Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults

Abstract

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 MEASURESAll 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). RESULTSEleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately (continued)

Advances in Clinical Management of Persistent Postconcussion Symptoms—The Danish National Clinical Guideline

“…To help guide clinical management of this condition, the Danish Health Authority convened a multidisciplinary panel to summarize the evidence regarding the effectiveness of selected nonpharmacological interventions in adults with PPCS and to generate a national guideline with recommendations for clinical practice. In this issue of JAMA Network Open , Rytter and colleagues present the results of the systematic reviews and meta-analyses that provided the basis for their attendant clinical recommendations. They conclude that the evidence base, albeit limited, supports weak or conditional recommendations for the systematic provision of early information and advice, the use of graded physical exercise, vestibular rehabilitation, manual therapy for the cervical and thoracic spine, psychological treatment, and interdisciplinary rehabilitation.…”

“…The primary outcomes for source studies were not always the same as those chosen by Rytter and colleagues for their meta-analyses, which focused largely on the broad spectrum of PPCS. 3 The assignment of complex, multimodal interventions to specific treatment domains could be questioned (eg, interventions in the exercise category involved more than prescribed exercise). Most meta-analyses involved only 1 or 2 studies, with many studies included in multiple analyses; and studies included in…”

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

“…Vestibular rehabilitation has been suggested to be beneficial in reducing dizziness and improving balance in individuals with persistent concussion symptoms although the randomised trial evidence base is yet very limited [ 13 , 37 , 38 ]. It has been proposed that therapy should focus on habituation, gaze stabilization, head-eye coordination, balance and mobility exercises with graduated challenges to the base of support [ 13 , 39 , 40 ]. Ocular therapy in some cases may require more specialized interventions such as speeded saccadic eye movements, visual pursuit, tracking tasks, reading tasks and visual attention tasks [ 32 , 41 ].…”

“…A PubMed and Google scholar literature review using search terms including "chiropractic/chiropractors" and "sports related concussion" or "concussion", "chiropractic treatment" and "concussion" searching for chiropracticspecific contributions in the SRC field, suggests a limited contribution by the chiropractic profession that is underweight in absolute terms compared to other medical and allied fields where physiotherapists are playing a leading role. Chiropractors have contributed predominantly in the broader area of systematic reviews of mild traumatic brain injuries (mTBIs) and concussion, with less of a focus on SRC and athletic populations specifically [10][11][12][13][14]. Papers referring to the involvement of chiropractic specifically in SRC primarily centre around knowledge surveys, case series, non-systematic narrative reviews, with only one consensus statement from 2012 [9,[14][15][16][17][18][19][20].…”

“…Tools such as the vestibular ocular motor screening (VOMS) tool and balance error scoring system (BESS) may be useful at identifying potential areas requiring further in depth assessment; especially when they are used as part of a multimodal assessment approach [34][35][36]. Vestibular rehabilitation has been suggested to be beneficial in reducing dizziness and improving balance in individuals with persistent concussion symptoms although the randomised trial evidence base is yet very limited [13,37,38]. It has been proposed that therapy should focus on habituation, gaze stabilization, head-eye coordination, balance and mobility exercises with graduated challenges to the base of support [13,39,40].…”