Abstract
Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS. To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice. 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. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS. A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. 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. Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention). Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. 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. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus. Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.
Highlights
Concussion or mild traumatic brain injury accounts for up to 90% of all TBIs.[1]
Recommendations are based on systematic reviews and follow the principles described in GRADE.[18]
The search date for individual studies for this question was limited to the date of the latest search in the included systematic review,[33] and here we identified 2 relevant randomized clinical trials (RCTs).[42,43]
Summary
Concussion or mild traumatic brain injury (mTBI) accounts for up to 90% of all TBIs.[1] The yearly incidence in Denmark is 457 per 100 000 inhabitants[2]; these numbers do not include those who consult general practitioners or do not seek care. The true incidence is estimated to be around 600 per 100 000.3. Most people who sustain a concussion or mTBI recover quickly, but a significant proportion experience long-term symptoms.[8,9,10] According to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10),[11] recovery from concussion is expected within the first 2 to 3 weeks, and persistent symptoms are defined as those lasting for more than 4 weeks after injury.[12] Studies indicate that up to 34% to 44% of patients with concussion or mTBI experience symptoms at 3 to 6 months after injury, and between 5% and 20% experience symptoms at 12 months after injury.[8,13,14,15]
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