CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

BEST PRACTICE FOR CONCUSSION MANAGEMENT

Clinical Question:
What is best practice for treating patients with oculomotor dysfunction following a concussion or mild TBI? Include recommendations
for screen time after a concussion, as well as factors that may affect recovery (prognostic factors).

Specific Focus: What factors can be identified in patients suffering from a concussion/mTBI that indicate a prolonged recovery?

Clinical Bottom Line:

The literature shows that every patient who experiences a concussion progresses through recovery differently, but the research identifies
that the following factors are indicative of a prolonged recovery after experiencing a concussion or mild traumatic brain injury; being
female, being older, having symptoms of vestibular-occulomotor symptoms, and experiencing sleep disruption. These factors are often
out of the control of both the patient and the treating therapist, but are useful in determining a prognosis and writing goals for patients.
Understanding the timeline of the recovery is also important in educating the patient on the plan of care and what to expect, and these
variables are crucial to include in the examination of patients reporting after a concussion or mTBI.

Refresh Date: March 2nd, 2020

Author(s): Andrew Hovell Date Created: March 2, 2018

Reviewer(s): Date Updated:
Key Findings
 General Summary: Overall there is a growing body of evidence regarding the prognosis of patients after they experience a concussion or
mTBI, but the literature is still slightly limited due to complexity of the neurological system and the individualistic recovery process associated
with brain injuries
 Quality of Research: On the subject of concussions and prognostic factors impacting the time of recovery, there is limited evidence due to the
extreme variability in symptoms experienced between subjects, and therefore the available evidence achieves a level of 3 on the oxford level
of evidence scale.
o The available studies are cohort studies that are both valid and reliable due to the high quality methodologies and steps taken to
reduce bias of the authors
o Prospective or retrospective cohort studies make up the majority of the available evidence
o Threats to validity include small sample sizes and most studies included utilized an adolescent patient population
 The biggest limitations in the available evidence are the limited number of validated outcome measures and the variability between
practitioners in determining the criteria for having recovered from a concussion. Due to this, an appropriate refresh date would be in 2 years
as this subject is gaining in public interest.
 Take home Message: Every patient recovers from a concussion differently, but Vestibular Occulumotor Screening (VOMS) including smooth
pursuit, horizontal and vertical saccade, convergence, horizontal and vertical VOR, and VMS, as well as female gender, increased age, and
sleep disturbances are all indicative of a prolonged recovery from a concussion or mTBI
 Clinical Significance: Each patient recovering from a concussion or mTBI should be treated on a case by case basis due to the individualized
recovery process, however the research supports that while performing an initial evaluation on a patient reporting after a concussion or
mTBI, all of the above listed factors should all be involved in the subjective and objective portions of the exam.

Search Methodology: (This section should include enough detail to make the search repeatable)
Search Resources Search Terms Limits # of Articles
1 PubMed Concussion Prognosis None 646
2 PubMed “Concussion” “Prognostic Factors” Systematic Reviews 52
3 PEDro Concussion None 18
4 SPORTdiscus Concussion + Prognosis Academic Journals 31

Search Results Summary:

Results Reasons for Inclusion Reasons for Exclusion # of Articles
Included

Author(s): Andrew Hovell Date Created: March 2, 2018

Reviewer(s): Date Updated:
 80 SR None of the studies are to be included. All of the articles included in the 0
117 RCT search called for more research,
221 Case Control stating the current literature is
18 Cohort inconclusive. The fact that so many
1 210 proposals
articles were inconclusive indicates
there is insufficient evidence, or
this search needed to be refined due
to the vagueness of the terms used.
52 SR Articles that included discussions Articles were excluded if they did 2
about factors influencing the length of not discuss prognostic factors.
2
recovery from either a concussion or
mTBI
2 SR None of the studies are to be None of the articles discussed 0
3 16 Clinical Trials included prognostic factors or length of
recovery
5 SR Discussion of Prognostic factors Statistical analysis of the impact of 4
4 21 Clinical Trials the prognostic factors on time of
5 retrospective chart reviews recovery

Research Participant and Study Characteristics:

Reference Participant Key Clinical
Characteristics
Anzalone et al - Ages 11-19 years old (69
female, 98 male)
- Diagnosed with Sports
Related Concussion
- Tested using the VOMS at
initial visit and before
returning to play
Bramley et al - Ages 13-18 years old (254
male, 163 female)
- Diagnosed with a concussion
within 3 weeks of initial
Control Group
Adolescents diagnosed with a
sport related concussion
without any abnormal findings
on the VOMS
At initial visit, reported not
having any difficulty falling
asleep or staying asleep
Experimental Group Level of
Evidence
Adolescents diagnosed with a Level 3
sport related concussion with
at least one abnormal finding
on the VOMS
At initial visit, reported Level 3
having difficulty with falling
asleep and/or staying asleep

Author(s): Andrew Hovell Date Created: March 2, 2018

Reviewer(s): Date Updated:
 injury
- Sleep disturbance was not
further investigated beyond
whether or not it was
experienced
Duprey et al - Ages 10 – 21 years old (147 Athletes with normal NPC (< Athletes with abnormal NPC Level 2
male and 123 female) or = 6cm) (> 6 cm)
- All subjects were athletes
who reported to the same
Sports Medicine Clinic
- At initial visit, underwent the
SCAT3 symptom checklist
and NPC measurements were
taken at initial and final visits
Lau et al - Ages 13-19 years old (Males Rapid Recovery Group = < 7 Prolonged Recovery Group = Level 2
only) days till return to play >21 days till return to play
- High School Football
Players
- 9 teams were recruited,
relying on the certified AT
staff to report
- 13 on field symptoms were
tested, and the athletes were
split into rapid and prolonged
recovery groups
Sufrinko et al - Average Age = 15.3 years No Control Group Athletes were grouped based Level 2
old (51 male, 18 female) on the length of their
recoveries

Outcomes:
Reference Event/Outcome Positive Mean (SD) in days Effect Size

Author(s): Andrew Hovell Date Created: March 2, 2018

Reviewer(s): Date Updated:
 (may have more than one VOMS Control Group Experimental Group
per reference) Domain
Anzalone et al Time of recovery is defined Smooth 13.4 (8.2) 23.2 (12.3) .987
as time of incident until all Pursuit
symptoms have resolved Horizontal 22.9 (12.3) .910
Saccades
Vertical 23.4 (13.9) .857
Saccades
Horizontal 22.3 (10.4) .974
VOR
Vertical VOR 23.0 (12.9) .909
Near Point of 26.0 (14.9) 1.305
Convergence
Accomodatio 23.2 (11.5) 1.078
n

Reference: Outcome Variable Control Mean (IQ range) Experimental Effect Size
Bramley et al Time of recovery is defined Self-reported 29 (18-84) 111 (27-311) Not able to
as time between the initial sleep calculate due
visit and the final visit disturbance to lack of
reported
statistics

Reference: Outcome Variable Mean (SD) Effect size

Control Experimental
Duprey et al Time of recovery is defined NPC 19.2 (14.7) 51.6 (53.9) .823
as time between the initial
injury and being cleared of
all symptoms by the
Physician and returning to
play or full school
responsibilities

Author(s): Andrew Hovell Date Created: March 2, 2018

Reviewer(s): Date Updated:
 Reference: Outcome Variable Number of Athletes Effect size not
Rapid Recovery Prolonged Recovery calculated due
Lau et al Time of recovery is defined Confusion 45 34 to authors not
as time between the date of Headache 58 35 reporting
the initial injury and the day LOC 14 11 Standard
the athlete returned to play PTA 24 18 deviations
after being cleared of all Retrograde 25 35
symptoms by the Certified Amnesia
Athletic Trainer. The time of Balance 15 10
recovery determine which Problems
group the athletes belonged, Dizziness 41 25
number of athletes was then Visual 31 19
reported. Problems
Personality 31 16
Chagnes
Fatigue 17 7
Sensitivity to 11 2
light/sound
Numbness 15 5
Vomiting 11 2

Reference: Outcome Positive Test Number of Athletes Conclusion

<14 days 15-29 days 30-90 days
Sufrinko et al Time of Recovery was Smooth 2 4 7 All VOMS
defined as the amount of Pursuit different for
time between the initial visit Horizontal 2 4 8 each group
and being cleared to return to Saccade using p-value
play by the attending Vertical 2 4 9 of .05 using
physician Saccade univariate
Convergence 3 4 7 calculation
Horizontal 2 4 9
VOR
Author(s): Andrew Hovell Date Created: March 2, 2018
Reviewer(s): Date Updated:
 Vertical VOR 2 5 9
VMS 3 6 11

Author(s): Andrew Hovell Date Created: March 2, 2018

Reviewer(s): Date Updated:
Systematic Review/Meta-Analysis Characteristics
Reference Data Sources/Author Search
Processes
King Medline, Embase, Cinahl, and Psych
INFO were searched using search
terms under the expanded thesaurus
“Brain Concussion” and “POST-
CONCUSSION SYNDROME”
Inclusion/Exclusion Criteria Number of Studies Reviewed and
Included (Data Extraction in
Meta Analysis)
Inclusion: Injuries associated with 1341 abstracts were identified by
GCS 13-15 and/or PTA less than 24 the search, and 77 full papers were
hours and/or loss of consciousness then analyzed. 6 of those had data
less than 6 hours, mean time post on prolonged recovery related to
injury of 12-18 months, minimum gender and age. 10 studies had data
sample size of 6, sustained between for samples either selected or not
16 and 65 years old, data reported selected.
on relationship between gender/age
and prolonged recovery, English
Language
Exclusion: Artificially restricted
age ranges or gender mix, samples
where age or gender was reported
for less than 75% of the subjects,
letters to editors and editorials.

Systematic Review/Meta-Analysis Outcomes:

Reference Author Conclusions (Data Synthesis in Meta- Analysis)
King In individuals who experience a mild TBI, the female
gender and older age were both found to be correlated with
prolonged recovery in a majority of studies, while none of
the studies found a negative correlation.
Limitations
Only one author indicates a higher risk for bias. The
study also included low quality studies into the
review, limiting the validity of the conclusions
drawn. The studies included in the review had
subjects reporting for persistent symptoms after
experiencing a mTBI, which may skew the results.

References:
Anzalone AJ, Blueitt D, Case T, McGuffin T, Pollard K, Garrison JC, Jones MT, Pavur R, Turner S, & Oliver JM. A Postive
Author(s): Andrew Hovell Date Created: March 2, 2018
Reviewer(s): Date Updated:
 Vestibular/Ocular Motor Screening (VOMS) Is Associated with Increased Recovery Time after Sports-Related Concussion in
Youth and Adolescent Athletes. AJSM PreView on October 27, 2016 doi:10.1177/0363546516668624
Bramley H, Henson A, Lewis MM, Kong L, Stetter C, & Silvis M. Sleep Disturbance Following Concussion is a Risk Factor for a
Prolonged Recovery. Clinical Pediatrics 2017, Vol. 56(14) 1280–1285
DuPrey KM, Webner D, Lyons A, Kucuk H, Ellis JT, & Cronholm PF. Convergence Insufficiency Identifies Athletes at Risk of
Prolonged Recovery From Sport-Related Concussion. Am J Sports Med. 2017 Aug; 45(10):2388-2393
King NS. A Systematic Review of Age and Gender in Prolonged Post-Concussion Symptoms After a Mild Head Injury. Brain Inj,
2014; 28(13–14): 1639–1645
Lau BC, Kontos AP, Collins MW, Mucha A, & Lovel MR. Which On-Field Signs/Symptoms Predict Protracted Recovery From
Sport-Related Concussion Among High School Football Players. Am J Sports Med 2011 39:2311
Sufrinko AM, Marchetti GF, Cohen PE, Elbin RJ, Re V, & Kontos AP. Using Acute Performance on a Comprehensive
Neurocognitive, Vestibular, and Ocular Motor Assessment Battery to Predict Recovery Duration After Sport-Related
Concussions. Am J Sports Med. 2017 Apr;45(5):1187-1194

Author(s): Andrew Hovell Date Created: March 2, 2018

Reviewer(s): Date Updated: