CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

BEST PRACTICE OF 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: The affects of physical and cognitive rest on the recovery period after experiencing a concussion/mTBI

Clinical Bottom Line:

Every subject who experiences a concussion will recover in a different manner, but the research supports that the rehabilitation
following a concussion should include a short period of rest (1-2 days) followed by a gradual return to normal daily activities and
cognitive activity. This should also include light to moderate aerobic activity, even if symptoms are present and slightly increased during
the activity. This rehabilitation process should be overseen by a medical professional, such as a Physical Therapist.

Refresh Date: March 16, 2019

Author(s): Andrew Hovell Date Created: March 16, 2018

Reviewer(s): Date Updated:
Key Findings
 General Summary – Overall there is a lot of new research being added to the currently lacking body of evidence. Because it is difficult and
expensive to use neurological imaging. The breadth of the literature is lacking high quality research.
 Quality of Evidence – The body of evidence is of low quality. There is a lot of inconsistency in the outcome measures used when working with
patients with concussions. Currently we rely heavily on self-reported outcomes. There is a need for standardized, objective data before the
effectiveness of interventions can be examined
o There are a few CPG and SR, but most of the literature is made up of retrospective cohort studies
 Due to the study types and limitations noted below, the overall grade of the available literature is a 3 on the oxford level of evidence scale.
 General Limitations – The SR’s and CPG included do not report the data used to draw conclusions and there reliability is therefore
significantly dropped. There is also a strong need for the development of standardized outcomes data.
 Take Home Findings – The literature is currently lacking standardized outcome data to then validate the use of any interventions on the
rehabilitation after experiencing a concussion. Based on the available evidence, it is advisable to prescribe a short period of rest, followed by
a gradual return to normal activities. Normal activities should be resumed for a 2-3 days before beginning a progression to sport related
activities. These decisions need to be based on the severity of the injury and the symptoms experienced by the patient.
 Clinical Relevance – As Physical Therapists, we work closely with athletes. We also now have direct access and may be the first Medical
Professional to see a patient who recently experienced a concussion. Current research says that a short period of rest followed by slow and
gradual return to normal activities meets the criteria of best practice. Management of symptoms is the priority of early treatment, and
provoking those symptoms via light-moderate aerobic activity may decrease the risk of a prolonged recovery.

Search Methodology: (This section should include enough detail to make the search repeatable)
Search Resources Search Terms Limits # of Articles
SPORTdiscus Concussion No Limits 5
1
Screen Time
Cochrane Database for RCTs Concussion No Limits 0
2
Screen Time
Cochrane Database for RCTs Concussion No Limits 52
3 Interventions or strategies or best
practice
PubMed Concussion No Limits 29
4
Screen Time
PubMed Rest No Limits 102
5
Concussion Recovery

Author(s): Andrew Hovell Date Created: March 16, 2018

Reviewer(s): Date Updated:
Search Results Summary:
Results Reasons for Inclusion Reasons for Exclusion # of Articles
Included
1 RCT Discussed the affects that a Sport Did not include any information 0
1 Cohort Study Related Concussion (SRC) can have about the amount of screen time a
1 3 others on the Neurological System patient should be limited to after
experiencing an SRC
2 No Results No results No Results 0
19 RCTs Discussed interventions following a No articles utilized limited screen 0
3
SRC time as an intervention
1 RCT Discussed interventions following a No articles used solely rest or 0
4 1 SR SRC limited screen time as an
1 Controlled Clinical Trial intervention
6 RCT Discussed interventions following a Only compared the differences 4
14 SR SRC between rest and not resting on the
time of recovery and severity of
symptoms
5 Included search methodology
Reports statistical data used to form
conclusions
One article was a CAT of an
already included article

Research Participant and Study Characteristics:

Reference Participant Key Clinical
Characteristics
Thomas et al 11 to 22 year old individuals
reporting to the ED for a
direct blow to the head were
included. All subjects were
English speaking, were not
intellectually disabled or
suffering from any mental
Author(s): Andrew Hovell
Reviewer(s):
Control Intervention
(frequency/duration)
Control group underwent
normal concussion protocol of
1-2 days of rest followed by
gradual return to normal
activities prescribed by their
primary care physician
Date Created: March 16, 2018
Date Updated:
Experimental Intervention Level of
(frequency/duration) Evidence
Experimental group was Level 2
placed on 5 days of strict rest
before being allowed to start a
gradual return to sport and
classroom functions
 disease or illness, and were all
capable of completing
assessments of signs and
symptoms, neurocognition,
and balance.

Outcomes:
Reference Event/Outcome Time to Mean (SD) ES &/or NNT
(may have more than one Event Control Group Experimental Group
per reference)

Thomas et al Rating of ability to perform 10 days After 10 days, 25% of After 10 days, 40% of SD not
the following activities the control group the intervention group provided by the
compared to before the head reported continuation of reported continuation of authors and
injury: sleeping, sitting, symptoms symptoms (emotional could not be
standing, walking indoors, and physical were the computed
walking outdoors, low most commonly
intensity activity, moderate reported continuing
intensity activity, and high symptoms)
intensity activity,

Author(s): Andrew Hovell Date Created: March 16, 2018

Reviewer(s): Date Updated:
Systematic Review/Meta-Analysis Characteristics
Reference Data Sources/Author Search
Processes
Choe et al All data was collected from articles
provided by the American Academy of
Neurology, the American Academy of
Pediatrics State Advocacy Focus,
Centers for Disease Control and
Prevention, and the National
Conference of State Legislatures (TBI
legislation).
Harmon et al The clinical practice guideline put
forth by the American Society for
Sports Medicine does not state the
search criteria, but does provide a
quality of evidence grade for each
catergory reviewed, and hand
searching the references reveals 226
articles of low to moderate quality
Schneider et al PubMed, CINAHL, PsychInfo,
Cochrane Controlled Trials Registers,
Health STAR, SPORTdiscus,
EMBASE, Web of Science, and
Proquest were searched for the
following terms; Brain Concussion or 
Post­Concussion Syndrome or Sport­
related concussion or mild traumatic 
brain injury AND Rest or Treatment 
Outcome or Cognitive rest or Physical
exertion or Therapy or Rehabilitation 
Author(s): Andrew Hovell
Reviewer(s):
Inclusion/Exclusion Criteria
Articles were included if they
utilized rest protocols or examined
the side effects of returning to
normal activity before normal
medical clearance criteria was met.
Best available evidence on the
diagnosis, prognosis, and treatment
of sports related concussions.
Articles were included if they
included the original research,
reported on sport related
concussions, and evaluated the
effect of rest as an intervention
Date Created: March 16, 2018
Date Updated:
Number of Studies Reviewed and
Included (Data Extraction in
Meta Analysis)
Authors include 60 articles in their
review, and then narrowed these
down to 6 articles discussing rest as
an intervention, but did not report
the data and therefore meta analysis
was not performed on this data.
The article is a synthesis of
information and a clinical practice
guideline, but does not state any
statistical data to back up its claims.
The authors are using the clout of
their organization as ethos for their
claims
749 articles met the search criteria,
which were then narrowed down to
13 included studies based on the
inclusion criteria.
 or Treatment AND Sport. 
Systematic Review/Meta-Analysis Outcomes:
Reference Author Conclusions (Data Synthesis in Meta- Analysis)
Choe et al The authors found that total cognitive and physical rest
beyond 3 days led to prolonged recovery time in pediatric
patients returning to sport and class room, and that gradual
increases in physical activity and normal school function
over the course of the first week after a concussion are
correlated with a normal course of recovery. They define
physical activity as moderate aerobic exercise, and one
source they reviewed identified that activity induced
symptoms in the acute phase of recovery
Harmon et al On the topic of rest, the authors conclude that each subject
needs to be prohibited from returning to play until
medically cleared by their treating Physician. They attest
that returning to light to moderate aerobic activity can be
beneficial to the recovery process, however this activity
needs to be supervised and symptom based.
Schneider et al There is not enough literature available to decisively say
whether or not cognitive and physical rest is either
beneficial or hindering to the healing process. However in
multiple animal studies, short periods of rest followed by
gradual increases in physical and cognitive stressing in a
progression to normal activities has been shown to increase
neuroplastic markers in the brain. In most of the
retrospective studies available, any Physician who
prescribed prolonged rest after injury did so due to
increased severity of the injury, and those individuals
therefore had a prolonged recovery.
Author(s): Andrew Hovell Date Created: March 16, 2018
Reviewer(s): Date Updated:
Limitations
The authors do not include the data from the original
articles, they provide their conclusions on post-
concussion management. The authors are also both
Medical Doctors, not Physical Therapists, which may
impact the conclusions that we can draw. All of the
subjects included in the review were between 11 and
18 years old and experienced a sport related
concussion.
The only limitation is a major one; the authors do not
present the data they utilized to draw their
conclusions.
There are only 3 studies included in the review, all of
low to moderate quality. The author then includes
some animal study conclusions as well as some
neuroplasticity investigations in individuals after
experiencing a stroke. The animal studies may not
yield the same results in humans, and the
pathophysiology of a stroke is very different from a
mTBI or sport related concussion (according to the
authors).
References:
Choe M, & Barlow KM. Pediatric Traumatic Brain Injury and Concussion. Continuum – Child Neurology 2018;24(1):300-311

Harmon KG, et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Br J Sports Med
2013;47:15–26

Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport
related concussion: a systematic review of the literature. Br J Sports Med 2013;47:304–307

Thomas DG, Apps JN, Hoffmann RG, McCrea M, & Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized
Controlled Trial. Pediatrics 2015;135(2):213-223

Author(s): Andrew Hovell Date Created: March 16, 2018

Reviewer(s): Date Updated: