stability, postural stability, ocular-motor control, habituation, and aerobic activities. The exercises were performed during a weekly clinic visit and via a home exercise program. RESULTS Except for near-point convergence distance, all VOMS items were significantly interrelated. Over the course of VPT, significant improvements in VOMS performance were observed, and discharge scores were similar to scores observed in adolescents without concussion. CONCLUSIONS The VOMS measured moderately related functions and captured changes over the course of VPT. Clinicians should consider the contextual risk of "false positive" in their interpretation of VOMS.
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Abstract
Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.
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Abstract
Despite advances in the assessment, diagnosis, prognosis, and management of the patient with mild traumatic brain injury (mTBI) or concussion, the condition continues to frustrate clinicians and researchers. The November 2019 special issue of the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) supports and represents an interdisciplinary approach to assessment, management, and treatment of mTBI/concussion. The articles further highlight the evolving role of the physical therapist throughout the clinical course post concussion. It is with gratitude to the authors who contributed to this special issue of JOSPT that we present the evidence and practices currently available to clinicians in the assessment and treatment of mTBI/concussion. J Orthop Sports Phys Ther 2019;49(11):766-767. doi:10.2519/jospt.2019.0107.
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