According to the Centers for Disease Control and Prevention, 3 million Americans experience a concussion — a traumatic brain injury caused by a blow or jolt that causes the brain to move rapidly inside the skull — every year.
While the condition has more recently become the subject of study and practice guidelines in the contexts of athletics and battlefields, there has not been a set of clinical practice guidelines to direct physical therapists in treating more routine concussions until now.
Earlier this year, a group of physical therapists, including Professor of Clinical Physical Therapy Rob Landel, DPT, with the USC Division of Biokinesiology and Physical Therapy, published a list of clinical practice guidelines (CPG) in the Journal of Orthopaedic and Sports Physical Therapy called “Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury.”
“Existing guidelines had relatively sparse information to guide the physical therapist in the rehabilitation of individuals with concussion, particularly those who don’t resolve in 10 to 14 days,” Landel explained. “The purpose of this CPG was to provide recommendations to physical therapists on the best practices for the management of individuals who have experienced a potential concussive event.”
Grading the interventions
Traditional physical therapy for individuals who have experienced a concussive event has not been consistent between individual physical therapists, institutions or even patients because there was no single codifying document to turn to for guidance. The new CPG fills this void. The guidelines involve screening a patient for potentially urgent or emergency conditions (and then making the appropriate referrals), assessing impairments in cervical musculoskeletal function, vestibulo-oculomotor function, autonomic dysfunction/exertional tolerance and motor function and then addressing any deficits found in those areas.
In the clinical practice guidelines, the research team identified and evaluated a number of typical tests and interventions based on comprehensive literature reviews. Most clinical practice guidelines take one or two years to complete; these took five years due to the ever-evolving body of knowledge surrounding concussion as well as the complex nature of the injury.
The research team gave each recommendation a letter grade, from an A (something that physical therapists must absolutely be doing) to a B (something that a physical therapist should do) all the way down to an F (a consensus opinion made by the authors, without any data to support it).
More work to do
But a recommendation receiving an F is not one that should be avoided altogether, Landel explained.
“The F grades mean that there is little research evidence to date to support the recommendation,” Landel said. “The Fs are important because they highlight where we are deficient in literature, and thus they serve as guideposts to where future research efforts might best be focused.”
Publishing the clinical practice guidelines was only the beginning, according to Landel.
“We are now working on knowledge translation and implementation so that the majority of physical therapists who treat patients after a concussive event are applying the best available evidence to their efforts,” he said. “In other words, are the recommendations graded A and B being done routinely? If not, why not? How do we get PTs to adopt the recommendations into their routine standard of care for these patients?”
The effort to create the first-ever evidence-based clinical practice guidelines for physical therapists was undertaken by 23 healthcare professionals from across the country, with Landel representing USC.
“I feel very fortunate to have been asked to join the effort and collaborate with an outstanding group of authors,” Landel said. “I learned a lot from my co-authors, both about managing patients after a concussive event and about the process of creating a CPG. I hope, in return, they learned a bit from me, and that those implementing the guidelines will benefit from my contributions. I was also very pleased that USC, with one of the premier DPT programs in the world, was represented.”
— John Hobbs