EBP LITERATURE REVIEW

PORTFOLIO:
BEST PRACTICE FOR
CONCUSSION MANAGEMENT
Carroll University
Doctor of Physical Therapy Program
PTH522: Evidence Based Clinical Decision
Making
Spring, 2018

Group #6

Clinical Partners:​ Kris Erickson, PT, MS, NCS;

Gretchen Kramer, PT; Rose Nelson, DPT
Students:​ Tacy Camenga, SPT; Andrew Hovell,
SPT; Paige Lyford, SPT; Corianne Strupp, SPT
Instructors:​ Dr. Mark Erickson, PT, DScPT, OCS;
Dr. Joe Johnson, PT, DPT
 Best Practice for Concussion Management

Clinical Question
What is best practice for treating patients with oculomotor dysfunction following concussion or
mild traumatic brain injury (mTBI)? Include recommendations for screen time following
concussion, as well as the factors that contribute to or slow recovery (i.e., prognostic factors).

Clinical Question Subtopics

1. Buffalo Concussion Treadmill Test for Diagnosis

2. Patient Characteristics and Symptoms that Indicate a Prolonged Recovery

3. Vestibular Oculomotor Tests for Prognosis

4. Balance Training Intervention

5. Decreased Screen Time for Concussion Management

6. Physical and Cognitive Rest After Experiencing a Concussion

7. Office Based Convergence, Version and Accomodation Therapy for Convergence

Dysfunction in Individuals with mTBI

8. Pencil Push-ups for Convergence Dysfunction in Individuals with mTBI

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Subtopic EBP Literature Critically Appraised Topic (CAT) Summaries

1. Buffalo Concussion Treadmill Test for Diagnosis

a. Literature Breadth and Quality
Overall, the breadth of literature in regard to the Buffalo Concussion Treadmill
Test (BCTT) is very limited. Therefore, there is extremely limited evidence for the
BCTT as a diagnostic tool for return to play. Slightly more evidence is available
regarding the Balke protocol, which is the basis for the BCTT. The majority of the
literature pertained to non-exercise related concussion tests. The quality of the
evidence is poor. There are numerous threats to validity, including lack of
protocol explanation so that it can be reproduced, blinding the examiners, and
referencing a gold standard. Lack of statistical analysis and baseline
measurements also limit the research quality. The level of evidence for the
literature is poor (levels range from 3-5). Cross-sectional design and
retrospective chart reviews were included. Even though these studies utilize
reference standards, they were downgraded due to no statistical analysis, no
defined measurements, no blinding, and mechanism-based reasoning.

b. Key Findings
■ Current evidence focuses on multiple aspects of concussion recovery in
relation to the BCTT and and Balke protocol.
● Limited evidence regarding the accuracy of the BCTT’s diagnostic
ability for safe return to sport.
■ Limited evidence is not reliable for diagnosing concussion recovery for
return to play.
■ BCTT should not be used alone to diagnose readiness for return to play
after sport related concussion.
● Perform with other neurocognitive tests to determine if a patient
is safe to return to play.

c. Influence on Clinical Reasoning

■ Diagnostic Line of Thought:
● No evidence indicates BCTT’s ability to diagnose readiness for
return to play from a sport related concussion. Therefore, PTs
should recognize that the BCTT should be performed in
conjunction with the computerized neurocognitive assessment
tools to diagnose a patient as safe to return to play.
■ Prognostic/Predictive and Intervention Lines of Thought:
● Literature shows that the BCTT is more effectively used as a tool
to assess exercise tolerance, which is helpful for predicting
aerobic exercise tolerance when prescribing interventions.
■ Psychosocial/Intervention Lines of Thought:
● Understanding how a concussion affects the patient as a person
and what the patient’s motives are will help the PT encourage
alternative strategies to enhance the patient’s quality of life while

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they are still recovering prior to return to sport. Working with the
patient to prescribe safe, yet fun, alternatives will help build
rapport with the patient and enhance their psychosocial
well-being.

d. Clinical Bottom Line

Sensitivity of the BCTT does not accurately determine exercise tolerance in
patients following concussion for return to sport since there is no current
evidence supporting this. I recommend clinicians perform the BCTT in
conjunction with other neurocognitive scores to determine if a patient has
recovered from a sport related concussion to a safe level. This will ensure that
other factors not accounted for in graded treadmill testing are considered in
order to decrease adverse events from returning to play too early.

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 Best Practice for Concussion Management

2. Patient Characteristics and Symptoms that Indicate a Prolonged Recovery

a. Literature Breadth and Quality
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. 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.

b. Key Findings
■ The recovery process is individualized to each case
■ Prognostic factors that influence recovery period
● being female
● being older
● having symptoms of vestibular-oculomotor symptoms
● experiencing sleep disruption

c. Influence on Clinical Reasoning

■ Biopsychosocial Line of Thought:
● Patients who have these prognostic factors may experience a
longer rehabilitation process which can be stressful mentally and
physically. Patients experiencing prolonged recoveries may have
to stick to physical and cognitive rest prescriptions, leading to
decreased participation in school, athletics, and with friends.
■ Examination Line of Thought:
● When a concussion is experienced, it is recommended to perform
a VOMS to determine the complexity of the rehabilitation and
prognosis of the client. It is also crucial to include questions about
sleep while taking a history.
■ Prognostic Line of Thought:
● Identifying patients with these factors can indicate an extended
recovery period.
■ Interventions (Teaching) Line of Thought:
● After identifying these factors, the clinician will have to decide if
informing the patient that they may have a prolonged recovery
will be detrimental or beneficial to the healing process.

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 Best Practice for Concussion Management

d. 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-oculomotor 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.

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 Best Practice for Concussion Management

3. Vestibular Oculomotor Tests for Prognosis

a. Literature Breadth and Quality
Overall, the breadth of literature in regard to oculomotor testing predicting
recovery time after a concussion is limited. More evidence is available regarding
ocular motor testing as a tool for assessing dysfunction post-concussion rather
than as a prognostic tool. The quality of evidence is moderate. The validity of the
evidence is moderate for patients who are younger and sustain concussions from
sport related injuries. However, the designs of these studies include numerous
threats to validity pertaining to adults and patients who sustain non-sport
related concussions. The level of evidence for the literature is moderate due to
the limited number of articles being cohort studies, and therefore, level 2
evidence.

b. Key Findings
■ Delayed recovery associated with positive VOMS score (for any domain
except near point convergence and accommodation)
■ Smooth pursuit, horizontal saccade, and vertical saccade: most predictive
of 15-19 day recovery period
■ Smooth pursuit alone: most predictive of 30-90 day recovery period
■ Use VOMS as a baseline to guide treatment

c. Influence on Clinical Reasoning

■ Prognostic/Predictive Lines of Thought:
● Moderate literature shows that a positive VOMS score for any
domain, except near point convergence and accommodation,
indicates increased recovery time after a sport related concussion.
which helps clinicians establish a prognosis.
■ Psychosocial Line of Thought:
● PTs will need to educate their patients about the likelihood of
provoking uncomfortable symptoms with this assessment.
Developing rapport with the patient and allowing the patient to
feel in control during this assessment will reduce anxiety about
performing the VOMS.
■ Intervention Line of Thought:
● The results of the VOMS can be used as a baseline for treatment
and then progressed with association and dissociation to reduce
the brain’s perception of such movements as threats.
■ Examination and Outcomes Lines of Thought:
● As the patient progresses through therapy, the PT can reassess
the patient using the VOMS to document progress and make
adjustments to the plan of care if needed.

d. Clinical Bottom Line

The vestibular/ocular motor screening (VOMS) is associated with increased
recovery duration from sport related concussions in adolescents. Patients with

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positive VOMS scores are likely to return to sport after a longer recovery period
than patients without positive VOMS scores. I recommend clinicians utilize the
VOMS in conjunction with other assessments to accurately predict recovery time
in adolescents with sport related concussions. This will ensure that other factors
not accounted for in the VOMS are considered in order to provide patients with
the most accurate prognosis for their recovery.

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 Best Practice for Concussion Management

4. Balance Training Intervention

a. Literature Breadth and Quality
Since concussion management is a “hot topic” there is high quantity of available
literature regarding concussions, including sport-related concussions, motor
vehicle accidents, acute recovery etc. This research readily addresses the use of
balance training as an intervention for individuals with mTBI. The most up-to
date research about balance training as an intervention for mTBI includes
primarily clinical commentaries and literature reviews. Due to the nature of
literature reviews, the quality of research is low, especially as compared to the
quantity. The most recently published systematic review, notes that original
research regarding mTBA and balance training is of low quality, due to the lack of
consistency within balance intervention protocols and prescriptions.

b. Key Findings
■ Current research supports the use of balance training for adults and
children with delayed recovery from mTBI to:
● reduce dizziness
● facilitate improvements in gait and balance function
■ Balance interventions should be implemented using a case-by-case
prescription, to limit patient symptoms as they progress through the
standard phases of concussion recovery.
■ In spite of the wide breadth of available literature, the quality of current
research regarding mTBI and balance training is low, and future research
is necessary to determine appropriate parameters for balance training.

c. Influence on Clinical Reasoning

■ Intervention Lines of Thought & Reasoning:
● The treatment progression correlates to 3 phases of recovery:
Protection, Deficit Management, Return to Sport.
● Current research supports the use of balance training for adults
and children with delayed recovery from mTBI to reduce dizziness,
and facilitate improvements in gait and balance function.
○ Implement after the critical rest period of 24-48 Hours
● All interventions should be implemented using a case-by-case
prescription, to limit patient symptoms as they progress through
the standard phases of concussion recovery.
● Treatment should be individualized and monitored over time for
modifications (progression, regression).
● There is a strong need for well-designed intervention studies,
especially in relation to prolonged recovery.
■ Collaborative Reasoning:
● Approach each patient presenting with a concussion as an
individual, getting to know their goals and priorities.

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 Best Practice for Concussion Management

d. Clinical Bottom Line

Balance training is an appropriate intervention for patients with mTBI,
experiencing delayed recovery. Evidence supports use of balance training after
24-48 hours of cognitive and physical rest, a time frame which is long past for
patients with chronic symptoms. Specific parameters for balance training are not
provided, thus each patient should be monitored individually to ensure
provocation of symptoms is minimal. Current clinical practice, which combines
use of balance training with oculomotor challenges would be increasingly
appropriate as the patient moves beyond symptom management to the
neuroplasticity phase of recovery.

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 Best Practice for Concussion Management

5. Decreased Screen Time for Concussion Management

a. Literature Breadth and Quality
There is low quantity of available literature directly related to screen time for
mTBI, as this is influenced by so many areas of life from schooling and work, to
leisure activities. The current quality of research regarding this topic is very low.
Conclusions about screen time primarily stem from recommendations for
cognitive effort. Current guidelines are not based on direct evidence, and
specific parameters are not available.

b. Key Findings
■ Cognitive exertion, and therefore screen time are discouraged within
24-48 hours of impact.
■ Return to use of technology after initial rest period should be graded,
within symptom-free bouts
● Targeting a rest-activity balance with moderation may improve
recovery times (​neurocognitive scores & reaction times​)
● guidelines do not provide information on the timing, duration,
type, or other specifics
■ Long-term limiting of activities, including technology use could lead to
adverse effects: anxiety, depression
■ “Screen time” is a major component of academics, social life, leisure
time, and even work. Some activities involving screen time require very
low cognitive effort (watching movies, use of social media) while others
(school and work tasks) require much more, but all increase exposure to
light.
■ Individuals have decreased awareness of the magnitude of effects from
symptom-provoking stimuli
● “As tolerated” is often used to determine appropriate activity
levels, but often patients miss the subtle symptoms.
■ Every case varies: treatment should be individualized and monitored over
time for modifications (progression, regression).
■ There is a strong need for well-designed intervention studies, especially
in relation to prolonged recovery.

c. Influence on Clinical Reasoning

■ Intervention Lines of Thought & Reasoning:
● Limiting screen time should be implemented for all patients
post-concussion within the initial 24-48 Hours
● Screen time should be re-introduced progressively to limit patient
symptoms as they progress through the standard phases of
concussion recovery.
■ Teaching Reasoning:
● Throughout recovery it is important to educate patients about
symptom provoking stimuli and the importance or rest.

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 Best Practice for Concussion Management

○ Be aware that it is not recommended to prescribe limited

screen time based on patient’s perceived tolerance, since
they may have decreased perception
● Emphasizing screen time reduction during the acute phase of a
concussion should incorporate education about prioritizing
activities which require screen use to help limit symptoms.
■ Psychosocial Lines of Thought & Collaborative Reasoning:
● Discuss typical use of technology with patient, to allow for
discussion of temporary modifications required.
● Collaborate with pt to make reduction of screen time manageable
○ Long-term limiting of technology use could lead to adverse
effects: anxiety, depression

d. Clinical Bottom Line

Limiting screen time should be used as an intervention for all patients after
concussion or mTBI. Cognitive rest, specifically within the first 24-48 hours, is the
general consensus within available literature. Evidence also shows that while
patients recognize light sensitivity, their symptoms affect their tolerance more
than they report or recognize. Since screen time incorporates both light and
varying levels of cognitive effort, it is not advisable to recommend screen time
“as tolerated,” especially in the initial 24-48 hour window. Beyond the initial
time frame, patients should be encouraged to slowly and increase screen time in
a prioritized manner in order to return to school, work, social life, and leisure
activities without reproduction of symptoms.

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 Best Practice for Concussion Management

6. Physical and Cognitive Rest After Experiencing a Concussion

a. Literature Breadth and Quality
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. 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

b. Key Findings
■ Every person experiences a concussion and the subsequent
■ Physical Rest - minimize physical activity as long as symptoms persist at
baseline
● Once symptoms at rest resolve, begin gradually increasing
intensity of aerobic activity
● This aerobic activity is OKAY to aggravate symptoms as long as
they return to normal afterwards
■ Cognitive rest - 1-2 days of cognitive rest followed by a slow and gradual
return to normal cognitive activities to tolerance

c. Influence on Clinical Reasoning

■ Intervention Line of Thought:
● Patients should undergo a short period of cognitive and physical
rest, followed by a very slow and gradual return to normal
activities
● Teaching the patient about the benefits of the rest and the risk of
prolonging recovery if that rest is not adhered to may help to
improve patient compliance
■ Biopsychosocial Line of Thought:
● Patients may experience a negative mindset from having to sit out
of participation experiences such as missing class, missing
practices, and having to restrict physically activities with friends.
■ Prognosis Line of Thought:
● Patients who do not undergo cognitive and physical rest after
experiencing a concussion have been found to have a delayed
recovery time

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 Best Practice for Concussion Management

d. 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.

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 Best Practice for Concussion Management

7. Office Based Convergence, Version and Accomodation Therapy for Convergence

Dysfunction in Individuals with mTBI
a. Literature Breadth and Quality
There is not a lot of research on the use of PT interventions but there is a lot of
research relating to optometrist implemented interventions. The research that
exists is mainly clinical trials, case series and case reports. Few studies have been
conducted regarding the long term effects of office based convergence, version
and accommodation therapy. Most of the sample sizes of the studies are small
with low quality research. All of the research found regarding this topic was
performed by optometrists, which could potentially impact the results of the
study.

b. Key Findings
■ Rehabilitation interventions for vergence, version and accommodation
are shown to improve reading rate, VSAT (Visual Search Attention Test)
percentile, fixation and VEP (Visual Evoked Potential) amplitude.
■ The combination of COR (Computerized Oculomotor Rehabilitation) with
other treatments improved reading rate and fixation measurements.
■ While these specific interventions are not used in the physical therapy
setting, if an individual has chronic convergence insufficiency, these
treatments may be important in their recovery.

c. Influence on Clinical Reasoning

■ Intervention Line of Thought
● This is not an intervention PT’s are able to perform but is an
appropriate treatment for individuals whose convergence
insufficiency is persistent.
■ Collaborative reasoning
● This intervention is more effective than exercises performed in
the clinic, but is more expensive and will involve additional
doctors appointments for the patient. It is important to discuss
the treatment options with the client so that the appropriate
intervention for the client can be chosen.

d. Clinical Bottom Line

There is evidence that vergence, version and accommodation therapy are
effective for treating convergence dysfunction in individuals with a mTBI. More
high-quality research needs to be performed to be more confident in the efficacy
of this treatment. Due to the lack of evidence on this protocol, this is the best
available evidence.

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8. Pencil Push-ups for Convergence Dysfunction in Individuals with mTBI

a. Literature Breadth and Quality
The majority of the research relates to convergence insufficiency in children or
adults that did not have mTBI, this could impact the applicability of this research
to PT practice. The research performed is relatively recent, as this is a topic that
is still being researched. Literature is written mainly by optometrists and many of
the articles are written by the same person or group of people. Most research
are randomized controlled trials and no research was found to discuss the use of
Physical Therapy in the rehabilitation of patients from this population. Since
many articles are written by the same individual, it could be biased towards his
perspective. Sample sizes in some studies may lend individual studies to bias
towards a particular group.

b. Key Findings
■ Pencil push ups are not more effective than placebo interventions for
convergence insufficiency.
■ Office based vergence/accommodation therapy is more effective than
placebo interventions.
■ Home-based computer vision therapy/orthoptics were more affected
than pencil push-ups to improve convergence and positive fusional
vergence.
■ Office based vergence/accommodation therapy can prevent
reoccurrence of convergence insufficiency symptoms.
■ Current research indicates office based vergence/accommodation
therapy performed by optometrists is the most effective intervention for
individuals with convergence insufficiency.
■ More research needs to be conducted on individuals with mTBI and
convergence insufficiency and the role of Physical Therapy in their
recovery.

c. Influence on Clinical Reasoning

■ Intervention Line of Thought
● While this intervention may not be as effective as others, it is the
most cost effective, so it could be utilized to reduce cost.
■ Ethical Reasoning
● Since the literature does not support the use of pencil pushups, it
the clinician has to decide how ethical it would be to spend a large
amount of treatment time on it.
■ Collaborative reasoning
● It is important to discuss the treatment options with the client so
that the appropriate intervention for the client can be chosen.

d. Clinical Bottom Line

The best available evidence indicates that pencil push ups are no more effective
than placebo therapy at treating convergence dysfunction in individuals with

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convergence insufficiency. Research indicates that office-based therapy is slightly

more effective than placebo therapy at controlling convergence insufficiency
symptoms.

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Acknowledgements
Thank you to our Clinical Partners: Kris Erickson, Gretchen Kramer, and Rose Nelson for your
guidance of the research focus and to our instructors: Dr. Mark Erickson, Dr. Joe Johnson for
your expertise and critiques throughout the research process.

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