(B) Treatment of persistent symptoms following SRC | |||||
Study | Treatment modality | Key outcome measures | Key results | Level of evidence | Downs and Black score |
Moser et al (2012)36 | Rest | Graded symptom checklist, computerised cognitive test battery (ImPACT) | Performance on ImPACT prerest and postrest demonstrated improved cognitive function (verbal memory, visual memory, processing speed) p=0.001 and total symptoms p=0.001. | 4 | 11 |
Moser et al (2015)33 | Rest | Graded symptom checklist, computerised cognitive test battery (ImPACT). | Significant difference between prerest and postrest scores in all four IMPACT composite scores (verbal memory p=0.004. Visual memory p=0.002. Reaction time p=0.006. Motor speed p=0.017 and in the total symptoms score (p=0.02). | 4 | 11 |
Gagnon et al (2009)16 | Subsymptom threshold activity | Graded symptom checklist, time to return to normal physical activity | All subjects were reported to recover (ie, return to normal lifestyle and sport participation). Mean duration of intervention=4.4 weeks (SD 2.6). | 4 | 5 |
Gagnon et al (2016)17 | Subsymptom threshold activity | Graded symptom checklist, Beck Depression Inventory, Paediatric Quality of Life Multidimensional Fatigue Scale, balance and coordination, computerised cognitive test battery (ImPACT). | Symptoms decreased between start of intervention and the 6-week follow-up assessment (p=0.004). Subjects recovered in a mean of 6.8 weeks (range of 2–15 weeks). | 4 | 9 |
Leddy et al (2010)23 | Subsymptom threshold activity | Graded symptom checklist, exercise duration, time to return to work/sport | Overall symptom reduction from baseline to post-treatment (p=0.002); all individuals were reported to have recovered at 1.6–16 weeks. Exercise time improved significantly from a baseline mean of 9.75 (6.38) min to 18.67 (2.53) min at treatment termination (p=0.001) | 4 | 10 |
Leddy et al (2013)24 | Subsymptom threshold activity | fMRI using a math task from the Automated Neuropsychological Assessment Metrics (ANAM), performance on ANAM, HR on treadmill test, number of symptoms on post-concussion symptom scale. | After treatment, the exercise group did not differ from healthy controls, but the stretching group had less activity in the cerebellum (p<0.05), the anterior cingulate gyrus and thalamus (p<0.001) than healthy controls. Following treatment, the exercise group had greater exercise HR (p<0.001) and less symptoms (p<0.0004) compared with stretching group. Cognitive performance did not differ by group or time. | 3 | 11 |
Kurowski et al (2016)21 | Subsymptom threshold activity | Graded symptom checklist | Patients in the active treatment group demonstrated a greater rate of symptom improvement than the stretching group (p=0.044). The effect size for the difference between the groups was moderate to large (Cohens d 0.81 across time points and 0.51 at week 7). | 2 | 23 |
Hugentobler et al (2015)34 | Physical therapy | Graded symptom checklist, clinical evaluation of the cervical spine, oculomotor screen and postural control assessment (BESS) | All patients had lower resting symptom severity at the final session. 4/6 patients made fewer errors on the BESS. Improvements were also observed in symptom scores, gaze stability, balance and postural control measures and patient self-management of symptoms. One patient had returned to full preinjury activity levels at the time of their final assessment. 4/6 had returned to preinjury levels within 3–6 months of discharge from physical therapy. | 4 | 4 |
Schneider et al (2014)11 | Physical therapy | Primary outcome = time to medical clearance to return to sport (as determined by blinded study sport medicine physician according to best practice guidelines). Secondary outcome measures=11 point Numeric Pain Rating Scale score, Activities-specific Balance Confidence Scale, Dizziness Handicap Index, SCAT2, Dynamic Visual Acuity, Head Thrust Test, modified Motion Sensitivity Test, Functional Gait Assessment, Cervical Flexor Endurance and Joint Position Error test. | 73% (11/15) in intervention group were medically cleared compared with 7% (1/14) of the control group. Individuals in the treatment group were 3.91 (95% CI 1.34 to 11.34) times more likely to be medically cleared to return to sport by 8 weeks when compared with the control group | 2 | 23 |
McCarty et al (2016)20 | Collaborative care including CBT | Primary outcome measures: graded symptom checklist, PHQ-9 to assess depressive symptoms, PROMIS-PA8 (version a) to assess anxiety symptoms, Paediatric Quality of Life Inventory (PedsQL), self-reported satisfaction with care | ‘Collaborative care’ group experienced clinically and statistically significant improvements in postconcussive symptoms in addition to functional gains at 6 months compared with ‘Usual care’. Six months after the baseline assessment, 13.0% of intervention patients and 41.7% of control patients reported high levels of postconcussive symptoms (p=0.03), and 78% of intervention patients and 45.8% of control patients reported≥50% reduction in depression symptoms (relative risk 1.71, 95% CI 1.05 to 2.79, p=0.02). No changes between groups were demonstrated in anxiety symptoms. Median number of CBT sessions=8 (range 0–12). 1/3 of patients received subsequent medications. | 2 | 23 |
Sohlberg and Ledbetter (2015)25 | Cognitive rehabilitation | Client selected functional goal | 83% of clients achieved self-selected functional goals | 4 | 3 |
Reddy et al (2013)18 | Amantadine | Graded symptom checklist, computerised cognitive test battery (ImPACT) performed at the time of initial assessment and 40–50 days postinjury | At the pretest the amantadine treated group were significantly lower than controls on verbal memory (p=0.007) and visual memory (p=0.04). and higher on total symptoms (p=0.01). Participants in both groups reported a decrease in symptoms and demonstrated improvement in verbal and visual memory, visual processing speed and reaction time scores from pre to post-test. Improvements were larger in the amantadine treatment group on verbal memory (p=0.07), visual memory (p=0.04) and total symptoms (p=0.01) | 4 | 12 |
Dubrovsky et al (2014)35 | Nerve blocks for persistent headache | Review of clinical history and patient satisfaction survey to assess response to injection; ‘good’ therapeutic effect defined as benefit sustained >24 hours and/or requested repeat injection, partial therapeutic benefit defined as benefit <24 hours. | Patients received 1–6 injections (mean 2.1), all patients reported reduction in headache intensity. Mean (SD) preinjection and postinjection headache scores were 5.6 (1.6) and 0.4 (0.9); 93% good therapeutic effect, 7% partial effect. 23/28 responded to the survey (82%), 83% recalled immediate relief of headaches, 61% indicated improved or resolved headaches in days to weeks following injection | 4 | 5 |
Bramley et al (2015)19 | Amitriptyline for persistent headache | Review of clinical history to assess response to medication | Median time to recovery=80 days for females versus 34 days for males, n=68 (17%) were prescribed amitriptyline— 82% (95% CI 70% to 91%) reported improvement in their symptoms, 23% (95% CI 12% to 38%) reported side effects. | 4 | 6 |
BESS, balance error scoring system; CBT, cognitive behavioural therapy; PHQ-9, patient health questionnaire 9; PROMIS, patient reported outcome measurement information system; RCT, randomised controlled trial; SCAT, sport concussion assessment tool; SRC, sport-related concussion.