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Commonly applied nonpharmacologic interventions such as physical exercise and psychological therapy are recommended for the treatment of persistent postconcussion symptoms (PPCS) but carry only weak scientific support for their use, according to a systematic review and meta-analysis published in JAMA Network Open. The findings from the study form the basis of guideline recommendations for the management of PPCS.
Most people who sustain a concussion tend to recover within the expected 2- to 3-week time frame, but those with PPCS continue to experience symptoms for more than 4 weeks after injury. PPCS symptoms include a combination of physical, cognitive, and emotional or behavioral symptoms, and can sometimes be tied to personality changes and difficulty with personal and professional identity. The effect of nonpharmacologic interventions on PPCS is uncertain and there are limited meta-analyses on the topic.
The objective of the current study was to evaluate and summarize the evidence for the efficacy of nonpharmacologic interventions in adults with PPCS and to inform clinical practice.
The study included a systematic literature review of interventional studies of interventions used for PPCS. The review was performed by a multidisciplinary guideline panel who selected interventions based on their use frequency and need for decision support among healthcare providers. These interventions included the provision of early information and advice, vestibular rehabilitation, graded physical exercise, psychological therapy, interdisciplinary coordinated rehabilitative treatment, manual treatment of the neck and back, and oculomotor vision treatment.
Overall, a total of 19 studies (n=2007) were included in the review. The researchers noted that evidence for 7 interventions ranged between “no evidence meeting the inclusion criteria to very low and low levels of evidence” supporting their use. Additionally, the researchers made weak recommendations for provision of early information and advice, vestibular rehabilitation, psychological therapy, graded physical exercise, manual treatment of the neck and back, as well as interdisciplinary coordinated rehabilitative treatment for PPCS treatment.
There was no relevant evidence for oculomotor vision therapy. They noted that it is good clinical practice to consider oculomotor vision therapy for patients with persistent visual symptoms following concussion.
A limitation of the study was its focus on only adult patients, thereby limiting the applicability of the findings across adolescents.
The researchers wrote that “given the best available evidence to date, and based on the findings of this systematic review and meta-analysis, active management and treatment of PPCS is recommended, both through individual disciplines targeting specific problems and through interdisciplinary rehabilitation.”
Rytter HM, Graff HJ, Henriksen HK, et al. Nonpharmacological treatment of persistent postconcussion symptoms in adults: A systematic review and meta-analysis and guideline recommendation. JAMA Netw Open. Published online November 9, 2021. doi:10.1001/jamanetworkopen.2021.32221