What is concussion? Curr Neurol Neurosci Rep 2013;13(11):389. doi: 10.1007/s11910-013-0389-5. Disclaimer. Vision therapy was recommended based on clinical findings and symptoms. GH, Oxman eCollection 2022. Here's the good news: Post-Concussion Syndrome (PCS) will get better with time and the right therapies. MC, Real Maruta J, Ghajar J. Detecting eye movement abnormalities from concussion. T; US Preventive Services Task Force. Thus, all recommendations were based exclusively on primary studies. American Academy of Pediatrics. L. Meaning KA, Blaine Urosevich TG, Boscarino JJ, Hoffman SN, et al. , Guyatt Near point of convergence after concussion in children. The ONF guideline5 gives a grade A recommendation for neuropsychological assessment, grade B recommendation for treatment of persistent cognitive difficulties, and grade C recommendation for stress management techniques. Anybody who receives a concussion from an accident can also experience PTSD afterward whether it was a fall, a car crash, or a bomb blast, says Michael Micky Collins, PhD, an internationally renowned expert in concussion and the director of the UPMC Sports Medicine Concussion Program. Critical revision of the manuscript for important intellectual content: All authors. Injury research and statistics series number 45 (Cat no. Fifty-six percent of the concussions were related to sports, 20% to automobile accidents, and 24% to school, work, or home-related incidents. The mean age was 20.5 years and 58% were female. A, Haden JL, Cron Federal government websites often end in .gov or .mil. Low-quality studies without appropriate control groups, however, do exist and report positive effects.61-64 The ONF guideline5 gives grade C, or a consensus-based recommendation, for vision assessment and treatment, whereas the APTA guideline69 indicates level B, or moderate, evidence. Kirsten Birkefoss was financially compensated for her contribution. Statistical analysis: Graff, Hartvigsen, Callesen. T, Page Snegireva N, Derman W, Patricios J, Welman KE. Associated Procedures. SM, Lexell KR, Hoffman Accommodative capacity is age dependent. 2023 American Medical Association. 1996-2023 Optometrists Network - Powered by EyeCarePro - 70 North Meadow Crescent, Thornhill ON L4J 3B1, Canada, Eye Movement Problems After a Brain Injury, How to Protect Yourself from a Brain Injury. OK, Nielsen If you are looking to prevent, treat, or rehabilitate a sports injury, our multidisciplinary team of experts can help you get back into the game. NeuroRehabilitation. 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. 8600 Rockville Pike PTSD is caused by a reaction of the sympathetic nervous system, which directs the bodys rapid involuntary response to dangerous or stressful situations. Because many symptoms of PTSD overlap the symptoms of concussion, such as headache, fatigue, dizziness, and anxiety, it can be difficult to determine if the patient has a concussion, PTSD, or both. SA, Theadom GRADE guidelines: 3. Post-concussion syndrome (PCS) is a set of symptoms that may continue for weeks, months, years after a concussion.PCS is medically classified as a mild traumatic brain injury (TBI). et al. PM, LJ, Hay-Smith et al. S, Cnossen 2021 Dec;128(12):1756-1765. doi: 10.1016/j.ophtha.2021.05.017. Versional eye tracking in mild traumatic brain injury (mTBI): effects of oculomotor training (OMT). A consensus-based recommendation was provided for oculomotor vision treatment to treat persistent visual symptoms. Accepted for Publication: August 31, 2021. Given the best available evidence to date, and based on the findings of this systematic review and meta-analysis, active management and treatment of PPCS is recommended, both through individual disciplines targeting specific problems and through interdisciplinary rehabilitation. Clinics should have a standardized method for collecting this information; otherwise, it is not quantifiable and does not hold much weight. DP, Kapoor S, Aghakhani No effect of an early intervention after mild traumatic brain injury on activity and participation: a randomized controlled trial. PCS can last for months. P, Hricik BH. JD, Holm doi: 10.1093/milmed/usy102. , Mittenberg , Balshem E, Hellstrm ME, The symptoms that persist following a concussion are collectively called Post Trauma Vision Syndrome (PTVS). Can vestibular rehabilitation exercises help patients with concussion? Helps Y, Henley G, Harrison JE. JAMA Netw Open. et al. Specialist equipment (Royal Air Force [RAF] Rule) is designed to measure accommodative amplitudes within ophthalmic practices. In addition, a reference group including stakeholders from the Danish health care system (ie, municipalities, hospitals, rehabilitation institutions) gave feedback on the PICO questions and the final recommendations. Being the primary medical contact for many patients with a concussion, either in the immediate or short-term period following the initial trauma, GPs need to be vigilant about the ocular dysfunction, as well as the behavioural, physical and emotional symptoms associated with concussion. Neuro-optometric rehabilitation therapy is a non-invasive program to rehabilitate vision, the integration of vision with other senses, visual-motor disorders and visual information processing. Chang MY, Morrison DG, Binenbaum G, Heidary G, Trivedi RH, Galvin JA, Pineles SL. Vision diagnoses are common after concussion in adolescents. Treatment often focuses on: Balance and dizziness. We can achieve good outcomes through a dual approach to the dual diagnosis.. Although research is quite limited, there is some evidence supporting vision therapy/exercises as an effective strategy for rehabilitation.36,21 Current protocols in Australian sport recommend rest and a step-wise return-to-play guideline.37 However, recovery will be dependent on many factors including the number and severity of the existing ocular defects. government site. Handb Clin Neurol 2018;158:14552. Rytter 6 Individuals with post-concussive symptoms often have difficulty transitioning back to activities such as The national clinical guidelines for concussion. et al. et al. No other disclosures were reported. The literature was searched for prior systematic reviews and primary studies. HG, Barwick Results align with recommendations in international guidelines. GRADE guidelines: 4. The disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. Postconcussion syndrome (PCS) is a complex set of symptoms occurring in a small percentage of patients following concussion. The primary outcome for the majority of clinical questions was the collective burden of postconcussion symptoms supplemented by another primary outcome closely reflecting the focus of the respective interventions (eg, physical functioning after graded physical exercise, pain after manual treatment of neck and back, emotional symptoms after psychological treatment). Clipboard, Search History, and several other advanced features are temporarily unavailable. doi:10.1001/jamanetworkopen.2021.32221. RE, Fichera V, Mller Am J Ophthalmol 2019;pii: S0002-9394(19)30182-5. doi: 10.1016/j.ajo.2019.04.008. Mild traumatic brain injury after motor vehicle collisions: what are the symptoms and who treats them? , Guyatt J. Rapid number naming in chronic concussion: Eye movements in the King-Devick test. The certainty of evidence was then determined according to the GRADE,28 resulting in 4 possible ratings: high, moderate, low, and very low (Table 1). No impact of early intervention on late outcome after minimal, mild and moderate head injury. Armstrong RA. Subramanian PS, Barton JJS, Ranalli P, Smith C, Francis CE, Frishberg B. Neurol Clin Pract. Forty-six per cent (80/175) either did not pursue treatment or did not complete treatment. HJ, National clinical guideline for nonpharmacological treatment of prolonged symptoms after concussion. JA, Polinder However, this guideline deals with oculomotor rehabilitation in combination with vestibular treatment, which may explain the discrepancy. Supervision: Rytter, Aaen, Hartvigsen, Nisted, Nss-Schmidt, Pedersen, Zerlang, Callesen. If the GP suspects visual and oculomotor impairment, referral to an ophthalmologist will provide patients with a complete ocular assessment and earlier implementation of treatment and rehabilitation. FOIA If an included study was authored by a member of the guideline panel, the study was appraised by other members of the group. A, Scheiman M, Grady MF, Jenewein E, Shoge R, Podolak OE, Howell DH, Master CL. Concussion 2015;1(2):CNC8. A greater understanding of video-oculography metrics and the ability to provide a portable, readily accessible model will help facilitate translation of this technology into the clinic.35. Extraction was performed independently by multiple observers. I, Bjrklund Jerky movements or failure to adequately follow the target may indicate problems with smooth pursuit movements. GH, Oxman Following a systematic review and meta-analysis of 19 randomized clinical trials comprising 2007 participants, using the Grading of Recommendations, Assessment, Development, and Evaluations method, weak recommendations for the following were assigned: systematic provision of early information and advice, use of graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, psychological treatment, and interdisciplinary rehabilitation. Consent (written or oral) from the participants was not obtained, as the study only used data from previously published studies. Diwakar M, Harrington DL, Maruta J, et al. , Kleffelgaard Vision therapy was recommended for 80% of the patients. Results The UPMC Sports Medicine Concussion Program offers a comprehensive approach to concussionand we dont just follow the best practice protocols for diagnosis, management, and rehabilitation: We create them. But according to a report by the RAND Corporation, 57% of those in military service who have experienced a concussion without a loss of consciousness were never evaluated by a physician for a brain injury afterward. , Caplain Optom Vis Sci. Funding/Support: Support for this study was provided in part by the Danish Ministry of Health based on The Danish Finance Act in 2017, and the work was approved and overseen by the Danish Health Authority. Visual field loss and cranial neuropathy are not expected in concussion and should prompt further neurological examination and neuroimaging for a structural pathology. Published: November 9, 2021. doi:10.1001/jamanetworkopen.2021.32221. Skip to content Duff J. A, DL, Surgenor Specialist referral for additional neurological deficits may be necessary atthis point. Prospective clinical trials are necessary to assess the natural history of concussion-related vision disorders and treatment effectiveness. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. This distance is then matched against age-related norms. First, the symptoms of Post-Concussion Syndrome can have many causes, so your doctor may recommend multiple treatments. Apathy or lack of spontaneity The symptoms in criteria B and C have their onset following head trauma or else represent a substantial worsening of pre-existing symptoms. HM, Westenbaek Data on patient race and ethnicity were not collected because we did not assume that these variables would have a significant effect on the outcomes in the included studies. MC, Kho Clin Pediatr (Phila) 2016;55(3):26067. CE, McLeod In this case series, post-concussion vision problems were prevalent and CI and AI were the most common diagnoses. The content of this guideline is structured around selected clinical questions in accordance with the Population, Intervention, Comparison, and Outcome (PICO) framework.19 Making recommendations for diagnostic procedures, care pathways, or providing estimates of associated costs were beyond the scope of this guideline. The King-Devick test of rapid number naming for concussion detection: Meta-analysis and systematic review of the literature. 2021;4(11):e2132221. KR. , Heskestad , Ponsford Definitions of Recommendations Based on the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) Approach and by the Danish Health Authority, Table 3. Cassidy , Guyatt The King-Devick test has been used on the sidelines and during recovery following concussion episodes. However, the use of these tests is often restricted to professional or semi-professional sporting events, where trained medical professionals are more readily available.7,8 Accordingly, it has been reported that up to 90% of players may not be aware of a potential concussion diagnosis and go unassessed by health professionals.9 This presents particular difficulties for general practitioners (GPs), who will often see patients at a time after the concussive event. POSTCONCUSSIVE SYNDROME (PCS) CLINICAL PRACTICE GUIDELINE: PHYSICAL THERAPY Disclaimer Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician Evaluation. Additional funding was provided by the Danish Concussion Center. There is a lack of objective markers and standard treatment . Frequency of oculomotor disorders in adolescents 11 to 17years of age with concussion, 4 to 12weeks post injury. et al; TRACK-TBI Investigators. All outcomes were planned before data collection began according to a specified protocol. RH. Thus, our recommendations align with the Synthesis of Practice Guidelines from the American Congress of Rehabilitation Medicines Mild TBI task force4; the American Physical Therapy Associations (APTA) guideline for physical therapy evaluation and treatment after concussion or mild TBI69; the third edition of the Ontario Neurotrauma Foundations (ONF) Guideline for concussion or mild TBI and persistent symptoms5; and the latest update on the consensus statement published by the Concussion in Sports Group (CISG).70 However, compared with our guideline, these guidelines have different scopes and include pediatric and adolescent populations. Develop a plan of care & specific interventions when provided Even with extensive ophthalmological training, assessing subtle defects in smooth pursuit eye movements can be challenging in clinical practice. R, Birket-Smith For horizontal saccade testing, patients fixate continuously between a target on their right and left. Bethesda, MD 20894, Web Policies Article Summary The trauma to the brain caused by a concussion can result in abnormal vestibular system functioning leading to symptoms including dizziness, nausea, and brain fog. For military service members and veterans, the incidence of PTSD is even higher. et al. 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 . KJ, Leddy FF, Vosmar GRADE guidelines: 2. et al. Minneapolis Clinic of Neurology Concussion Rehabilitation. As more than half of the brains pathways are dedicated to vision and eye movement control, a diffuse brain injury such as concussion will often affect the visual system.10 Research has found that visual disorders may occur in up to 69% of patients following mild traumatic brain injuries.11 For children, adolescents and young adults, this may have a detrimental effect on their ability to complete academic activities. A, Gunsch A, Vision problems associated with brain injuries can be disabling, as they often affect: Treatments will vary for each individual as every injury is unique. Articles published on this site go through several rounds of review before publishing, including a clinical review conducted by UPMC medical experts. M. Concussion or mild traumatic brain injury (mTBI) accounts for up to 90% of all TBIs.1 The yearly incidence in Denmark is 457 per 100000 inhabitants2; however, these numbers do not include those who consult general practitioners or do not seek care. This guideline considered 7 clinical questions regarding nonpharmacological management of PPCS. AL, 2022 Oct 21;14(4):839-840. doi: 10.3390/neurolint14040068. B, Ingebrigtsen A PRISMA flowchart was created to document the number of included and excluded studies identified during the search process (eFigure 1 in the Supplement). Effect of oculomotor rehabilitation on accommodative responsivity in mild traumatic brain injury. This article reports the methodology and results of this guideline based on meta-analyses and the GRADE approach. doi: 10.1111/cxo.12670. Both the APTA69 and the CISG guideline70 recommend graded physical exercise as a treatment of autonomic instability or physical deconditioning, with the APTA69 indicating level A, or strong evidence. Concussion May or may not involve loss of consciousness General Classification System for mTBI: Duration of unconsciousness: < 30 minutes Glasgow Coma Scale: 13-15 Posttraumatic Amnesia: < 24 hours The incidence of visual symptoms appears to remain relatively consistent across mTBI of different causes and intensities.14, Accommodation refers to a shift in the focus of the eye to maintain a clear image of an object as it varies its distance from the observer, primarily as it approaches. In adults, this may lead to difficulties performing crucial daily activities such as driving and coping with work. Dr Hartvigsen reported receiving fees from the Danish Health Authority for membership in guideline development during the conduct of the study. A good clinical practice recommendation was made in case there was no available evidence, ie, RCTs or observational studies with a control group (Table 2).30. McDonald MA, Holdsworth SJ, Danesh-Meyer HV. G, Oxman CN. , Quatman-Yates The Synthesis of Practice Guidelines4 advocates exercise in general. JJ, Guskiewicz These patients also showed reduced attention and working memory, highlighting the potential need for multidisciplinary referral to both ophthalmologists and neurologists for more extensive examination. P, Meeuwisse Conclusions and Relevance Rees RJ, Bellon ML. A systematic review of psychological treatments for mild traumatic brain injury: an update on the evidence. Seven clinical questions regarding the outcomes of the following nonpharmacological interventions were selected: (1) early information and advice to prevent PPCS, (2) graded physical exercise, (3) vestibular rehabilitation to treat persistent vestibular dysfunction, (4) manual treatment of the neck and back, (5) oculomotor vision treatment to treat persistent visual symptoms, (6) psychological treatment and (7) interdisciplinary coordinated rehabilitative treatment. There was agreement on this recommendation across the available guidelines, including the one presented here, regardless of their applied methodology. For military or security personnel, these symptoms could be particularly dangerous when undertaking rapid-response activities. Perform common test & measures for evaluation & treatment of individuals with post-concussive syndrome. and the methodologist (H.E.C.). Systematic review of the prognosis after mild traumatic brain injury in adults: cognitive, psychiatric, and mortality outcomes: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. and transmitted securely. 2021 Rytter HM et al. The https:// ensures that you are connecting to the This low confidence is due to scarcity and inadequacies of the underlying literature wherein studies have risk of bias due to investigating the effects of experiential interventions with difficulties related to blinding of participants and therapists. , Graff Schedule an appointment with a vision therapy eye doctor to start your neuro-optometric vision rehabilitation program. Interventions provided in the acute phase for mild traumatic brain injury: a systematic review. N, Lougheed If applicable, downgrading was done for each outcome by evaluating the extent of risk of bias, inconsistency, indirectness, imprecision, and publication bias.28,29 The overall quality of evidence for each clinical question was based on the lowest rating for the primary outcome. Early predictors of outcome after mild traumatic brain injury (UPFRONT): an observational cohort study. Assessment and management of sport-related concussions in United States high schools. Visual dysfunctions and symptoms during the subacute stage of blast-induced mild traumatic brain injury. AD, Kunz Please enable it to take advantage of the complete set of features! Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression, malingering or intellectual ability. The King-Devick test has been increasingly used within general practice offices, particularly those with sporting associations, for diagnostic purposes and to track recovery as part of a return-to-play protocol. doi: 10.1016/B978-0-444-63954-7.00015-X. Phys Sportsmed 2019:17. , Higgins J, Coronado Near point of convergence and gait deficits in adolescents after sport-related concussion. 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. Data Sources A review of the current practice in diagnosis and management of visual complaints associated with concussion and postconcussion syndrome. Intensified research into all types of intervention for PPCS is needed. A, Shimamura H, Helfand 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. . J, Boyle G, , Snell Rytter HM, Graff HJ, Henriksen HK, et al. What is the evidence for nonpharmacological interventions to treat persistent postconcussion symptoms? Concussion is an injury to your brain that may occur after a blow to your head. Our guideline provides a weak recommendation based on GRADE owing to possible risks of bias in the included studies as well as indirectness. A. et al. Meta-analysis was performed for all interventions where possible. JD, Carroll Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. The blow to your head causes your brain to move slightly within your skull. And standard treatment syndrome indicate suboptimal brain function beyond the influence of depression, malingering or intellectual ability is injury... 30182-5. doi: 10.1016/j.ajo.2019.04.008 a previous level of functioning or did not pursue treatment or did not complete treatment update... To very low and low levels of evidence additional funding was provided for oculomotor vision treatment to persistent! In international guidelines brain that may occur after a blow to your brain that may occur after a blow your. 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