Running head: COMBINED CARE IN CONCUSSION TREATMENT

The Effect of Combined Mental Health and Physical Treatment on
Clinical Outcomes following Concussions in Adolescent/Young Adults

A DISSERTATION
Submitted to the Faculty of the School of Graduate Studies and Research of California
University of Pennsylvania in partial fulfillment of the requirements for the degree of
Doctor of Health Science (DHSc) in Health Science and Exercise Leadership

Patrick J. Smith

Research Adviser, Dr. Ellen West
California, Pennsylvania
2019
CALIFORNIA UNIVERSITY of PENNSYLVANIA
CALIFORNIA, PA

COMBINED CARE IN CONCUSSION TREATMENT

DISSERTATION APPROVAL

Health Science and Exercise Leadership

We hereby approve the Dissertation of

Patrick J Smith
Candidate for the degree of Doctor of Health Science (DHSc)

COMBINED CARE IN CONCUSSION TREATMENT

Acknowledgements
I’d like to thank all of those involved both directly and indirectly in my pursuit of
completing the Doctor of Health Sciences program. First, I’d like to thank my
dissertation committee of Dr. Tom West, Dr. Rebecca Hess, Dr. Anthony Kontos, and Dr.
Ellen West. Dr. West served as both a committee member and my research advisor. She
provided countless hours of revisions and advice and was accessible at all hours of the
day and night. All of you have contributed significantly to my understanding of my topic,
my understanding how to engage in research, and you have all supported me as I’ve
grown personally and professionally. Your expertise and knowledge have been incredibly
valuable and appreciated every step of the way.
Next, I’d like to thank the staff at the UPMC Concussion Research Lab,
especially Cyndi Holland, a Clinical Research Coordinator, Kara Viggiano who was also
a Clinical Research Coordinator at UPMC, and Dr. Anthony Kontos who is both a
Research Director at UPMC and a leading researcher across the world in the field of
concussion study. Because of their help, I was able to visit the site several times, observe
one of their doctors, and learn more about the process of concussion treatment in a
cutting-edge environment.
I’d also like to thank Dr. Melissa Sovak who continually provided support for the
statistical analysis of my research, who answered my questions at all hours of the day,
and who provided calm guidance when I was feeling overwhelmed. I am also grateful to
my classmates, who provided text message check-ins and continued support throughout

COMBINED CARE IN CONCUSSION TREATMENT

the program. I was truly impressed with how close I felt to all of them despite being so
far apart.
Lastly, but certainly not least, I’d like to thank my family for all their support
throughout this process. Every little thing helped, from my girlfriend Erin taking the dogs
outside while I was working, to my mother bringing over a casserole dish, to my father
helping me with yardwork, and to my son for watching movies on the couch with me
while I worked on my laptop. You have all made sacrifices to help me complete this
program that are too numerous to name. I am beyond grateful to all that you’ve done for
me.

COMBINED CARE IN CONCUSSION TREATMENT

Table of Contents
List of Figures…………………...................................................................i
List of Tables………………………………………………………………ii
Abstract…………………………………………………………………….iii
Introduction………………………………………………………………...1
Methods…………………………………………………………………….8
Research Design……….……………………………………………8
Operational Definitions……………………………………………..9
Data…..……………….…………………………………………….11
Treatment Groups…………………………………………………..12
Clinical Profiles……………………………………………………..15
Instruments……………………………………………………….…………17
Immediate Post-Concussion Assessment and Cognitive Testing…..17
Post-Concussion Symptom Scale………………………………...…20
Vestibular/ Ocular Motor Screening (VOMS)………………………21
Chart Abstraction Form……………………………………………..22
Data Collection Form…………………….….………......………..…22
Procedures…………………………………………………………..……….22
The Research Database………….…….……….…………...….…….23
Data Collection…………………………….….………......…………24

COMBINED CARE IN CONCUSSION TREATMENT

Data Analysis…………………………………….…..……...……….………25
Summary of Results……………………………….……….…....….……..27
Descriptive Data…………………………………………………...27
Treatment Group Comparisons……………………………………29
Clinical Profiles……………………………………………………30
General Discussion………………………………….………..……………35
Clinical Implications and Future Research………….……………………..42
Conclusion…………………………………………………………………44
References………………………………………………………………….46
Review of the Literature, Appendix A……………………………………..56
Assessment, Diagnosis, and Current Treatment Models…………...58
Prevalence………….…………………………………...….59
Protocols and Procedures…….…………………………….60
Population Differences……………………………..61
Assessment Tools…………………………………..62
Importance of Quick Response…………………….63
Currently Accepted Treatment Approaches………….…….64
Population Assessment in Concussion Management……………….67
Gender Differences in Concussion Recovery….……….…..68
Body Mass Index Differences……….……………...………69

COMBINED CARE IN CONCUSSION TREATMENT

High School versus College Athletes……….………………70
Diagnostic Tools……….……………………………………72
Active Recovery and Prescription of Physical Activity………….....76
Visual/Vestibular Treatments Post-Concussion Symptoms……...…79
Screening and Assessment….……………………………….79
Balance and Gait Treatment….……………………………..80
Visual Therapies….…………………………………………82
Cognitive Issues in Collaborative Care……………………………..84
Prevalence and Scope of Cognitive Issues…….……………85
Explanatory Style on Recovery……….…………………….90
Cognitive Behavioral Treatments….………………………..91
Executive Functioning Training in CBT…………....95
Psychological Referrals in Concussion Treatment….………97
Physical and Mental Health Collaborative Care…….………99
Psychoeducational Interventions in Collaborative Care….…101
Conclusion…………………………………………………………...104
Problem Statement, Appendix B…………………………………………….108
Additional Methodology, Appendix C………………………………………111
Appendix C1 ImPACT® Testing….…………….…………….……..112
Appendix C2 VOMS……………………………………………...…119
Appendix C3 Chart Abstraction Form……………………………....122
Appendix C4 Data Collection Form……...………………………….124

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C5 Sample Consent Form...………………………………126
Appendix C6 IRB Approval of Submission…………………………136
Appendix C7 Certificates of Training……………………………….140
References……………………………………………………...……………146

COMBINED CARE IN CONCUSSION TREATMENT
List of Figures

Figure
1

Title

Page

Days to recovery based on first visit PCSS insomnia score…..……32

COMBINED CARE IN CONCUSSION TREATMENT

List of Tables

Table

Title

Page

Descriptive statistics for sample……………………………..28

Gender and personal history per group..…………………….28

Distribution statistics for sample…………………………….29

Days to recovery per treatment group……………………….31

Clinical profile distribution per group……………………….31

Predictors to prolonged recovery…………………………….32

COMBINED CARE IN CONCUSSION TREATMENT

iii

Abstract
Concussions and traumatic brain injuries (TBI) are a major health concern, with an
average of 2-4 million concussions occurring in the United States each year (Langlois,
Rutland-Brown, & Thomas, 2006). Among these injuries, 79.6% required emergency
department care, 16.8% required admittance to a hospital, and 3.6% of these cases
resulted in death (Langlois, et al., 2006). Concussions are individualized with different
symptoms and impairments, which may be delayed or changing in presentation (McCrory
et al., 2017). Although many concussions resolve within a few weeks some involve longterm continued physical, behavioral, cognitive, and sleep symptoms (McCrory et al.,
2017). The purpose of this research was to investigate the hypothesis that a combined
physical and mental health treatment would be associated with a more rapid recovery
(i.e., resolution of symptoms) and improved cognitive outcomes. This causal-comparative
quasi-experimental design involved data from 29 adolescents and young adults (13
females, 16 males) aged 16-25 years with a sport-related concussion (SRC) between
January 2017 and December 2019. The deidentified data were accessed from an
electronic health records database at a concussion specialty clinic located in the midAtlantic region. The data of 25 patients who received only a physical health intervention,
consisting of dynamic or aerobic exertion therapies and sport-specific training as
clinically appropriate, formed the physical health treatment control group. The data of
four patients who received a combined mental health and physical health treatment
formed the mental health treatment group. The mental health treatment group received
both a physical and a mental health treatment consisting of dynamic or aerobic exertion

COMBINED CARE IN CONCUSSION TREATMENT

therapy or sport-specific training, and a targeted mental health treatment such as
cognitive behavioral therapy or psychiatric care as clinically appropriate. Results of an
ANOVA and generalized linear model indicated that subjects receiving the mental health
treatment recovered in 116.50 days (SD = 39.06), whereas the physical health treatment
control group recovered in 29.44 days (SD = 16.34) (p<.001, effect size [ES]= .25).
Initial reports of problems sleeping in both groups, as measured on the Post-concussion
Symptom Scale (PCSS) (p=.006), elevated second visit ImPACT® (p=.02) scores, VOMS
total scores (p=.01), and loss of consciousness (p=.02) were all significantly correlated
with a longer recovery. Other medical history and injury-related factors, such as a
personal history of migraine, concussion history, disorientation at time of injury, posttraumatic amnesia, and gender, were unrelated to recovery. These findings suggest that
differences in treatment groups’ symptoms and clinical presentation may indicate more
complex initial injuries that could be responsible for both the referral to mental health
treatment and prolonged recovery. Patients who experience mental health symptoms
post-concussion may be more likely to require specialized treatment and take longer to
recover.

COMBINED CARE IN CONCUSSION TREATMENT

Concussions are brain injuries caused by direct or indirect traumatic force to the
head, neck, or body that is transferred to the head that can lead to mental and physical
harm over a range of clinical presentations, including impaired brain functions and
disruptions in brain processes (McCrory et al., 2017). Concussions and traumatic brain
injury (TBI) are prevalent in contact and non-contact sports and occur in athletes of all
ages (Coleman, 2016). In the general population, the Centers for Disease Control and
Prevention (CDC) estimates that concussions were involved in 2.87 million emergency
room visits, hospital stays, or as a cause of death in 2014 (CDC, 2019; “TBI: Get the
facts,” 2017). Specifically, for individuals under the age of 18, it is estimated that 1.1
million to 1.9 million individuals incur a concussion from sports or recreational activities
(Bryan, Rowhani-Rahbar, Comstock, & Rivara, 2016). Each year, approximately 329,000
of these injured adolescents require treatment in emergency rooms for SRCs in the
United States alone (“TBI: Get the facts,” 2017).
In organized sports the injury rate of concussion can reach nearly one injury per
1,000 exposures to sport (Daneshvar, Nowinski, McKee, & Cantu, 2011). Because some
individuals seem to recovery quickly from concussions while others have prolonged
symptoms, recovery from concussions has been a topic of discussion in the news and
popular culture as several high-profile cases have arisen.
Concussions are unique injuries with some athletes recovering quickly and some
experiencing long-lasting effects (Coleman, 2016). These differences in recovery have
led researchers to investigate possible effects based on gender, body mass index (BMI),

COMBINED CARE IN CONCUSSION TREATMENT

and age. Some differences in athletes’ recoveries from concussions have been noted
across genders; these differences may be related to biological and situational factors such
as increased prevalence of migraines in females, increased rates of depression in
adolescent females, differences in use of coping skills, and less total neck mass to absorb
impacts that may cause concussions (Kontos, Elbin, Appaneal, Covassin, & Collins 2013;
Neidecker, Gealt., Luksch, & Weaver 2017). Early reports of certain symptomology may
be an indicator of prolonged recovery risk. Individuals reporting impairments in the
vestibular and oculomotor systems have lower scores on neurocognitive measures and
experience prolonged concussion recovery (Sinnott, Elbin, Collins, Reeves, Holland, &
Kontos, 2019). Other differences in recovery from concussions have been seen based on
BMI. Athletes who had a BMI less than 25 were more likely to have their concussive
symptoms return to baseline within two weeks from injury than those who had a BMI
over 30 (Lee, Wu, Zuckerman, Stanko, LaChaud, Solomon, & Sills, 2016). Nelson et al.
(2016) suggested that college athletes and high school athletes may experience similar
injury patterns and recovery due to recovery times between groups only varying based on
injury severity.
Athletes suspected of having a concussion must be appropriately assessed and
diagnosed so they may receive adequate and timely treatment. Numerous assessment and
diagnostic tools, including balance testing using the Balance Error Scoring System
(BESS), cognitive assessments such as the Sports Concussion Assessment Tool Third
Version (SCAT-3), and vision and ocular testing such as the King-Devick Test (Hobbs et

COMBINED CARE IN CONCUSSION TREATMENT

al., 2016) are commonly used. Additionally, to measure visual and ocular motor
impairment symptoms such as dizziness, balance problems, and gait issues, the
Vestibular and Ocular Motor Screening (VOMS) tool has been developed (Mucha et al.,
2014). It has been shown to be a valid and reliable tool and measures dysfunction in the
vestibular, vision, and somatosensory systems and can effectively distinguish between
concussed and non-concussed patients (Kontos & Collins, 2018; Mucha et al., 2014;
York, Smith, Babcock, & Alsalaheen, 2017). Also, the Glasgow Coma Scale (GCS) is
frequently used to measure baseline symptoms and consciousness (McLernon, 2014), and
Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) with PostConcussion Symptom Scale (PCSS) testing procedures have been shown to effectively
measure concussion symptoms in athletes (Allen & Gfeller, 2009; Elbin, Schatz, &
Covassin, 2011; Merritt, Bradson, Meyer, & Arnett, 2017).
Once a concussion is diagnosed, treatment referrals can be made. Evidence
suggests that physical rehabilitation programs can be beneficial in reducing concussion
symptoms of poor balance, poor cognitive functioning, and reduced perceived quality of
life in adolescents recovering from sport concussions (Chan et al., 2018). Vestibular
therapies have also been shown to reduce post-concussive symptoms, particularly
dizziness, nausea, poor balance, gait problems, and sensory processing errors in
adolescents and adults recovering from sport-related concussions (SRC) and non-athletic
concussions (Alsalaheen et al., 2010; Kleffelgaard, Soberg, Bruusgaard, Tamber, &
Langhammer, 2016; Kontos, Deitrick, Collins, & Mucha 2017). Visual therapies

COMBINED CARE IN CONCUSSION TREATMENT

(Alsalaheen, Mucha, Morris, Furman, & Sparto, 2013; Fimreite, Willeford, & Ciuffreda,
2016) and optometry interventions (Clark et al., 2017) have been shown to reduce postconcussive symptoms such as photosensitivity in adolescents and adults recovering from
concussions caused by both sport and non-sport experiences.
Additionally, mental health treatments have been shown to reduce the effects of
post-concussion symptoms in SRCs (Brown et al., 2014; Conder & Conder, 2015; WieseBjornstal, White, Russell, & Smith, 2015). Mental health treatments have also been
shown effective in reducing symptomology for those experiencing other TBI or brain
injuries not related to sports (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2009).
These interventions aim to reduce post-concussive symptoms to allow individuals to be
more functional in their daily lives. A link has been demonstrated between athletes
experiencing concussions and an increase in negative mental health symptoms afterwards
such as increased anxiety and depression (Vargas, Rabinowitz, Meyer, & Arnett, 2015).
Pre-existing conditions such as a history of repeated concussions, sustained through sport
or non-sport means, is a predictive factor for post-concussion depression in adolescents
(Chrisman & Richardson, 2014). Other pre-existing mental health conditions, such as
attention deficit hyperactivity disorder (ADHD) and depressive symptoms prior to injury,
may lead to more severe mental health symptoms following an SRC (Wiese-Bjornstal et
al., 2015). Additionally, adolescents with a personal history of somatization, or reporting
symptoms that cannot be fully explained through testing or diagnosis, are often slower to
recover from concussions (Root, et al., 2016).

COMBINED CARE IN CONCUSSION TREATMENT

Cognitive behavioral therapy (CBT) is a therapeutic psychological treatment
approach that aims to teach helpful patterns of behavior, coping skills for difficult
situations, and skills for recognizing thought distortions. CBT assists subjects in
reframing negative cognitions and is a treatment that can be used to treat symptoms of
depression and anxiety in various populations (“What is cognitive behavioral therapy?”,
2018). CBT and skills training have been shown to treat these common effects often
associated with delayed recovery from concussion; both athletes and non-athletes
engaging in these interventions have reported decreased depression, anxiety, improved
perceived quality of life, and increased confidence in their recoveries (Cantor et al., 2014;
Conder & Conder, 2015, Silverberg et al., 2013).
Collaborative care models are those that implement and coordinate treatment
between physical healthcare and mental healthcare and have been shown to reduce postconcussive symptoms in various populations (Asarnow, Rozenman, Wiblin, & Zeltzer,
2015; Makdissi et al., 2017; McCarty, Zatzick, Stein, Wang, Hilt, & Rivara, 2016). The
collaborative care model is not well-defined in the literature, but current research
suggests defining it as embedding mental health treatment interventions, such as CBT,
care management, and pharmacological consultation with physical interventions
(McCarty et al., 2016) or integrating behavioral health treatments into primary care
(Asarnow et al., 2015).
Researchers investigated the effects of a collaborative care intervention consisting
of teaching of coping skills, positive thinking skills, sleep hygiene, advocacy within the

COMBINED CARE IN CONCUSSION TREATMENT

school, and coordination of care among mental health and physical health providers
among adolescents experiencing post-concussion symptoms. These individuals receiving
a collaborative care treatment showed a reduction of symptoms more quickly than those
receiving physical health treatment, which consisted of consultation with a rehabilitation
specialist and submaximal exercise as appropriate (McCarty et al., 2016). Collaborative
care models have also shown promise in reducing high-risk behavior associated with
traumatic head injuries, such as weapon carrying and substance abuse when using CBT,
motivational interviewing, and educating primary care physicians (Asarnow et al., 2015).
The purpose of this research was to investigate the effects of a mental health
treatment intervention consisting of a combined mental health treatment and physical
health treatment on post-concussive symptoms in adolescents and young adults. The
hypothesis tested was that adolescents and young adults aged 16 to 25 who have
experienced a concussion and have participated in a combined mental health and physical
health treatment will recover more quickly from their post-concussive symptoms, as
measured on the ImPACT® and time to clearance, than those who received a physical
health intervention alone. Physical health treatments were referred to as “physical health
treatment” and included physical interventions such as working with an athletic trainer,
physical therapist, vestibular therapist, or receiving rest and gradual return to activity.
The mental health treatment group received physical treatment and was combined with
behavioral health interventions such as CBT, referral for psychiatric care, medication
management, cognitive skill building, or case management. A secondary research

COMBINED CARE IN CONCUSSION TREATMENT

purpose was to explore other group differences on select characteristics and clinical
profiles to help determine key clinical differences between groups that may also influence
time to recovery.

COMBINED CARE IN CONCUSSION TREATMENT

Methods

The following description of methodology will address details of the completed
research. This section consists of subsections including specific research design and
subject information. The research design subsection provides the rational for design,
strengths, and weaknesses of the completed research design. Additionally, the data and
treatment groups subsections discuss general characteristics and demographics of
subjects, sampling of subjects’ data, and details inclusion and exclusion criteria for
participation in the study. The methods section also details the instruments, procedures,
and data analysis used.

Research Design
This study involved a causal-comparative quasi-experimental design featuring a
between-subjects variable and a within-subjects variable. The independent variable,
which was the between-subjects variable, was type of treatment received, “mental health
treatment” or “physical health treatment.” The dependent variables, which were the
within-subjects variables, consisted of the initial scores on the six ImPACT®
neurocognitive tests identifying concussion symptoms and PCSS. Also included were the
ImPACT® and PCSS scores at time of clearance to return to normal activity, and number
of days from time from injury to clearance. Other factors included in the dependent

COMBINED CARE IN CONCUSSION TREATMENT

variables were gender, concussion history, migraine history, and if the concussion was
incurred during sports. This research design was used to establish relationships between
variables whereby the type of treatment used, a combined mental health and physical
health treatment or physical health treatment only, were tested for differences in time to
clearance to return to normal activity as determined to be clinically appropriate by the
treating clinicians, and computerized neurocognitive testing scores at initial appointment
and time of clearance.
For participants’ data to be included in this study, they must have been treated for
an SRC between January 2017 to December 2019. Participants whose data was chosen
for inclusion were between the ages of 16 to 25 years old at the time of injury. Data were
excluded for individuals outside of the targeted age group, those treated outside of the
specified timeframe, and for those with a psychiatric treatment history, including current
or past psychiatric medication and/or therapy, as assessed at intake. Examples of preexisting psychiatric needs included being engaged in mental health therapy at the time of
injury, personal history of psychiatric disorder, or previous history of using psychiatric
medications.

Operational Definitions
Concussion was defined as an injury resulting from direct or indirect traumatic
force that affects the brain and its subsequent processes, causes impairment of

COMBINED CARE IN CONCUSSION TREATMENT

functioning, and often results in inconclusive neuroimaging scans. A concussion is a
brain injury that can result in neuropathological changes that typically follows a
progressive course of recovery, but in some cases can result in continued post-concussive
symptoms. Common concussion symptoms include headache, mental fogginess,
behavioral or emotional changes, headache, nausea, loss of consciousness, and sleep
problems (McCrory et al., 2017).
For this study, physical health treatment referred to treatment including dynamic
or aerobic exertion therapies or sport-specific physical training. The type of physical
activity was an individualized and targeted approach for each subject’s unique needs
potentially including targeted vestibular or oculomotor therapy if clinically warranted.
The mental health treatment referred to the application of all the treatments
offered to the physical health treatment plus the addition of a targeted and appropriate
mental health treatment referral. Symptoms related to depression and anxiety were treated
using mental health treatment referrals to CBT, psychotherapy, psychiatric care, or
psychotropic medication management as clinically appropriate.
Both treatment groups also received a behavioral regulation treatment as clinically
appropriate. This intervention included tools for managing stress, sleep regulation,
nutritional and hydration support, and physical activity to improve knowledge. The goal
for this treatment was to increase awareness and individual ability to cope with
concussion symptoms (Kontos & Collins, 2018).

COMBINED CARE IN CONCUSSION TREATMENT

To properly compare the treatment groups through time, recovery from
concussion must be defined. Concussion recovery will be defined as the ability to return
to full athletic or academic demands based on a lack of symptomology or impairment and
measured by the return to baseline, or near baseline, on neurocognitive assessments
(McCrory et al., 2017). During this study, clinicians used the additional guidelines
discussed by Kontos and Collins (2018) in that patients must show improved assessment
scores immediately after exertion, and be able to show improvements following a
progressive, moderate cardiovascular activity and dynamic exercise treatment. Lastly,
patients must show improvements when considering their clinical profile assignment and
their daily tasks in which they must be functional before they received clearance to return
to normal activities.
Data
Data were selected from an existing database of those who received treatment at a
specialty concussion clinic in the mid-Atlantic region. Data for those who received a
physical health treatment at the clinic were referred to as the physical health treatment
group. Data for those who received a physical health treatment combined with a mental
health treatment after receiving a referral to a participating mental health provider site
were referred to as the mental health treatment group.
When diagnosed at the clinic, patients’ groupings were identified by six clinical
profiles depending on clinical presentation: vestibular impairment, oculomotor, cognitive

COMBINED CARE IN CONCUSSION TREATMENT

fatigue symptoms, post-traumatic migraine, cervical injury, and anxiety and mood
impairment (Collins et al., 2016, Kontos & Collins, 2018). At the time of diagnosis,
patients were assigned by their treating clinician to a primary, secondary, and tertiary
clinical profile depending on their symptomology and reported impairments. Because of
differences in symptoms, patients could also fall into multiple clinical profiles equally or
have more prominent profiles (Kontos & Collins, 2018). Clinical profiles were prioritized
by completing a thorough assessment of symptoms across multiple areas of impairment.
Although this presents a complex clinical challenge, it allows clinicians to document
symptoms and risk factors relevant to providing treatment (Kontos, Sufrinko, Sandel,
Amami, & Collins, 2019).

Treatment Groups
The following sections provide detail about two groups of data studied in this
research; included is how data were selected for each group, common symptomology,
and the types of treatments typically provided in each group.
Physical health treatment. A physical health treatment group, consisting of data
from individuals receiving physical rehabilitation only or rest and gradual return to
activity as clinically indicated was chosen from the database. All patients whose data
were collected in the database were prescribed targeted and individualized therapies to
assist with their specific symptoms and clinical presentation. These individualized

COMBINED CARE IN CONCUSSION TREATMENT

therapies used an interdisciplinary approach and could have included vestibular
treatment, oculomotor treatments, dynamic and aerobic exertion therapies, or sportspecific trainings depending on symptomology and clinical presentation.
Additionally, all patients were expected to participate in a physical intervention as
part of the treatment for their concussion symptoms regardless of their clinical profile
assignment. This could have included, depending on clinical presentation of the athlete,
aerobic exertion therapy or dynamic exertion therapy. Clinicians assigned treatment
based on what is most relevant to the athlete’s goals and safety needs. The aerobic
exertion therapy was individualized for each patient based on his or her fitness level and
ability to tolerate exercise, and could include activities such as running, cycling, or using
an elliptical (Kontos & Collins, 2018). The dynamic exertion training treatment was
designed to mimic the demands athletes will experience during competition and prepare
them for return to sport as their symptoms allow. Dynamic exertion training was
performed with a licensed physical therapist and consisted of 30 minutes of moderately
intense cardiovascular exercise, such as cycling, and progressed to whole body exercises
including lunges and medicine ball rotations. If patients progressed through these tasks,
they began functional dynamic exertion training designed to simulate sport-specific
demands and to tax the cardiovascular, vestibular, and visual systems of the patient
(Kontos & Collins, 2018).
In addition to aerobic or dynamic exertion treatment, all patients at the concussion
specialty clinic received behavioral regulation treatment. The components of the

COMBINED CARE IN CONCUSSION TREATMENT

behavioral regulation treatment are stress management, sleep regulation, nutritional and
hydration support, and physical activity (Kontos & Collins, 2018). This aspect of
concussion treatment is aimed at delivering education, improving awareness, and
improving positive coping skills to help patients and their families manage concussions
and symptoms in a healthy manner.
Mental health treatment. The data for those diagnosed with a psychological
issue were identified for inclusion to the mental health treatment group due to being
referred to a mental health treatment for treatment of their symptoms. The presenting
mental health issues, along with a referral to a mental health treatment, are the primary
differences between groups; however, groups may vary in their predisposition to mental
health symptomology or coping response (Sandel, Reynolds, Cohen, Gillie, & Kontos,
2017). Therefore, the presentations of symptomology of those in the mental health
treatment group were likely more complex and clinically acute than those in the physical
health treatment only group.
All primary clinical profiles were considered for inclusion if the patient was
referred to a mental health treatment by a psychiatrist or other mental health professional
including CBT and related therapies. Those who were selected for the mental health
treatment group were also expected to participate in a physical health intervention as
described above.

COMBINED CARE IN CONCUSSION TREATMENT

Clinical Profiles
The following sections provide specific detail regarding the clinical profiles
assigned at the concussion specialty clinic which includes common symptomology and
clinical approaches. Assignment to treatment groups, physical health treatment or mental
health treatment, was determined based on clinical profiles and treatment referrals. Of
note, more than one clinical profile could be assigned for each person of either treatment
group.
Vestibular impairment. Physical interventions were completed with patients of
all clinical profiles; however, the clinical profile assignment influenced what specialized
treatments were performed. The vestibular impairment profile often consisted of
symptoms involving visual motion sensitivities, problems maintaining gaze, dizziness,
and slowed reaction speed. Treatments for those in the vestibular profile included aerobic
or dynamic exertion therapy, dual task attention exercises, sensory orientation training,
and practice processing visually demanded environments as clinically appropriate
(Kontos & Collins, 2018).
Oculomotor impairment. Common symptoms in the oculomotor profile were
visual convergence problems, blurry vision, and trouble reading. Typical treatments for
the oculomotor profile included aerobic or dynamic exertion therapy, visual therapies

COMBINED CARE IN CONCUSSION TREATMENT

such as visual convergence training, shifting visual focus from near objects to far objects,
and saccadic eye movements (Kontos & Collins, 2018).
Cognitive fatigue. The cognitive fatigue profile is characterized by fatigue and
drowsiness, headache, and symptoms that worsen with employment or academic tasks.
Concentration and attentional problems also occur with this profile. Common treatments
for the cognitive fatigue profile included aerobic or dynamic exertion training and
neurostimulant prescription (Kontos & Collins, 2018).
Post-traumatic migraine. Symptoms typical of the post-traumatic migraine
profile included headache, nausea, sensitivity to light or sound, and sometimes dizziness
or vision problems. Common treatments for the post-traumatic migraine profile included
aerobic or dynamic exertion therapy, prescription of psychotropic medications
specifically tricyclics, selective serotonin reuptake inhibitors, and anticonvulsants
(Kontos & Collins, 2018).
Cervical injury. The cervical injury profile typically presents with injury to the
neck area because of the force associated with the concussion injury. Patients
experienced pain in the neck and head, numbness, or tingling. Patients in this profile
often experienced less functional impairment that the other clinical profiles. Typical
treatments included aerobic or dynamic exertion therapy, acupuncture, biofeedback,
medications, or potentially surgery as deemed clinically appropriate (Kontos & Collins,
2018).

COMBINED CARE IN CONCUSSION TREATMENT

Anxiety and mood. The anxiety and mood clinical profile typically presented
with anxiety and depression as evidenced by excessive worry, intrusive thoughts, sleep
problems, racing thoughts, loss of energy, feeling overwhelmed or hopeless, and
irritability. Patients in this profile were often treated with aerobic or dynamic exertion
therapy, CBT, psychotherapy, psychiatric referral and medications, mindfulness training,
or art and music therapies (Kontos & Collins, 2018).

Instruments
Four instruments were used for this research, the ImPACT® test and it’s PCSS
subscale (Appendix C1), the VOMS (Appendix C2), a Chart Extraction Form (Appendix
C3) used by the concussion specialty clinic to extract the blinded subject data, and a Data
Collection Form (Appendix C4) for the secondary analysis of data for this research. The
ImPACT® test, PCSS subscale, and VOMS were used to collect data. The demographic
data were captured on the ImPACT® initial visit.

Immediate Post-Concussion Assessment and Cognitive Testing®. At the
concussion specialty clinic, concussion symptoms were assessed and scored using the
Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) which
included six subscales and the Post-Concussion Symptom Scale (PCSS). The ImPACT®
was delivered in an electronic format which was used at initial contact with subjects upon

COMBINED CARE IN CONCUSSION TREATMENT

each visit to the concussion specialty clinic. This computerized neurocognitive test takes
about 30 minutes to complete and collects demographic and medical histories before
moving on to the six neurocognitive tests that generate the clinical profile (Appendix C1)
(Solomon, 2011). It is common practice for these tools to be used by athletic training
and/or sports medicine staff to gather baseline data and at periodic intervals during
treatment of a concussion to determine when an athlete is ready to return to play
(Covassin, Elbin, Stiller-Ostrowski, & Kontos, 2009).
The demographic data collected included height, weight, age, name, organization,
dominant hand of the participant, gender, and education history including history of
special educational needs (Solomon, 2011). Next, a medical history was gathered by the
treating clinicians. Medical data gathered included history of seizures, epilepsy, surgery
on the brain, history of brain infections such as meningitis, previous psychiatric care, and
previous treatment history for substance use disorders (Solomon, 2011).
The first neurocognitive test involves word discrimination. Each participant
rapidly viewed five sets of words and identified the target word. This test evaluated
attention and verbal recognition in short-term memory (Solomon, 2011). The second test
followed a similar format but asked subjects to remember shapes instead of words to test
visual recognition and attention (Solomon, 2011). The third test examined visual working
memory, visual processing, and performance when faced with distraction tasks. The test
involved four trials of randomly placed x and o letters that the participant must recall, and
then a reaction speed test (Solomon, 2011). The fourth test evaluated short-term memory

COMBINED CARE IN CONCUSSION TREATMENT

and processing speed using symbol matching (Solomon, 2011). The fifth test, consisting
of matching colors and color words, tested impulse control and reaction speed in the
participant (Solomon, 2011). The sixth and final test focused on working memory and
processing speed by asking the participant to click on the numbers in reverse order,
followed by a letter recollection exercise (Solomon, 2011).
Composite scores are generated for verbal memory, visual memory, reaction time,
processing speed, and impulse control scores as well as a total symptoms score. Test
results show the number of scores correctly answered and increase or decrease in
percentage of correctly answered questions in the composite scores (ImPACT®
Applications, Inc, 2007). The cognitive efficiency index is also generated, which
compares speed of response to percentage of correct answers to determine if the
participant is trying to work quickly or is focusing on accuracy (ImPACT® Applications,
Inc, 2007). The scores are generated at each visit to the concussion specialty clinic and
are used to help inform assignment to clinical profiles. These clinical profiles are used by
clinicians to provide targeted treatment for specific symptomology.
To demonstrate reliability of the ImPACT® scale, researchers have assessed high
school student athletes scores to determine test and retest reliability (Elbin et al., 2011). A
total of 369 high school varsity athletes were given the ImPACT® scale as a preseason
testing protocol over a two-year period. The researchers compared the results of the
preseason testing and found moderate to high reliability (ICC.569-.851 for scores) for the

COMBINED CARE IN CONCUSSION TREATMENT

ImPACT® scale (Elbin et al., 2011). Highest reliability was reported for motor processing
speed, reaction time, and visual and verbal memory (Elbin et al., 2011
The validity of the ImPACT® scale has also been tested against another
commonly used tool, the National Football League’s (NFL) neuropsychological testing
battery (Allen & Gfeller, 2009). One hundred subjects completed both testing methods,
with half of the group completing the ImPACT® first and the other half completing the
NFL battery first. The researchers found correlations across tests for verbal memory
components, visual motor speed, and reaction time (Allen & Gfeller, 2009). These
findings suggest that the ImPACT® scale presented in an electronic format demonstrates
validity similar to accepted pencil and paper assessments like those used in the NFL
battery (Allen & Gfeller, 2009).
Post-Concussion Symptom Scale (PCSS). The PCSS is a 22-item selfreported symptoms scale that is included as part of the ImPACT® test. The PCSS is used
to track concussion symptoms such as dizziness, trouble sleeping, nausea, difficulty
remembering, drowsiness, and sensitivity to light and sound. The PCSS asks participants
to rank their symptoms experienced in the past 24 hours on a scale of 0 (none) to 6
(severe) (Solomon, 2011). The PCSS is also administered in an electronic format at initial
contact and with subjects each time they visited the specialty concussion clinic for
treatment. The measures within the PCSS, such as cognitive symptom cluster, physical
symptom cluster, and affective system cluster showed moderate to low reliability (ICC
.765, .441, .494) (Merritt et al., 2017). The ImPACT® and PCSS subscale used together

COMBINED CARE IN CONCUSSION TREATMENT

have been shown to have high test-retest reliability when used at different testing points
across time (p<.01) (Merritt et al., 2017). The ImPACT® scale and PCSS subscale
together have also demonstrated validity in its ability to differentiate between those
athletes who have been diagnosed with a concussion and those who have not with 81.9%
sensitivity and 89.4% specificity (Schatz, Pardini, Lovell, Collins, & Podell, 2006).
Vestibular/Ocular Motor Screening (VOMS). The VOMS tool was developed
to assess vestibular and oculomotor symptoms and impairment following a concussion
(Appendix C2) (Mucha et al., 2014; York et al., 2017). The VOMS measure includes 1)
smooth pursuits, 2) saccades (horizontal, vertical), 3) near point convergence (NPC)
distance, 4) vestibulo-ocular reflex (VOR) (horizontal, vertical), and 5) visual motion
sensitivity (VMS). The tool takes between five and seven minutes to administer and
assesses symptom provocation following each item on headache, dizziness, nausea, and
fogginess using a 0-10 Likert-type scale following each item (Mucha et al., 2014). The
VOMS generates seven item symptom provocation scores and includes an average
measure of NPC across three trials. VOMS clinical cut-offs are greater than or equal to
two on any symptom provocation item and greater than or equal to 5cm on average NPC
distance (Mucha et al., 2014). York et al. (2017) showed that the VOMS has a high level
of test-retest reliability when completed in a within-subjects design (ICC = .95, p<.001).
The VOMS can accurately identify concussion from controls in 89% of cases (95% CI,
p<.001) (Mucha et al., 2014).

COMBINED CARE IN CONCUSSION TREATMENT

Chart abstraction form. The chart abstraction form is a paper document created
by the concussion specialty clinic (Appendix C3). This form is completed by a worker at
the lab when a researcher wishes to obtain data from the patient database. One form is
completed per patient dataset within the database. This form prevents external researchers
from accessing patient-identifying information such as name, date of birth, address, etc.
The form allows the concussion specialty clinic worker to document ImPACT® and
PCSS scores, VOMS scores, mental health and concussion history, visit number, clinical
profiles, treatment referrals, and time to clearance to be transferred to researchers.
Data collection form. The data collection form was developed by the researcher
to organize data gathered from the concussion specialty clinic into a meaningful and
workable format (Appendix C4). The data collection form compiled all data gathered
across the numerous chart abstraction forms into one password-protected Excel
workbook which was entered into data analysis software.

Procedures
The researcher attended meetings at the concussion specialty clinic with the
research director and clinical research coordinator to discuss feasibility and opportunities
for research. These meetings and verbal discussion resulted in the development of a
research proposal that outlined the steps taken to gather data and ensured proper analysis
would be conducted to test the hypothesis. Once the proposal was reviewed, an

COMBINED CARE IN CONCUSSION TREATMENT

Institutional Review Board (IRB) request was submitted to the university associated with
the concussion specialty clinic. After approval by the IRB and the California University
of Pennsylvania IRB (Appendix C6), the data for this study were collected via a database
at the concussion specialty clinic located in the mid-Atlantic region. Following approval
of the IRB requests, a formal request for records, which described the information to be
collected including details of the inclusion and exclusion criteria for patient records, was
completed and submitted to the concussion specialty clinic. The data for this secondary
analysis were collected onto Chart Abstraction Forms (Appendix C3) for each set of
subjects’ data by a researcher at the concussion specialty clinic. The dataset was then sent
electronically to the researcher via the Data Collection Form (Appendix C4) in a
Microsoft Excel format for analysis.
The research database. The database contained the subjects’ entire medical
records, including demographic information, past relevant medical history, treatment
plan, referral information, and computerized neurocognitive testing scores. The
ImPACT® and PCSS subscale were performed via an electronic testing format taking
approximately 30 minutes that provided an electronic memory, motor speed, reaction
control, impulse control, total symptom score, and delivered a clinical profile to the
treating clinician (ImPACT® Applications, Inc., 2007). The tests were automatically
scored in the electronic format and produced a detailed clinical report of demographic
information and neurocognitive data points (ImPACT® Applications, Inc., 2007).
Information and scores contained in the database were censored of any identifying

COMBINED CARE IN CONCUSSION TREATMENT

information to the researcher. Information that was removed included name, date of birth,
address, insurance and billing information, and any recurrences of this information
throughout the record. This task was completed by a concussion specialty clinic
researcher using the chart abstraction forms.
Data collection. A convenience sample of subjects’ data was selected by a
researcher from the database center for patients who received treatment for SRC from
calendar year 2017 to 2019 for individuals between the ages of 16-25 years old at the
time of initial concussion injury. Exclusion criteria was individuals outside of the target
age group or with pre-existing psychiatric needs identified during intake, such as being
prescribed psychiatric or behavioral health medication, or being in mental health therapy
at the time of injury. Only 4 sets of data matched the criteria for the intervention group
and were included in the sample. The convenience sample of those meeting criteria for
the physical health treatment group was generated by a researcher at the concussion
specialty clinic and resulted in 25 sets of data being included. Subjects had already
completed consent to engage in research (Appendix C5) upon beginning treatment at the
facility.
Subjects’ data were deidentified by a researcher at the concussion specialty clinic
of any patient identifying information. Data were then recorded onto a Chart Abstraction
Form (Appendix C4) by a team member and uploaded electronically into the Data
Collection Form (Appendix C5), which was a secure Microsoft Excel spreadsheet. In this
manner, patient-identifying information was not viewed and did not leave the facility as

COMBINED CARE IN CONCUSSION TREATMENT

per the facility’s policies and procedures. Data collected consisted of computerized
neurocognitive testing scores and VOMS scores at the initial appointment and at time of
clearance, number of days to return to play, and referrals as outlined on the Chart
Abstraction Form (Appendix C4). The Chart Abstraction Form also recorded loss of
consciousness, disorientation, confusion, ADHD symptoms, personal and family histories
of migraine, motion sickness, ocular disorders, personal and family histories of anxiety
and depression, and previous concussion history. The form also detailed the clinical
profiles assigned to each data set.

Data Analysis
The following subsection is an outline of the metrics and techniques used to
analyze the data collected. This research aimed to investigate the overriding hypothesis
that adolescent and young adults aged 16-25 receiving a combined treatment consisting
of a mental health and physical health care would have a faster resolution of postconcussion symptoms as measured by time to clearance to return to normal activity and
scores on computerized neurocognitive testing tools. The independent variable was type
of treatment received, mental health treatment or physical health treatment, was not be
manipulated by the researcher. The dependent variables were the within-subjects
variable, which included repeated measure scores on the computerized neurocognitive

COMBINED CARE IN CONCUSSION TREATMENT

testing for total composite and six subscales, PCSS, VOMS, and time to recovery as
measured by the number of days until the individual was cleared to return to normal
activity.
Data were represented and summarized using standard techniques, including
descriptive statistics. Analysis of data using a repeated measures ANOVA was completed
to compare the within-subjects’ data, including total composite scores on the
computerized neurocognitive tool to compare improvements within subjects over time
and between-subjects’ data, including differences in scores seen across interventions as
well as number of days until clearance to return to activity. A significance level of α = p
≤ 0.05 was used for all quantitative analyses. Effect sizes were calculated for any
differences found between groups to gain perspective on differences seen across groups
and to limit Type I and Type II errors. Effect sizes were used in conjunction with
significance testing to help determine the power of this study. In doing so, data were
properly analyzed to identify potential changes over time across groups.

COMBINED CARE IN CONCUSSION TREATMENT

Summary of Results

Descriptive Data
A convenience sample was extracted from the database which resulted in 29
records being included. The physical health treatment group, consisting of 25 patients’
data, represented an age range of 16-19 years old, with a mean age of 16.96 (SD = .98)
years, and included 10 (40%) females and 15 (60%) males. All participants were being
treated for SRC. The physical health treatment group attended a mean of 2.6
neuropsychiatric visits (SD = .86), with a minimum amount of 2 visits, and a maximum
number of 5 visits (Table 1). The mental health treatment group (four total) consisted of
three females’ data and one male’s data with subjects aged 16-18 years old, with a mean
age of 17 (Table 2). The mental health treatment group attended a mean number of 4.5
neuropsychiatric appointments (SD = 2.38) with a minimum of 2, and a maximum of 7
visits. The mental health treatment group and physical health treatment group did not
significant differ in distribution of traits for age (p=.93), gender (p=.26), or days from
injury to first visit (p=.51, Table 3).

COMBINED CARE IN CONCUSSION TREATMENT

Table 1. Descriptive statistics for sample
Physical Health Treatment
Variable

Mean SD

Min

Max

Visits

2.6

.86

Days to recovery

29.4

16.34

Age

16.9

1.01

Days from injury to

7.9

4.16

Mental Health Treatment
n

Mean SD

Min

Max n

4.5

2.38

116.5

39.06

164

.81

8.16

First visit

Table 2. Gender and personal history per group
Physical Health Treatment

Mental Health Treatment

Variable

N=25

N=4___________

Gender

10 female, 15 male

3 female, 1 male

Concussion history

6 yes, 19 no (24% prevalence)

2 yes, 2 no (50% prevalence)

Migraine history

7 yes, 18 no (28% prevalence)

1 yes, 3 no (25% prevalence)

COMBINED CARE IN CONCUSSION TREATMENT

Table 3. Distribution statistics for sample
Physical Health
Treatment
Mental Health Treatment

p = .93

Physical Health
Treatment
Mental Health Treatment

p=.26

Physical Health
Treatment
Mental Health Treatment

p=.51

Treatment Group Comparisons
A one-way between subject’s ANOVA was conducted to compare the effects of a
mental health treatment on the amount of days to recovery. There was a significant effect
of treatment received on the days to recovery [F (1,27)=64.23, p=<.001]. The results
showed that the group receiving mental health treatment recovered in 116.50 days (SD =
39.06) and required an average of 4.5 visits (SD = 2.38). The physical health treatment
group recovered in 29.44 days (SD = 16.34) and attended a mean of 2.6 appointments
(SD = .86). The physical health treatment group attended the first treatment appointment

COMBINED CARE IN CONCUSSION TREATMENT

an average of 7.9 days after a concussion (SD = .416), and the mental health treatment
group attended the first treatment appointment an average of 11 days after a concussion
(SD = 8.16). These findings were not statistically significant towards days to recovery
(p=19).
These findings do not support the hypothesis that those receiving a mental health
treatment would recover more quickly than those receiving physical health treatment.
Effect sizes were calculated using a difference of means between groups. The finding
supported a small effect size of .25 (Table 4).

Clinical Profiles
The physical health treatment group had a primary assignment to the posttraumatic migraine clinical profile (14), with the vestibular profile receiving the second
most frequent assignment (6). The most common secondary profile assignment for the
physical health treatment group was vestibular (4). The mental health treatment group
had a primary assignment to the vestibular profile (3), with a secondary profile of posttraumatic migraine being the most common (3, Table 5). This highlights differences seen
across groups regarding clinical presentation and assignment of treatment.

COMBINED CARE IN CONCUSSION TREATMENT

Table 4. Days to recovery per treatment group
Group

Mean

Min

Max

Physical health treatment

29.4

16.34

Mental health treatment

116.5

39.06

164

Table 5. Clinical profile distribution per group
Physical Health Treatment (n=25)
Primary Profile (n)

Secondary Profile (n)

Mental Health Treatment (n=4)
Primary Profile (n)

Secondary Profile (n)
PTM (3)

PTM (14)

Vestibular (4)

Vestibular (3)

Vestibular (6)

Ocular (2)

Anxiety/Mood (1)

Additional findings. A generalized linear model was completed to analyze if
other items were related to time to recovery. Sleep issues were investigated first,
specifically trouble falling asleep, hypersomnia, and insomnia for both groups across the
first and second visit. Those in either treatment group who reported trouble sleeping on
the PCSS at the initial visit experienced a longer recovery time (Figure 1) than those who
did not (p=.006), but insomnia symptoms were not significant if reported at the second
visit (p=.162).

COMBINED CARE IN CONCUSSION TREATMENT

COLLABORATIVE CARE IN CONCUSSION TREATMENT

Figure 1. Days to recovery based on first visit PCSS insomnia score

The model demonstrated that the second visit PCSS total score was significantly
related to days to recovery (p = .02), and the second visit VOMS total score was
significantly related to a longer recovery (p = .01). These details align with the research
supporting the VOMS tool and its ability to differentiate between concussed and nonconcussed patients (Kontos & Collins, 2018; Mucha et al., 2014; York, Smith, Babcock,
& Alsalaheen, 2017). Continued symptom reporting on the VOMS may be indicative of
underlying neurological issues that may prolong concussion recovery (Clark et al., 2017).
Loss of consciousness was significantly related to time to recovery (p=.02) and may be
indicative of more severe concussion injuries. Disorientation was not significantly related
to days to recovery (p=.95), and neither was personal history of migraine (p=.42), motion
sickness history (p=.32), post-traumatic amnesia (p=.91), nor personal concussion history

COMBINED CARE IN CONCUSSION TREATMENT

(p=.56). Reports of confusion were also not significantly related to recovery (p=.77), and
neither was age (p=.52) nor gender (p=.22, Table 6).
In addition, a stepwise linear model was completed to determine if the order of
variable entry influenced the relationships seen above. The stepwise regression was
calculated to review relationships between the type of treatment received, computerized
neurocognitive testing total scores, and VOMS total scores across visit one and two to see
which variables were most directly related to prolonged recovery. A significant
regression equation was found for the type of treatment only (R2= .704, F(4,29) =64.23,
p<.0001) suggesting type of treatment received was biggest predictor of recovery. This
analysis was completed to minimize Type I and Type II errors.

COMBINED CARE IN CONCUSSION TREATMENT

Table 6. Predictors to prolonged recovery.
Variable

Wald’s 95% Confidence

P_Value

Migraine history

.17

.42

Concussion history

.34

.56

Disorientation

.00

.95

Confusion

.08

.77

Motion sickness history

.98

.32

Age

.08

.52

Gender

.05

.22

Visit 1 PCSS total

.004

.85

Visit 1 VOMS total

.003

.76

Visit 2 PCSS total

.23

.02*

Visit 2 VOMS total

.27

.01*

Post-Traumatic Amnesia

.01

.91

Loss of Consciousness

5.33

.02*

*Those indicated with an asterisk are significant correlations

COMBINED CARE IN CONCUSSION TREATMENT

General Discussion

The research conducted showed that on average the adolescents and young adults
who were clinically appropriate to receive mental health treatment as part of their
concussion treatment experienced prolonged recovery. These findings may highlight a
clinical difference between the two groups. Those who were deemed appropriate for an
additional mental health treatment likely experienced worse or more complex symptoms
and may have required more time to return to baseline measurements than the group who
did not have mental health needs. It is likely that in comparing these two treatment
groups, two distinct patient groups were identified that had differing needs, and this key
difference is what drove recovery time.
The primary finding supported a statistically significant group difference that did
not support the proposed hypothesis (i.e. patients referred to mental health treatment
combined with a physical health treatment modality would experience a quicker recovery
as evidenced by fewer days reported to recovery). The small effect size, uneven group
design, and underpowered sample size were limiting factors in this study, which must be
considered when reviewing results. Each treatment group was clinically appropriate for
the treatment referral they received as assessed by their treating clinicians, which
demonstrates a difference in group symptom presentation. Because of this, it is likely that
the mental health treatment group presented with more severe concussion symptoms and
required the extra mental health treatment. This difference in the groups’ symptoms is

COMBINED CARE IN CONCUSSION TREATMENT

also responsible for a lack of support of the hypothesis because those with more severe
symptoms, and those requiring more treatment, are likely to take longer to recover from
their symptoms.
The statistical evaluations showed that common influencers of concussion
recovery, such as reported symptoms of disorientation, post-traumatic amnesia,
confusion, history of migraine, and concussion history, did not significantly influence
results. Concussions that presented with a loss of consciousness, elevated secondary total
scores on the computerized neurocognitive testing, and elevated VOMS scores were
related to prolonged recovery from concussion and are to be expected as they likely
indicate more severe injuries and that some individuals are continuing to experience
symptoms impacting their functioning. High initial symptom reporting after a concussion
has been linked to prolonged recovery (McCrory et al., 2017) and without a significant
improvement these symptoms are likely to be reported on follow up testing. Additionally,
Kontos et al. (2019) suggested that clinical profiles have complex interactions with each
other, and those patients experiencing mental health symptoms can be challenging to treat
because they lack awareness of psychological symptoms and how they influence
perception and presentation of symptoms. Similarly, distribution of clinical profiles
aligned in that post-traumatic migraine was the most common clinical profile and the
vestibular impairment profiles also occurred frequently.
This study also aligns with research completed regarding symptom reporting.
Other researchers have found that subjects reporting continued symptoms on the VOMS

COMBINED CARE IN CONCUSSION TREATMENT

between 10-20 days after initiating treatment were more likely to have prolonged
concussion recoveries (Sinnott, Elbin, Collins, Reeves, Holland, & Kontos, 2019). This
implies that additional neurological factors may be contributing to prolonged recovery.
Clark et al. (2017) suggested that those with persistent sensory problems may have
damage to the neurological pathways or other complex sensory processing issues. The
VOMS may have identified these issues common in prolonged recovery. Because these
symptoms were directly addressed in treatment, some symptoms of vestibular and
oculomotor problems may have been exacerbated during treatment, especially early in
treatment as seen by Kleffelgaard et al. (2016).
Insomnia reported on the PCSS at the initial visit was also linked to prolonged
recovery from concussion and may be related to high initial symptom presentation. This
is important to note as Kontos and Collins (2018) reported that sleep issues can improve
with concussion symptoms, or can become problematic and persist throughout treatment,
thus inhibiting recovery from concussion. Because of this, it is important to identify and
treat sleep issues early. Additionally, individuals who have a history of somatization have
been shown to have prolonged concussion recoveries (Root et al., 2016). This factor may
have been more common in patients experiencing mental health symptoms, as subjects
could have potentially misinterpreted or experienced their mental health symptoms in a
physical manner. This interaction was reflected in the findings, as mental health
symptoms were present in patients with a vestibular clinical profile in the mental health
treatment group.

COMBINED CARE IN CONCUSSION TREATMENT

The data may provide additional validation to the Clinical Profiles Treatment
Model suggested by Kontos and Collins (2018). These researchers suggested conducting
a comprehensive assessment following injury and accurate assignment of clinical profiles
most closely matching symptoms. In their model, those who are not experiencing
nervousness, anxiety, sadness, depression, or other mood disturbances would not be
referred to receive a mental health intervention. The researchers noted the difficulty
treating mental health symptoms and that many of the medications discussed for
treatment require weeks or months to demonstrate efficacy (Kontos & Collins, 2018).
Because of the prolonged recovery of those in the mental health treatment group, it is
possible that these subjects experienced this issue related to recovery. This research may
provide additional support for the assignment to mental health treatment based on
increased needs. Similarly, it appears that those who did not require additional mental
health treatments were accurately identified and assigned to the proper group as
evidenced by their quicker recoveries. Additionally, this research suggests that
underlying neurological problems may exist in those assigned to mental health treatment
as evidenced by continued symptom reporting and higher scores on the VOMS. This
finding aligns with problems identified by Sandel et al. (2017) that suggest neurological
changes following SRC may overlap with mood disorders and can lead to longer
recoveries.
Limitations/strengths. The use of pre-existing healthcare data is often used in
research due to available data and ethical concerns regarding assignment of treatment. A

COMBINED CARE IN CONCUSSION TREATMENT

strength of this type of research included that when there are existing databases, with
consent, researchers can use this data to observe and analyze relationships among
variables without intervention. An additional strength of the research design is that it
allowed this researcher to look at longer time periods without having to wait for the
duration of treatment to occur for those whom have already completed treatment.
There were several limitations to this research. This causal-comparative quasiexperimental design did not feature a random assignment to treatment types, and
therefore cannot be used to determine cause and effect but can simply highlight
correlations in the existing data. Additionally, the target sample size was 25 for the
physical health treatment group and 25 for the mental health treatment group. However,
although the goal of 25 for the physical health treatment group was achieved, only four
patients fitting inclusion criteria were located for the mental health treatment group.
Additionally, the specific types of treatment received by the two groups were not
measured. The research database only captured neuropsychological visits at the
concussion specialty clinic and did not track compliance with physical health or mental
health treatments. Also, differences in types of treatment received were not measured (i.e.
CBT compared to psychotropic medications in the mental health treatment group).
Despite finding a significant relationship, the small effect size and small sample was
insufficient to power this research. As such, any results should be viewed cautiously.
Therefore, the hypothesis cannot be confidently unsupported; however, evidence has

COMBINED CARE IN CONCUSSION TREATMENT

been gathered supporting differences in the treatment groups that may lead to prolong
recoveries.
Also, the possibility of confounding variables is present in this type of study,
because only correlations are observed. It is possible that there could be unidentified
outside variables that impacted the results of this study that were not considered. For
example, it was not evident how severe each concussion was and how this may have
impacted recovery. It is possible that those who experienced more severe concussions
were referred to more intensive treatment services, such as additional mental health
treatment. These highly acute clinical presentations would likely take more time to
resolve symptoms.
There were also limitations with the database used. The database reflected the
amount of neuropsychiatric appointments attended but did not document the amount of
physical therapy appointments attended. It is possible that the combined mental health
treatment group attended more neuropsychiatric appointments due to the nature of their
injuries, but there may have been a similar number of physical therapy appointments
attended between groups. Subjects may have been noncompliant with treatment
recommendations made by the clinicians at the concussion specialty clinic, and a lack of
participation in treatment would likely cause longer recovery. Referrals to outside
treatment services were documented in the database but because of the nature of the
existing database and the use of separate medical records the level of compliance was
unclear. It was also unclear if subjects attended these additional service appointments,

COMBINED CARE IN CONCUSSION TREATMENT

how frequently, or the level of progress attained in these services. This may have
impacted results because if those receiving referrals outside of the clinic, or to
participating departments within the clinic, did not comply with treatment
recommendations, their recoveries were likely prolonged. The mental health treatment
group would have likely been disproportionately affected by this potential issue as they
were referred to more services.

COMBINED CARE IN CONCUSSION TREATMENT

Clinical Implications and Future Research

In diagnosing and treating concussions, clinicians must be aware of the
importance of proper assessment for pre-existing factors that may influence concussion
recoveries. Clinicians must also be aware of the importance of appropriate clinical
referral and types of treatment that are evidence-based for concussion care.
Many treatment centers may not have the resources available to treat all
symptoms of concussion and must be able to make appropriate treatment referrals to
outside agencies. Sports programs in lower level sports, such as high school, and rural
areas may not have easy access to neuropsychiatrists or physical therapists in specialty
concussion treatments like vestibular or oculomotor therapies. These clinicians must be
invested in forming a treatment team using outside referral sources and work to ensure
proper coordination of care, communication, and continuity of treatment.
Future research should be conducted to provide further support for treatment
interventions in concussion recovery. Specifically, similar research should be conducted
on a larger sample size so that findings may generalize more to the population studied.
Also, researchers should follow patients for a longer period as they recover from
concussions to help identify and address any differences between patients who
experience prolonged symptoms beyond six months or longer from those who do not.
Other methodology, such as using randomized controlled trials, can be used to gather
stronger evidence for the support of combined mental health and physical health

COMBINED CARE IN CONCUSSION TREATMENT

treatment. Researchers should also compare patients who receive a physical health
treatment only to those who receive mental health treatment within the anxiety and mood
clinical profile. Lastly, further study should also be done across the concussion clinical
profiles to provide support for the assessment, assignment of clinical profiles, unique
problems seen across groups, and individualized treatment applied to all groups.

COMBINED CARE IN CONCUSSION TREATMENT

Conclusion

The initial findings of this research did not support the hypothesis that individuals
referred to a combined mental health treatment and physical health treatment would
experience a quicker recovery from concussion as evidenced by the computerized
neurocognitive testing scores and by requiring fewer days to clearance. However, the
effect size was small (.25), and the study was low in power. The intervention group who
received mental health treatment required more days to recover than the physical health
treatment group. This finding is likely due to those patients receiving the mental health
treatment having additional needs and symptoms outside of a physical health only
intervention that further compounds their symptoms. The review of data also showed that
reported symptoms of disorientation, confusion, migraine history, and concussion history
did not significantly impact the findings. Initial reports of insomnia, along with prolonged
symptom reporting, appears to be an influencer on recovery, especially higher scores on
the computerized neurocognitive testing.
This research provides support for the idea that there are differences in groups
receiving physical health treatment and mental health treatment. Those patients who are
clinically appropriate for a referral to mental health treatment likely presented with
increased symptomology at time of treatment, and those with continued symptom
reporting may be experiencing more advanced neurological issues. This highlights the
importance of appropriate clinical assessment, referral, and treatment based on patient

COMBINED CARE IN CONCUSSION TREATMENT

history and presenting symptoms. The appropriate clinical application of these results
will lead to more accurate identification and tracking of symptoms using targeted and
specific treatment approaches.
These findings also support the clinical profile treatment approach initially
proposed by Kontos and Collins (2018) and may provide validation for their assessment
and prescribing practices. If they accurate assessed an individual with higher recovery
needs, they may have appropriately referred to more types of treatment, and this type of
individual may be slower to recover due to the complexity of the injury. Mental health
symptoms presenting after a concussion are typically challenging to treat, and medication
interventions may take weeks or months to show benefits (Kontos & Collins, 2018).
Kontos et al. (2019) also suggested that these individuals may lack insight into how their
mental health symptoms influence their perceptions, behavior, and symptoms.
This highlights the importance of the development of an adequate treatment team
to assess and diagnose concussions, and work to develop a treatment team that can
manage patients’ needs. In many settings and communities, barriers may exist to
treatment. In these scenarios, it is important for clinicians to make outside referrals and
maintain appropriate coordination of care to ensure that all concussion needs are
addressed. These findings help clarify the underlying issues related with concussion
recovery and highlights the unique mental health and neurological needs exhibited by
those requiring mental health treatment.

COMBINED CARE IN CONCUSSION TREATMENT

References

Allen, B.J., & Gfeller, J.D. (2010). The immediate post-concussion assessment and
cognitive testing battery and traditional neuropsychological measures: A construct
and concurrent validity study. Brain Injury, 25(2), 179-191.
https://doi.org/10.3109/02699052.2010.541897
Alsalaheen, B.A., Mucha, A., Morris, L.O., Whitney, S.L., Furman, J.M., CamioloReddy, C.E…Sparto, P.J. (2010). Vestibular rehabilitation for dizziness and
balance disorders after concussion. Journal of Neurologic Physical Therapy,
34(2), 87-93. https://doi.org/10.1097/NPT.0b013e3181dde568
Alsalaheen, B., Stockdale, K., Pcchumer, D., & Broglio, S.P. (2016). Validity of the
immediate post-concussion assessment and cognitive testing (ImPACT®). Sports
Med, 46, 1487-1501. https://doi.org/10.1007/s40279-016-0532-y
Alsalaheen, B.A., Whitney, S.L., Mucha, A., Morris, L.O., Furman, J.M., & Sparto, P.J.
(2013). Exercise prescription patterns in patients treated with vestibular
rehabilitation after concussion. Physiotherapy Research Institute, 18(2013), 100108. https://doi.org/10.1002/pri.1532
Asarnow, J.R., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated medicalbehavioral care compared with usual primary care for children and adolescent

COMBINED CARE IN CONCUSSION TREATMENT

behavioral health. Journal of the American Medical Association Pediatrics,
169(10). https://doi.org/10.1001/jamapediatrics.2015.1141
Brown, N.J., Mannix, R.C., O’Brien, M.J., Gostine, D., Collins, M.W., & Meehan, W.P.
(2014). Effect of cognitive activity level on duration of post-concussive
symptoms. The American Academy of Pediatrics, 133(2), 299-304.
https://doi.org/10.1542/peds.2013-2125
Bryan, M.A., Rowhani-Rahbar, A., Comstock, R.D., & Rivara, F. on behalf of the Seattle
Sports Concussion Research Collaborative (2016). Sports and recreation-related
concussions in US youth. Pediatrics, 138(1). https://doi.org/10.1542/peds.20154635
Cantor, J., Ashman, T., Dams-O’Connor, K., Dijkers, M.P., Gordon, W., Spielman, L.,
…Oswald, J. (2014). Evaluation of the short-term executive plus intervention for
executive dysfunction after traumatic brain injury: A randomized controlled trial
with minimization. Archives of Physical Medicine and Rehabilitation, 95(1), 1-9.
https://doi.org/10.1016/j.apmr.2013.08.005
Centers for Disease Control and Prevention (2019). Surveillance Report of Traumatic
Brain Injury-related Emergency Department Visits, Hospitalizations, and
Deaths—United States, 2014. Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services.

COMBINED CARE IN CONCUSSION TREATMENT

Chan, C., Iverson, G.L., Purtzki, J., Wong, K., Kwan, V., Gangnon, I., & Silverberg,
N.D. (2018). Original research: Safety of active rehabilitation for persistent
symptoms after pediatric sport-related concussion: A randomized controlled trial.
Physical Medicine and Rehabilitation, 99(2), 242-249.
https://doi.org/10.1016/j.apmr.2017.09.108
Chrisman, S., & Richardson, L.P. (2014). Prevalence of diagnosed depression in
adolescents with history of concussion. Journal of Adolescent Health, 54(5), 582586. https://www.doi.org/10.1016/j.jadohealth.2013.10.006
Clark, J., Hasselfeld, K., Bigsby, K., & Divine, J. (2017). Colored glasses to mitigate
photophobia symptoms posttraumatic brain injury. Journal of Athletic Training,
52(8), 725-729. https://doi.org/10.4085/1062-6050-52.4.04
Coleman, J. (2016). Concussion diagnosis and management best practices. Retrieved
from:http://www.ncaa.org/sport-science-institute/concussion-diagnosis-andmanagement-best-practices
Collins, M.W., Kontos, A.P., Okonkwo, D.O, Almquist, J., Bailes, J., Barisa, M., … &
Zafonte, R. (2016). Concussion is treatable: Statements of agreement from the
Targeted Evaluation and Active Management (TEAM) approaches to treating
concussion meeting held in Pittsburg, October 15-16, 2015. Neurosurgery, 79(6),
912-929. https://doi.org/10.1227/NEU.0000000000001447

COMBINED CARE IN CONCUSSION TREATMENT

Conder, R., & Conder, A.A. (2015). Neuropsychological and psychological rehabilitation
interventions in refractory sport-related concussive syndrome. Brain Injury, 29(2),
249-262. https://doi.org/10.3109/02699052.2014.965209
Covassin, T., Elbin, R.J., Stiller-Ostrowski, J.L., & Kontos, A.P. (2009). Immediate postconcussion assessment and cognitive testing (ImPACT®) practices of sports
medicine professionals. Journal of Athletic Training, 44(6), 639-644.
https://doi.org/10.4085/1062-6050-44.6.639
Daneshvar, D.H., Nowinski, C.J., McKee, A., & Cantu, R.C. (2011). The epidemiology
of sport-related concussion. Clin Sports Med, 30(1), 1-17.
https://doi.org/10.1016/j.csm.2010.08.006
Elbin, R.J., Schatz, P., & Covassin, T. (2011). One-year test-retest reliability of the online
version of ImPACT® in high school athletes. The Journal of Sports Medicine,
39(11). 2319-2324. https://doi.org/10.1177/0363546511417173
Fimreite, V., Willeford, K.T., & Ciuffreda, K.J. (2016). Effect of chromatic filters on
visual Performance in individuals with mild traumatic brain injury (mTBI): A
pilot study. Journal of Optometry, 9, 231-239.
http://dx.doi.org/10.1016/j.optom.2016.04.004
Hobbs, J.G., Young, J.S., & Bailes, J.E. (2016). Sports-related concussions: Diagnosis,
complications, and current management strategies. Neurosurgery Focus, 40(4), 114. https://doi.org/10.3171/2016.1.FOCUS15617

COMBINED CARE IN CONCUSSION TREATMENT

ImPACT® Applications, Inc. (2007). ImPACT® Interpretation Manual: User Manual.
Retrieved from:
http://images.pcmac.org/Uploads/PortageAreaSD/PortageAreaSD/Departments/D
ocumentsCategories/Documents/Interpreting_the_ImPACT®_Clinical_Report.pd
f
Kleffelgaard, I., Soberg, H.L., Bruusgaard, K.A., Tamber, A.L., & Langhammer, B.
(2016). Vestibular rehabilitation after traumatic brain injury: Case series. Physical
Therapy, 96(6), 839-848. https://doi.org/10/2522/ptj.20150095
Kontos, A.P., & Collins, M.W. (2018). Concussion: A clinical profile approach to
assessment and treatment. Washington, DC: American Psychological
Association.
Kontos, A.P., Deitrick, J.M., Collins, M.W., & Mucha, A. (2017). Review of vestibular
and oculomotor screening and concussion rehabilitation. Journal of Athletic
Training, 52(3), 256-261. https://doi.org/10.4085/1062-6050-51.11.05
Kontos, A.P., Elbin, R.J., Appaneal, R.N., Covassin, T., & Collins, M.W. (2013). A
comparison of coping responses among high school and college athletes with
concussion, orthopedic injuries, and healthy controls. Research in Sports
Medicine, 21, 367-379. https://doi.org/10.1080/15438627.2013.825801
Kontos, A.P., Sufrinko, A., Sandel, N., Amami, K., & Collins, M.W. (2019). Sportsrelated concussion clinical profiles: Clinical characteristics, targeted treatments,

COMBINED CARE IN CONCUSSION TREATMENT

and preliminary evidence. Current Sports Medicine Reports, 18(3), 82-92.
https://doi.org/10.1249/JSR.000000000000573
Langlois, J. A., Rutland-Brown, W., & Thomas, K. E. (2006). Traumatic Brain injury in
the United States: Emergency department visits, hospitalizations, and deaths.
Atlanta, GA: Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control.
Lee, Y.M., Wu, A., Zuckerman, S.L., Stanko, K.M., LaChaud, G.Y., Solomon, G.S., &
Sills, A.K. (2016). Obesity and neurocognitive recovery after sports-related
concussion in athletes: A matched cohort study. The Physician and
Sportsmedicine, 44(3), 217-222. https://doi.org/10.1080/00913847.2016.1216718
Maerlender, A., Flashman, L., Kessler, A., Kumbhani, S., Greenwald, R., Tosteson, T., &
McAllister, T. (2010). Examination of the construct validity of ImPACT®
computerized test, traditional, and experimental neuropsychological measures.
Clin Neuropsychol., 24(8), 1309-1325.
https://doi.org/10.1080/13854046.2010.516072
Makdissi, M., Schneider K.J., Feddermann-Demont, N., Guskiewicz, K.M., Hinds, S.,
Leddy, J.L., …Johnston, K.L. (2017). Approach to investigation and treatment of
persistent symptoms following sport-related concussion: A systematic review.
British Journal of Sports Medicine, 0, 1-12. https://doi.org/10.1136/bjsports-2016097470

COMBINED CARE IN CONCUSSION TREATMENT

McCarty, C.A., Zatzick, D., Stein, E., Wang, J., Hilt, R., & Rivara, F.P. (2016).
Collaborative care for adolescents with persistent postconcussive symptoms: A
randomized trial. Pediatrics, 138(4), 1-13. https://doi.org/10.1542/peds.20160459
McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., … & Vos, P.
(2017). Consensus statement on concussion in sport – the 5th international
conference on concussion in sport held in Berlin, October 2016. British Journal of
Sports Medicine, 0, 1-10. https://doi.org/10.1136/bjsports-2017-097699
McLernon, S. (2014). The Glasgow Coma Scale 40 years on: A review of its practical
use. British Journal of Neuroscience Nursing, 10(4), 179-184. Retrieved from:
http://aann.org/publications/journal
Merritt, V.C., Bradson, M.L., Meyer, J.E., & Arnett, P.A. (2017). Evaluating the testretest reliability of symptom indices associated with the ImPACT® postconcussion symptom scale (PCSS). Journal of Clinical and Experimental
Neuropsychology, 40(4), 377-388.
https://doi.org/10.1080/12803395.2017.1353590
Mucha, A., Colling, M.W., Elbin, R.J., Furman, J.M., Troutman-Eneski, C., DeWolf,
R.M., …& Kontos, A.P. (2014). A brief vestibular/ocular motor screening
(VOMS) assessment to evaluate concussions. The American Journal of Sports
Medicine, 42(10), 2479-2486. https://doi.org/10.1177/0363546514543775

COMBINED CARE IN CONCUSSION TREATMENT

Neidecker, J.M., Gealt., D.B., Luksch, J.R., & Weaver, M.D. (2017). First-time sportsrelated concussion recovery: The role of sex, age, and sport. The Journal of the
American Osteopathic Association, 117(10). 635-642.
https://doi.org/10.7556jaoa.2017.120
Nelson, L.D., Guskiewicz, K.M., Barr, W.B., Hammeke, T.A., Randolph, C., Ahn, K.W.,
…McCrea, M.A. (2016). Age differences in recovery after sport-related
concussion: A comparison of high school and collegiate athletes. Journal of
Athletic Training, 51(2), 142-152. https://doi.org/10.4085/1062-6050-51.4.04
Root, J.M., Zuckerbraun, N.S., Wang, L., Winger, D.G., Brent, D., Kontos, A., &
Hickey, R.W. (2016). History of somatization is associated with prolonged
recovery from concussion. The Journal of Pediatrics, 174, 39-44.
https://doi.org/10.1016/j.jpeds.2016.03.020
Sandel, N., Reynolds, E., Cohen, P.E., Gillie, B.L., & Kontos, A.P. (2017). Anxiety and
mood clinical profile following sport-related concussion: From risk factors to
treatment. Sport, Exercise, and Performance Psychology, 6(3), 304-323.
https://doi.org/10.1037/spy0000098
Schatz, P., Pardini, J.E., Lovell, M.R., Collins, M.W., & Podell, K. (2006). Sensitivity
and specificity of the ImPACT® test battery for concussion in athletes. Archives
of Clinical Neuropsychology, 21, 91-99. https://doi.org/10/1016/j.acn.2005.08.001

COMBINED CARE IN CONCUSSION TREATMENT

Silverberg, N.D., Hallam, B.J., Rose, A., Underwood, H., Whitfield, K., … & Whittal,
M.L. (2013). Cognitive-behavioral prevention of postconcussion syndrome in atrisk patients: A pilot randomized controlled trial. Journal of Head Trauma
Rehabilitation, 28(4), 313-322. https://doi.org/10.1097/HTR.0b013e3182915cb5
Sinnott, A. M., Elbin, R.J., Collins, M.W., Reeves, V.L., Holland, C.L., & Kontos, A.P.
(2019). Persistent vestibular-ocular impairment following concussion in
adolescents. Journal of Science and Medicine in Sport, 22(2019), 1292-1297.
https://doi.org/10.1016/j.sams.2019.08.004
Spikman, J.M., Boelen, D.H.E., Lamberts, K.F., Brouwer, W.H., & Fasotti, L. (2009).
Effects of a Multifaceted treatment programme for executive dysfunction after
acquired brain injury on indications of executive functioning in daily life. Journal
of the International Neuropsychological Society, 16(1),118-129.
https://doi.org/10.1017/S1355617709991020
Solomon, G. (2011). Introduction to ImPACT® [PowerPoint presentation]. Retrieved
from: https://www.vumc.org/vscc-research/files/vsccresearch/public_files/IntroductiontoImPACT®Vanderbilt20131115.pdf
TBI: Get the facts. (4/27/2017). Centers for Disease Control and Prevention. Retrieved
from: https://www.cdc.gov/traumaticbraininjury/get_the_facts.html

COMBINED CARE IN CONCUSSION TREATMENT

Vargas, G., Rabinowitz, A., Meyer, J., & Arnett, P.A. (2015). Predictors and prevalence
of postconcussion depression symptoms in collegiate athletes. Journal of Athletic
Training, 50(3), 250-255. https://doi.org/10.4085/1062-6050-50.3.02
Wiese-Bjornstal, D., White, A.C., Russell, H.C., & Smith, A.M. (2015). Psychology of
sport concussions. Kinesiology Review, 4, 169-189.
https://doi.org/10.1123/kr.2015-0012
What Is Cognitive Behavioral Therapy? (2018). The American Psychological
Association. Retrieved from: http://www.apa.org/ptsd-guideline/patients-andfamilies/cognitive-behavioral.aspx
York, A.M., Smith, L., Babcock, M., & Alsalaheen, B. (2017). Validity and reliability of
the vestibular/ocular motor screening and associations with common concussion
screening tools. Sports Health, 9(42), 174-180.
https://doi.org/10.1177/1941738116678411

COMBINED CARE IN CONCUSSION TREATMENT

Appendix A
Review of the Literature

COMBINED CARE IN CONCUSSION TREATMENT

Recovery from concussions has been a topic of discussion in the news and
popular culture as several high-profile cases have arisen. These cases were highlighted by
compromised neurological function and other poor outcomes. Concussions and traumatic
brain injury (TBI) are prevalent in contact and non-contact sports and occurs in athletes
of all ages. The Centers for Disease Control and Prevention (CDC) estimates that in the
general population for all ages, concussions were present in 2.87 million emergency room
visits, hospital stays, or as a cause of death in 2014 (CDC, 2019; “TBI: Get the facts,”
2017). For those under the age of 18, it is estimated that 1.1 million to 1.9 million
individuals incur a concussion from sports or recreational activities (Bryan, RowhaniRahbar, Comstock, & Rivara, 2016). These injuries are subjective experiences, with some
athletes recovering quickly and some experiencing long-lasting effects (Coleman, 2016).
Despite the health risks and potential consequences of concussions incurred by athletes,
there has been little agreement among clinicians about optimal programs of recovery.
Additionally, subjective experiences of concussions have led to differentiated treatment
approaches per individual (Coleman, 2016; Hobbs, Young, & Bailes 2016).
Currently, there are numerous recommendations following concussion with little
consensus among professionals. Physical activity and gradual return to activity is
commonly prescribed (Chan, Iverson, Purtzki, Wong, Kwan, Gangnon, & Silverberg
2018; Coleman, 2016). Vestibular problems can be treated with posture control work,
physical therapy interventions, and visual therapies (Kontos, Deitrick, Collins, & Mucha,

COMBINED CARE IN CONCUSSION TREATMENT

2017). Mental health symptoms can be intensified following concussion, especially
depression (Chrisman, & Richardson, 2014), and cognitive behavioral therapy has been
used to teach effective coping skills for managing symptoms (Silverberg et al., 2013).
The purpose of this review was to investigate the effects of physical health
interventions, mental health interventions, and collaborative care treatment methods for
sport-related concussions in adolescent and young-adult athletes aged 16 to 25. The
review will cover the theoretical framework of the issue as well as the empirical
evidence. The population specifics of adolescents and adults will be reviewed as well as
active recovery programs, cognitive problems, treatment approaches, and balance and
vestibular treatments. Lastly, the benefits of applying a collaborative care model
incorporating aspects of both physical health and mental health treatment will be
reviewed.

Concussion Assessment, Diagnosis, and Current Treatment Models

Researchers have struggled to develop a focused and agreed upon definition of
concussions due to the varied experiences and recovery times associated with head
injuries. Recently, a consortium of experts defined a concussion as an injury resulting
from a traumatic force that affects the brain and its subsequent processes; causes
impairment of functioning, and often neuroimaging scans fail to show specific injury

COMBINED CARE IN CONCUSSION TREATMENT

(McCrory et al., 2017). These injuries may occur as a direct force to the head or to other
parts of the body which results in a secondary ImPACT® such as a helmet hitting the
ground. Concussions can occur from sport contact as well as through non-sport means. It
is essential that researchers agree upon this definition of concussions so that a proper
diagnosis can be rendered.

Prevalence of Concussions
To effectively treat a concussion in the sports population, athletes must first have
their injuries identified, be appropriately assessed, and diagnosed to be selected for
treatment (Coleman, 2016). Most often, the goals of concussion assessment, diagnosis,
and treatment are to remove the athlete from any unsafe conditions, reduce the possibility
of negative symptoms, and allow the athlete to return to play as quickly as possible. The
National Collegiate Athletic Association (NCAA) tracks data regarding their athletes and
injuries they sustain, including injuries such as broken bones, torn ligaments, sprains, and
concussions. This information is available via the NCAA Injury Surveillance Program
database (Zuckerman et al., 2016).
Using the NCAA database in a retrospective cohort study, Zuckerman et al.
(2016) used the NCAA Injury Surveillance Program to investigate the prevalence of
concussions in athletics, determine correlational factors related to prolonged recovery
from concussion, and to identify trends in athletes across sports, age, and sex. This

COMBINED CARE IN CONCUSSION TREATMENT

foundational study investigated the 2009-2010 and 2014-2015 athletic seasons and found
that there were a total of 1866 reported unique NCAA athletes who experienced
concussions. Out of these athletes, 7.4% went on to experience post-concussion
symptoms such as prolonged headache, dizziness, depression or anxiety, exercise
intolerance, and fatigue (Zuckerman et al, 2016). The most common sport for athletes to
receive a concussion was men’s American football which made up 38.6% of all
concussions. The rate of concussion in organized sports can reach as high as 1 diagnosed
injury per 1,000 exposures to sport (Daneshvar et al., 2011). Additionally, negative
outcomes as well as increased risk for repeated concussions were most associated with
symptoms of amnesia, dizziness, loss of balance, nausea, concentration problems, and
sensitivity to light and sound.

Protocols and Procedures
Problems with diagnosing. When an individual is suspected of having a
concussion, it is imperative that he or she be assessed and properly diagnosed. Hobbs et
al. (2016) noted the importance of early detection of concussions and potential
complications from concussions in athletes. The researchers reported that difficulties in
diagnosis arise due to the lack of visual evidence of concussion on traditional brain scans,
whereby athletic trainers and physicians must then rely on subjective reports. There is a

COMBINED CARE IN CONCUSSION TREATMENT

wide use of various concussion diagnostic tools, which can add to confusion when
multiple professionals are treating an individual. Further complicating that matter,
historically clinicians have struggled to agree on the definition of a concussion (McCrory
et al., 2017).
The course of injury may be different for everyone, and treating clinicians need to
be aware of the warning signs and symptoms that may present with a concussion
(Coleman, 2016; Hobbs et al., 2016). Researchers note that there are also other areas
impacted by concussions, including academic problems for students or student athletes,
financial problems, emotional and mental health symptoms, and peer relations issues;
these symptoms may be less apparent to the treatment team than physical symptoms
(Coleman, 2016; Hobbs et al., 2016).
Population differences. Additionally, there has been discussion about differences
in population regarding concussion symptoms, treatment, and potential outcomes.
Research has supported the idea that high school and college athlete populations respond
similarly when faced with similar injuries (Kontos et al., 2013; Nelson et al., 2016;
Williams, Puetz, Giza, & Broglio, 2016). The authors found that college and high school
athletes’ injuries and recoveries followed similar trajectories.
Also, noted differences among gender for coping skills were identified. Those
athletes who experience concussive injuries are less likely than their peers who
experience orthopedic injuries to use active coping skills, and male athletes are even less

COMBINED CARE IN CONCUSSION TREATMENT

likely than female peers to use coping skills. Female athletes are more likely when
injured to use support systems, humor, and distraction to cope with their injuries (Kontos
et al., 2013). Researchers noted that despite these differences, athletes reported similar
levels of cognitive performance (Nelson et al., 2016).
Other predictors of prolonged concussion recovery have been noted in a review of
the literature by Brent and Max, 2017. These authors found that children who are slow to
recover from concussions are more likely to have had a prior concussion. Depression or
psychiatric illness prior to a concussion may also increase time to recovery, as well as a
history of migraine headaches (Brent & Max, 2017). Adolescents who have a prior
history of somatization may also recovery more slowly from concussions (Root et al.,
2016).
Assessment tools. When a concussion is suspected, certified athletic trainers and
sports medicine staff play a vital initial role in early detection and are usually the first to
encounter an athlete who possibly has a concussion (Coleman, 2016). Balance testing
using the Balance Error Scoring System (BESS), cognitive assessments such as the
Sports Concussion Assessment Tool Third Version (SCAT-3), and vision and ocular
testing such as the King-Devick test and VOMS are all useful tools that can be
administered immediately after a suspected injury to increase the likelihood of early
detection of concussions in athletes (Hobbs et al., 2016; Mucha et al., 2014; York et al.,
2017).

COMBINED CARE IN CONCUSSION TREATMENT

The ImPACT® tool is a commonly used concussion assessment that consists of six
neurocognitive tests to generate composite scores regarding word discrimination,
attention and verbal memory, visual working memory, working memory, processing
speed, impulse and reaction speed, and processing speed (Solomon, 2011). The PostConcussion Symptom Scale (PCSS) is a multi-faceted subscale of the ImPACT® and has
been shown to have high test-retest reliability (Merritt et al., 2017). The measures within
the PCSS, such as cognitive symptom cluster, physical symptom cluster, and affective
system cluster also showed moderate to high reliability (Merritt et al., 2017). The
affective system cluster has also been shown to influence the responses to testing
protocols and is correlated with higher depressive symptom reporting, suggesting that
clinicians must be cognizant of observable affective symptoms (Ramanathan,
Rabinowitz, Barwick, & Arnett, 2011).
Importance of quick response. Quick and accurate assessment and diagnosis of
a concussion is important for reducing risks to athletes and delayed recovery (Hobbs et
al., 2016). It has been noted that athletes who return to play too quickly risk increased
symptomology, potential for increased time away from sport, as well as potential for
brain damage. Guskiewicz et al. (2003) noted that experiencing a concussion is a
predictive variable for future concussions and reported that ten out of eleven athletes who
experienced multiple concussions in the same sports season did so within ten days of the
initial injury. The National Collegiate Athletic Association’s (NCAA) best practices for
concussion management (Coleman, 2016) reported that athletes must immediately be

COMBINED CARE IN CONCUSSION TREATMENT

removed from play and other sports activities such as practice for at least the current day
when a concussion or brain injury is suspected to reduce likelihood of negative
complications.

Currently Accepted Treatment Approaches
Once a concussion has been diagnosed, team athletic trainers and physicians often
refer athletes to treatment. The NCAA best practices for concussion management
(Coleman, 2016) states that athletes will typically return to normal activities once they
return to their baseline measurements prior to the concussive injury. Athletes are
recommended to make a gradual return to normal activities as tolerated based on
symptomology. These steps are taken as a progressive series of achievements towards
physical and cognitive normalcy for each individual, with athletes beginning light activity
with return to regular activity as intolerance decreases. Researchers note that many
athletes will experience symptom complications and require further treatment (Hobbs et
al., 2016).
Rest and light activity are often the most prescribed form of treatment for those
experiencing a concussion (Thomas, Apps, Hoffman, McCrea, & Hammeke, 2018). Upon
initial diagnosis of concussion, most athletes are provided with instructions to only
engage in light activity until their symptoms begin to subside and they become more
capable of engaging in routine activities. This is a commonly accepted practice in the

COMBINED CARE IN CONCUSSION TREATMENT

medical and athletic field. However, research has shown that those participating in an
active rehabilitation program consisting of submaximal aerobic activity show little
differences in improvements for several major concussive symptoms such as balance,
cognition, and parental anxiety about progress post-concussion (Gagnon, Grilli,
Friedman, & Iverson, 2016). Little difference was also seen in Maerlender, Rieman,
Lichtenstein, and Condiracci’s (2015) work comparing athletes receiving active recovery
against those prescribed rest. These authors noted that both groups showed improvements
in their symptoms at a similar rate. Because of this, evidence supporting active recovery
only prescriptions are contradictory at this time.
Mental health symptoms are common after concussion and may be worsened by
prior history of concussion or family history of mental health symptoms (Chrisman &
Richardson, 2014; Conder & Conder, 2015). Cognitive behavioral therapy (CBT),
cognitive reframing, and biofeedback for concussions and brain injuries has shown
promise in the foundational literature (Conder & Conder, 2015; Mittenberg, Tremont,
Zielinski, Fichera, & Rayls, 1996, Silverberg et al., 2013).
Although Mittenberg et al. (1996) studied older adults (mean age of 43 in the
treatment group and mean age of 49 in the control group), the results may be applicable
to other populations. Those who participated in the treatment group received detailed
directions from a therapist about implementing CBT principles such as stress reduction,
tips for symptom improvement, biased thinking awareness, and tips for scheduling
activities to reinforce positive thoughts and actions. The treatment group showed

COMBINED CARE IN CONCUSSION TREATMENT

improvements over the treatment as usual group in terms of days to recovery, frequency
of symptoms six months later, days per week of symptomology, and severity of reported
symptoms (Mittenberg, et al. 1996).
While research remains somewhat limited and sometimes contradictory regarding
treatment of concussions, some schools have begun to act through utilizing the resources
available to them. The Sahuarita United School District 30 identified that at times,
athletes who experienced concussions had difficulty transitioning back into their
academic routine and school workloads. The district formed a collaborative team utilizing
their registered nurse (RN), parents, school board members, superintendent, community
healthcare providers, coaches, school psychologists, health assistants, and parents to
address this issue creatively (Dachtyl & Morales, 2017).
The team initially suggested using the Rehabilitation Act of 1973’s Section 504
plan to make accommodations for the injured students but reported that this was
unsatisfactory due to the 504 plan’s intent to assist those with more permanent disabilities
(Dachtyl & Morales, 2017). They developed the Cognitive Return to Exertion (CoRTEx)
concussion management protocol that utilizes interventions with a speech-language
pathologist as well as an athletic trainer.
The resulting developed program consisted of a multi-phased program beginning
with diagnosis, coordination with educational systems and physical health clinicians,
incorporation of testing of symptoms, modification to educational demands as

COMBINED CARE IN CONCUSSION TREATMENT

appropriate, and appropriate follow up. If a student’s concussive symptoms continue after
the intervention, then referrals are made for the appropriate 504 plan or Individualized
Educational Plan (IEP). An important part of the program is communication among
educators, treating clinicians, healthcare workers, team members, and family (Dachtyl &
Morales, 2017).
The researchers reported case studies of students who have completed the
program and note adequate support was provided. This initial research provides evidence
that changes can be made at the school level to help athletes recover from concussion
symptoms and reintegrate into their academic work. This program may be an example of
how school districts can utilize existing resources and services to create replicable
programs across school districts and may represent the beginning of a commonly
accepted practice.

Population Assessment in Concussion Management

In treating concussions and post-concussive symptoms, it is important that
clinicians provided targeted treatment towards the individual he or she is treating. Some
differences in recovery may exist based on gender (Kontos et al., 2013; Neidecker et al.,
2017), body mass index (Lee et al., 2016), as well as high school athlete or college athlete

COMBINED CARE IN CONCUSSION TREATMENT

status (Williams, Puetz, Giza, & Broglio, 2015). In addition to accurately understanding
individual needs, diagnostic tools must be selected that show valid and reliable results.
Evidence-based tools include the Glasgow Coma Scale (McLernon, 2014), the
ImPACT® and PCSS (Merritt et al., 2017), and the Beck Depression Inventory (Steer,
Cavalieri, Leonard, & Beck, 1999).

Gender Differences in Concussion Recovery
Other differences have been noticed across genders. Kontos et al. (2013), in a
study using high school and college-aged student athletes, observed that female student
athletes were more likely than male student athletes to use coping skills for recovery
across all injury types. Examples of more commonly used coping skills include
utilization of social supports, self-distraction, and humor. Differences have been noted
across injury types (Kontos et al., 2013). Those athletes who experienced orthopedic
injury were more likely than those who experienced concussion to utilize coping skills.
The concussion group reported lower acceptance, less coping for distraction, higher
substance use, more self-blame, and more denial than those experiencing orthopedic
injuries (Kontos et al., 2013).
Other gender differences have been noted in the literature (Neidecker et al.,
2017). These researchers compared medical records for male and female athletes aged
11-18 who experienced a first-time concussion to clarify any differences between sexes

COMBINED CARE IN CONCUSSION TREATMENT

for duration of symptoms and types of symptoms expressed. Athletes were considered
recovered from their concussion symptoms when their ImPACT® scores were similar to
their baseline scores. Most male athletes (75%) recovered from their symptoms within 3
weeks of injury, whereas only 42% of female athletes reported recovery from symptoms
within 3 weeks (Neidecker et al., 2017). The researchers noted that there were differences
in recovery from concussions based on gender and hypothesized that these differences
may be related to biological factors such as increased prevalence of migraines in females,
increased rates of depression in adolescent females, and less total neck mass to absorb
impacts that may cause concussions (Neidecker et al., 2017).

Body Mass Index Differences
Other differences in concussion recovery have been noted based on body mass
index (BMI). Lee et al. (2016) noted that among adolescent and young adult athletes who
experienced a sports concussion, obese individuals took longer to return to baseline in
numerous measures, including reaction time and PCSS scores. In this study, athletes were
matched based on age, gender, type of sport, and amount of previously diagnosed
concussions. Obese athletes who incurred a concussion experienced longer delays in
visual and verbal memory functions, reaction time, motor speed, and higher scores on the
PCSS than those who were within a normal weight according to the CDC standards.

COMBINED CARE IN CONCUSSION TREATMENT

Those athletes who had a BMI less than 25 were more likely to have their concussive
symptoms return to baseline in two weeks than those who had a BMI over 30 (Lee et al.,
2016).

High School versus College Athletes
There are numerous changes that occur physiologically among adolescents and
young adults. Because of this, it is worth investigating possible differences across
adolescent and young adult populations. Potential differences in expression of symptoms,
if any, may impact potential treatment recommendations or paths of recovery.
Some additional differences in concussion recovery have been noted in the
literature between high school athletes and collegiate athletes (Williams et al., 2015).
Adolescent and young adult athletes may recover similarly for cognitive symptoms, at 5
days and 7 days respectively. Despite this similarity, high school and collegiate athletes
may vary in their perceptions of required time needed to return to an asymptomatic state
at 15 days versus 6 days respectively (Williams et al., 2015). Despite this identified
difference, there may be a confounding variable present in that collegiate athletes may
feel more social pressures to return to play sooner, and therefore may underreport
symptoms when self-report is relied upon.
As previously mentioned, recovery from cognitive symptoms appears similar in
highs school and college athletes. Other symptomology following concussion in high

COMBINED CARE IN CONCUSSION TREATMENT

school and collegiate student athlete populations appear to be similar as well (Lee, Odom,
Zuckerman, Solomon, & Sills, 2013). Student athletes across both populations report
similar symptoms at both baseline and post-concussion when measured with the Total
Symptom Scale (TSS). Examples of symptoms measured include nausea, dizziness,
insomnia, irritability, emotional problems, visual problems, and problems with memory.
Both high school and college athletes also reported a similar return to baseline
symptomology in those who experienced symptom resolution. Athletes who experienced
symptom resolution in high school recovered within 5.5 days, and college athletes
recovered within 5.7 days (Lee et al., 2013).
Further research has been conducted comparing the high school athlete and
collegiate student athlete population (Nelson et al., 2016). In this research, athletes who
experienced a concussion were monitored on day 1, 2, 3, 5, 45, and 90 post-injury using
cognitive assessments and balance assessments. It was noted that high school student
athletes took approximately one to two days longer to recover than their collegiate
counterparts, but they also experienced more severe injuries and these differences in
recovery were not statistically significant. These findings suggest that similar injury
patterns may occur in these populations, and similar treatments may be appropriate for
high school and college athletes who sustain a sports-related concussion (Nelson et al.,
2016).

COMBINED CARE IN CONCUSSION TREATMENT

Diagnostic Tools
The Glasgow Coma Scale (GCS) is a frequently used assessment and diagnostic
tool designed to test impairment from head trauma or neurological injury (McLernon,
2014). The GCS is often used as an initial indicator in medical treatment centers to
communicate state of consciousness and potential level of injury experienced. This tool
measures a patient’s responsiveness with his or her eyes, verbal responsiveness, and
motor responsiveness and assesses several subcategories within each to develop a total
score.
McLernon (2014) reported that the measure produces moderately reliable ratings
in conscious patients but can lose inter-rater reliability when patients experience loss of
consciousness. Additionally, it has been found that training and education increase the
accuracy of administering the tool. In this sense, intra-rater reliability is enhanced with
proper training protocols. The researcher recommends that the assessment be completed
early after the injury, and then periodically to track changes in condition (McLernon,
2014).
It is noted that despite these limitations, the GCS remains an appropriate clinical
tool for assessing those experiencing head traumas due to its maintained reliability and
ability to predict continuing symptoms (McLernon, 2014). This makes the scale
appropriate to use for those experiencing concussion symptoms and is most valid with

COMBINED CARE IN CONCUSSION TREATMENT

individuals experiencing only short-term loss of consciousness as often seen in sportsrelated concussions.
Using testing measures that have demonstrated reliability is an important aspect
of an effective concussion testing and monitoring plan. Many tools to monitor
concussions are completed prior to injury for baseline reporting, immediately after a
concussion, and throughout the recovery period. Because of this, research reviewed the
test-retest reliability of commonly used tools including the ImPACT® Total Symptom
Score and the Post-Concussion Symptom Scale (PCSS) (Merritt et al., 2017). Researchers
reported that the ImPACT® scale is used to document subjects’ difficulties with verbal
and visual memories, reaction time, and impulse control, while the PCSS is a specific
component of the ImPACT® assessment. The PCSS used a Likert scale across 22
questions to measure severity of symptoms (Merritt et al., 2017). The PCSS showed
highest test-retest reliability for the cognitive symptom scale, but only showed moderate
reliability for the ImPACT® total symptom scale (Merritt et al., 2017). This research
demonstrates the need for the use of additional and specific measures to be used with the
ImPACT® Total Symptom Score and PCSS.
To further document the ImPACT® and PCSS’s effectiveness, a study of athletes’
affective states was conducted by researchers at the Pennsylvania State University who
proposed that athlete’s observable affective state may be indicative of their likelihood to
report positive or negative symptoms on their baseline assessments (Ramanathan et al.,
2011). The researchers’ purpose was to provide validation or critique to these tools so

COMBINED CARE IN CONCUSSION TREATMENT

that researchers understand their effectiveness, scope, and limitations. In doing so, it
allows researchers to understand their results within an affective context.
The researchers studied 256 Division I NCAA athletes who had sustained a
concussion during sport. The researchers used the Beck Depression Inventory Fast Screen
(BDI-FS), which has been demonstrated to be a reliable and valid measurement tool
(Steer, Cavalieri, Leonard, & Beck, 1999). The ImPACT® Total Symptom Score and
PCSS were additionally used for data collection. Also completed was an observational
rating tool designed for the researchers to rank the subjects’ affective states as they
completed the test battery. The researchers found that those experiencing an observable
negative affective state were more likely to score higher for depression on the BDS-FS
and suggested that those athletes who received a more positive affect rating report fewer
depressive symptoms. The researchers argue that it is imperative that clinicians document
athletes’ affects and understand the bias that observable affect may have when reporting
baseline or post-concussive measures (Ramanathan, Rabinowitz, Barwick, & Arnett,
2011).
Other symptoms of concussion may also be present following an injury to the
head. Adolescents and young adults who have been diagnosed with a concussion
sometimes experience symptoms such as dizziness, difficulties with balance, gait,
sensory processing problems, and difficulty with eye focus (Alsalahenn et al., 2010;
Kleffelgaard, et al., 2016; Kontos et al., 2017). The VOMS tool has been developed to
track these symptoms by assessing dysfunction of the vestibular, vision, and

COMBINED CARE IN CONCUSSION TREATMENT

somatosensory systems using assessments in five domains (Mucha et al., 2014; York et
al., 2017). The tool relies on verbal report of headache symptoms, dizziness, nausea, and
fogginess on a Likert scale of 0-10 when compared to their last assessment’s symptoms
(Mucha et al, 2014).
The VOMS has also shown to have a high level of test-retest validity when
compared through repeated tests within subjects (York et al., 2017). When compared to
other evidence-based tools that measure symptomology, such as the PCSS, the VOMS
scores were positively correlated with higher PCSS scores, suggesting its ability to
accurate identify concussion symptoms (Mucha et al., 2014). Researchers have also
suggested that the VOMS is a reliable and internally consistent tool (Mucha et al., 2014).
Using peer-reviewed tools and assessments, such as the GCS, ImPACT®, BDSFS, VOMS, and PCSS with athletes who potentially have a concussion, is an important
part of accurate and appropriate injury assessment. In using these tools, clinicians can
accurately diagnose a concussion, track and manage symptoms, and make appropriate
treatment referrals.
When clinicians can efficiently diagnose a concussion and identify
symptomology, an appropriate referral to treatment can be made. One of the commonly
prescribed forms of treatment is active recovery and gradual return to activities as
tolerated (Chan et al., 2018).

COMBINED CARE IN CONCUSSION TREATMENT

Active Recovery and Prescription of Physical Activity

Gradual return to activity as tolerated is a common recommendation for athletes
who sustain a sports-related concussion, but little research exists to support the safety and
effectiveness of these recommendations. Chan et al. (2018), in their randomizedcontrolled trial, compared the effects of an active rehabilitation program on nineteen
adolescents aged 12-18. Of those 19 subjects 14 were female. Those participating in the
control group received treatment as usual consisting of an educational session about
symptom management, a psychiatric consultation, and information regarding return to
school. Adolescents randomized to the experimental group engaged in submaximal
aerobic exercise, visualization training, coordination training, and a home exercise
program. The intervention lasted for six weeks.
The researchers found that those receiving active rehabilitation experienced
negative symptoms no more frequently than those receiving treatment as usual, and
showed greater improvements in balance, error scoring, cognitive functioning, and
quality of life measurements (Chan et al., 2018). They hypothesized that the intervention
may have supported cerebrovascular changes that assisted recovery. They reported that
the placebo effect may have occurred, in that those receiving active rehabilitation
believed they were recovery faster. The researchers also reported that by giving athletes

COMBINED CARE IN CONCUSSION TREATMENT

permission to exercise they may have resolved maladaptive beliefs about their situations
(Chan et al, 2018).
Maerlender, Rieman, Lichtenstein, and Condiracci (2015) showed no significant
improvements in post-concussion symptoms following an active recovery protocol
consisting of 20 minutes of moderate cycling in college athletes diagnosed with a sportsrelated concussion. The study included more females than males, and females may take
longer to recover from concussions which may have affected outcomes (Neidecker et al.,
2017). Also, the researchers may have failed to demonstrate a significant difference
between intervention and control group because 13 subjects experienced continued
symptoms and did not recover within the two-week period, which may have been tied to
a short intervention or the inability of female athletes to recover quickly.
The intervention group initially experienced increased post-concussive symptoms
at the onset of the physical activity intervention. Athletes who experience a concussion
may also show no more favorable outcomes when offered an early intervention treatment
with a rehabilitation medicine specialist than those who receive a treatment as usual
(Matuseviciene, Eriksson, & DeBoussard, 2016). However, this study involved high-risk
and low-risk populations and their quality of life three months post-intervention. It is
possible that high-risk populations may need a more comprehensive treatment approach,
and they may not recover in similar ways or timeframes as low-risk concussion
populations.

COMBINED CARE IN CONCUSSION TREATMENT

Conversely, in specifically investigating the effects of a prescription for strict rest,
Thomas, Apps, Hoffman, McCrea, and Hammeke (2018) randomly assigned children and
adolescents diagnosed with a concussion from any cause to either receive strict rest or to
treatment as usual. The treatment group was instructed to maintain five days of strict rest,
where the control group was recommended to rest for one or two days, then begin
returning to activity as usual. These researchers failed to show significant differences
between groups in neurocognitive function, balance, and self-reported symptoms in their
treatment periods. This may be due to the follow up occurring just ten days after
intervention, when the primary subjects of the research were female youth, and subjects
had other high-risk factors such as history of previous concussions and migraines
(Thomas, Apps, Hoffman, McCrea, & Hammeke, 2018).
Rest and gradual return to physical activity are common prescriptions following
sports-related concussion (Chan et al., 2018). Although there appears to be some
empirical support, some individuals continue to experience post-concussion symptoms
and may require further interventions to address persistent symptoms. These continued
symptoms may need additional treatments (such as visual or vestibular treatments) to
resolve.

COMBINED CARE IN CONCUSSION TREATMENT

Visual and Vestibular Treatments for Post-Concussion Symptoms
Many athletes who experience concussions experience problems including
dizziness, vertigo, balance problems, and difficulty with eye function such as focusing
and reading (Kleffelgaard, Soberg, Bruusgaard, Tamber, & Langhammer, 2016). Other
commonly experienced problems associated with concussions include nausea, balance
problems, unsteady gait, sensory processing difficulties (Alsalaheen et al., 2010). Kontos
et al. (2017) reported that to optimize outcomes of sports-related concussions, clinicians
must assess for, and adequately treat, vestibular and oculomotor dysfunction.

Screening and Assessment for Post-Concussion Symptoms
It is noted that screening and assessment tools currently accepted as valid and
reliable include the Vestibular/Oculomotor Screening Tool (VOMS), Dizziness Handicap
Inventory, Sports Concussion Assessment Tool 2, King-Devick testing (Hecimovich,
King, Dempsey, & Murphy, 2018; Mucha et al., 2014), ImPACT®, as well as the PCSS
(Merritt et al., 2017). Researchers report that dizziness and visual motion sensitivity are
common dysfunctions that can be treated with postural control, specialized work with a
physical therapist, and visual therapy programs. Although research is somewhat limited
in this area, current research has shown reductions in vestibular symptoms in athletes in
as little as eight weeks (Kontos et al., 2017).

COMBINED CARE IN CONCUSSION TREATMENT

Balance and Gait Treatment
Researchers performed a retrospective review to assess for the effectiveness of
treating commonly reported vestibular conditions following concussion in children and
adults including dizziness, nausea, confidence in balance, gait, and sensory processing
(Alsalaheen et al., 2010). Vestibular treatments and exercises were customized due to
participant complaint, with common exercises provided such as gaze maintenance,
walking, practicing balance, and traversing unstable surfaces such as walking on foam.
Improvements were seen in all subjects, especially children in the study (mean age = 16)
in areas such as dizziness, balance, and gait. However, with the mean intervention lasting
four sessions and 33 days, the researchers report that they cannot rule out spontaneous
remission of symptoms (Alsalaheen et al., 2010).
Other researchers have validated the efficacy of vestibular treatment for postconcussive symptoms. Kleffelgaard, Soberg, Bruusgaard, Tamber, and Langhammer
(2016) recruited adult subjects from the outpatient clinic at the Oslo University Hospital
who were diagnosed with a mTBI according to the Glasgow Coma Scale following a fall
or accident. All subjects reported experiencing dizziness, lack of range of motion, and
experienced reduced vestibular-ocular reflexes. The subjects engaged in a group and
home-based vestibular rehab program for 8 weeks. The program incorporated balance,
head and eye coordination exercises, sitting and standing exercises, light walking,

COMBINED CARE IN CONCUSSION TREATMENT

jogging, or swimming, and progressive relaxation. The researchers found that all patients
experienced some negative symptoms during the initiation of the program, but no serious
negative experiences were noted. Kleffelgaard et al. (2016) reported that as a result of the
intervention, subjects reported improvements in balance, reduced dizziness, and
improved quality of life which supports the inclusion of vestibular treatment as part of
concussion recovery protocol.
Alsalaheen et al. (2013) documented common vestibular prescriptions to provide
a foundation for clinicians who encounter concussion patients experiencing symptoms
such as dizziness, imbalance, and gait problems. The researchers reviewed 114 files at a
vestibular rehabilitation clinic to collect data on a sample of children and adults with a
mean age of 24 years old. They found that exercise to improve eye-head coordination,
standing balance exercises, and ambulatory exercises were most frequently prescribed to
patients to alleviate post-concussion symptoms. Because these are the most frequently
prescribed exercises for concussive symptoms, it can reasonably be inferred to be routine
practice for young adults (Alsalaheen et al., 2013). Additionally, vestibular therapies are
recommended to be active, dynamic treatments that engage athletes in addressing specific
symptoms and complaints involving the head and eyes (Kontos et al., 2017).

COMBINED CARE IN CONCUSSION TREATMENT

Visual Therapies
Vestibular symptoms of concussions can also include eye problems, such as
perceived eye strain, trouble focusing, and sensitivity to light. The effects of using
various chromatic filters have been investigated in attempts to identify potential benefit to
post-concussion patients experiencing visual problems (Fimreite, Willeford, & Ciuffreda,
2016). They investigated the preferences of 12 adults recovering from a sports-related
concussion or accident and injury concussion who were experiencing photosensitivity
post-concussion and compared their preferences with 12 controls. The researchers used a
Visograph to track eye movements and reading speed while subjects engaged in five
trials of different tinted lenses as well as no lens trial.
No differences between groups across trials for fixations, or regressions were
found, but a significant difference in reading rate was found. The control group read
faster than the trial group using the red and blue lenses while the intervention group
reported increased comfort using the colored lenses. This led the researchers to suggest
that future research could be conducted on colored lenses affecting the later stages of
visual processing as part of a comprehensive post-concussive symptom treatment
regimen and suggested that colored lenses could be used therapeutically to reduce
perceived strain and discomfort following concussions (Fimreite, Willeford, & Ciuffreda,
2016).

COMBINED CARE IN CONCUSSION TREATMENT

Additionally, further research has validated the positive effects of using chromatic
filters on those experiencing visual symptoms post-concussion (Clark, Hasselfeld,
Bigsby, & Divine, 2017). Subjects were adolescents and adults who were presenting with
continued concussion symptoms at least three weeks post-injury and who reported
continued photosensitivity as a primary symptom. The researchers in this cross-sectional
study used an LED penlight commonly used in visual assessments to determine subjects’
levels of photosensitivity for a baseline measurement. Then, subjects were presented with
thirteen different colored lenses, and asked if the lenses made the light better, worse, or
the same. Lenses that were helpful were worn for longer periods of time to retest their
effects, and then these preferred lenses were compared together. Subjects who reported
spending most of their days using screens, either for work or for academics, were also
tested using screens for their trials.
After trying the lenses, researchers concluded that 85% of those who experienced
visual problems noted improvements with colored lenses (Clark et al., 2017). These
researchers hypothesize that those athletes who experience photosensitivity postconcussion may have encountered retinal damage, damage to neurological pathways, or
damage to the visuosensory pathways regarding color processing. These symptoms may
be both indicatory of brain injury and may help dictate treatment.
These studies suggest that a variety of treatment approaches may be most
beneficial to address symptoms of concussion. Balance, gait, motor control, and other
physical challenges often present with post-concussive symptoms. Additionally, many

COMBINED CARE IN CONCUSSION TREATMENT

patients experience visual problems including sensitivity, discomfort, and difficulty
managing eye control. This research suggests that many factors should be considered
when assessing, diagnosing, and treating individuals who experience a concussion injury,
and comprehensive treatment may be needed to address the spectrum of patient concerns
including mental health symptoms.

Cognitive Issues and Collaborative Care
Adolescents and adults who are slow to recover from concussion may be at risk of
experiencing cognitive and mental health symptoms (Brent & Max, 2017; WieseBjornstal et al., 2015). Brown et al. (2014) identified that athletes may be at continued
risk for depression, memory problems, concentration problems, and may benefit from
mental health treatment. Additionally, research has supported the idea of executive
function training (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2009). Resources
such as the Concussion Care Manual: A Practice Guide (Brody, 2015) state that an initial
prescription for exercise and psychological treatment may be helpful. Furthermore,
additional support has been found for taking a collaborative care approach between
physical and mental health for adolescents and adults recovering from sports-related
concussions (McCarty, 2016; Makdissi et al., 2017).

COMBINED CARE IN CONCUSSION TREATMENT

Prevalence and Scope of Cognitive Issues
Another issue associated with concussions is the effect of injuries on cognitive
function and mental health symptoms, and the relationship between cognitive activity and
delayed recovery from post-concussive symptoms (Brown et al., 2014; Chrisman, &
Richardson, 2014; Mrazik, Brooks, Jubinville, Meeuwisse, & Emery, 2016; Rees &
Bellon, 2017; Vargas, Rabinowitz, Meyer, & Arnett, 2015). Researchers completed a
literature review regarding the prevalence of cognitive problems following concussions
and the treatment process for cognitive issues in concussions (Brown et al., 2014).
Further topics of the review included admission and initial interview, as well as specific
intervention strategies like education, skills training, cognitive behavioral therapy (CBT),
and others, as well as special population considerations. The researchers reported that it is
important to complete a thorough mental health status exam, including mental health
testing. Other tests important to conduct include executive dysfunction, learning,
memory, concentration, and sports-specific tests (Brown et al., 2014). This research helps
to form consensus on the presence of mental and cognitive impairments associated with
post-concussive symptoms.
Similarly, other authors have noted effects of psychological risk factors on the
outcome of concussions, as well as potential effects of concussions on mental health
(Wiese-Bjornstal et al., 2015). The authors described the integrated model of
psychological response to sport injury to understand the psychological factors relating to
concussion. This research focused on factors that make athletes at risk for injury or at risk

COMBINED CARE IN CONCUSSION TREATMENT

for delayed recovery. Further support was found by Root et al. (2016) for psychological
factors influencing concussion, specifically somatization. In their prospective cohort
study, the researchers completed the Children’s Somatization Inventory with patients to
gather clinical information regarding somatization history. Then, they compared the
PCSS and time to recovery across groups of high and low somatization history at two
weeks and four weeks post-injury. The researchers found that there was a significant
correlation between somatization and higher reported post-concussion symptoms at two
and four weeks into their recoveries.
Other psychological factors may influence the severity of concussions and
prolonged recovery. Several authors reviewed research conducted in the fields of
concussions and mental health and discovered that Attention Deficit Hyperactivity
Disorder (ADHD) and depression prior to and after an injury can be risk factors for poor
concussion recovery (Brent & Max, 2017; Wiese-Bjornstal et al., 2015). Researchers also
reported in their psychological response to sport injury model that the use of maladaptive
coping mechanisms can prolong recovery time, and concussion education is effective at
reducing risk of concussion (Wiese-Bjornstal et al., 2015). Numerous factors influence
recovery from concussion and can include behavioral symptoms, communication
difficulties, social context, and affective symptoms such as nervousness and frustration
can impair recovery. Other deficits are often seen such as memory, cognitive, and
processing problems frequently occur; rest, social support, CBT, concussion education,
and goal-setting interventions have all been demonstrated to improve concussion

COMBINED CARE IN CONCUSSION TREATMENT

outcomes (Brent & Max, 2017; Wiese-Bjornstal et al., 2015). These findings suggest that
there are numerous influential factors, both pre-injury and post-injury, that can delay
recovery from concussion. Additionally, athletes’ mental health concerns following
concussions can be addressed using specific interventions as part of the recovery process.
Other research has been conducted to help verify a link between concussions and
mental health problems. Chrisman and Richardson (2014) reviewed data collected from
the National Survey of Children’s Health that was completed in the United States via
telephone in 2007. This survey collected household health data from subjects across the
United States about medical insurance, physical and mental health histories of children in
the home, performance in the academic setting, and description of their local
neighborhoods. Subjects were asked about their children’s histories of concussion, as
well as mental health symptomology in the past and present.
Upon review of the data, the authors found a correlation between a previous
clinical diagnosis of concussion and current symptomology or diagnosis of depression.
The researchers discovered that children who had a prior clinical concussion diagnosis
were 3.3 times more likely to experience depression that those who did not experience
concussion, and children who reported that their parents had poor or fair mental health
were more likely to experience depression. The older the participant, the more likely he
or she was to experience depression after concussion. These results were independent
from gender (Chrisman & Richardson, 2014). This research suggests that depression may
be one of the long-lasting effects of concussions, and these effects may be more common

COMBINED CARE IN CONCUSSION TREATMENT

than realized. These results make a strong clinical case for the appropriate assessment,
diagnosis, and treatment of depression after an athlete experiences a concussion
diagnosis.
Other researchers have validated the increased risk of depression following
concussive injuries (Vargas et al., 2015). College athletes were given baseline
assessments at the beginning of the sport season consisting of the BDI-FS assessment,
and then were completed again for data comparison following concussion. Of the 84
athletes who experienced a concussion, the majority (71%) were retested within 48 hours,
and all subjects were retested within one week of concussion. The researchers found that
individuals who experienced a concussion were more likely to report depressive
symptoms post-injury than the non-injury group, and those who began sports at an older
age were more likely to experience depression after concussion (Vargas et al., 2015).
They also found that people of color were more likely to experience depression postconcussion than Caucasian athletes, and those with higher estimated IQ experienced
fewer symptoms post-concussion (Vargas et al., 2015). This research verifies the risk of
depression following concussion and highlights some of the potential population
differences in mental health following concussions.
When concussion symptoms persist for extended periods of time, mental health
symptoms are present in nearly all patients (Rees & Bellon, 2017). Researchers
investigating common symptoms and modalities of treatment found that nearly all adults
who experienced long-term post-concussion symptoms lasting two or more years

COMBINED CARE IN CONCUSSION TREATMENT

reported anxiety and depression as their two leading cognitive symptoms (Rees & Bellon,
2017). The researchers reported that long-term recurring affective and cognitive
difficulties may leave concussion patients feeling helpless, indecisive, and unable to cope
with their lives and may contribute to prolonged recovery from concussion (Rees &
Bellon, 2017).
Additionally, other differences may exist for populations not only based on
history of previous concussions, but for history of concussion combined with
musculoskeletal injuries as well (Mrazik, et al., 2016). Subjects chosen for this study
were 743 Canadian youth hockey players between the ages of 13-17. Athletes in this
study completed a Pre-Season Questionnaire (PSQ) as well as a Behavior Assessment
System for Children, 2nd Edition (BASC2) to gather data prior to the start of the athletic
season. Information regarding demographics, previous mental health symptoms, head
injuries, physical health injury histories, sports participation history, and medical
conditions was gathered.
The collected data were organized into subgroups of youth athletes, groups of no
prior injury, previous concussion history, previous musculoskeletal injury, and those
athletes who had experienced both musculoskeletal injuries as well as concussions. Upon
evaluating the data, it was discovered that athletes in the combined injuries group showed
numerous differences to the other groups such as more emotional symptoms, anxiety, and
attention problems than the musculoskeletal injury only group. The combined injury
group also experienced an increased sense of inadequacy, more loss of internal locus of

COMBINED CARE IN CONCUSSION TREATMENT

control, and increased somatization of symptoms when compared to the other groups
(Mrazik et al., 2016).

Explanatory Style on Recovery
Additionally, it appears that the internal explanatory style of athletes has an
impact on recovery times from concussions as well (Shapcott, Bloom, Johnston,
Loughead, & Delaney, 2007). The researchers define explanatory style as the patterns
individuals use to explain either positive or negative situations in their lives and often
form patterns in thought (Shapcott et al., 2007). In terms of analyzing one’s own status
post-concussion, individuals use an optimistic or pessimistic explanatory style for their
circumstances. Optimistic explanatory style communicates the message that the injury
was external of an individual’s control, was not related to constant or unchanging
circumstances, and was caused due to a specific event. Conversely, pessimistic
explanatory styles convey that injury causes are internal, somewhat unchanging, and do
not have specific causal factors.
Data were collected using the Attributional Styles Questionnaire (ASQ) to
quantify information regarding personal explanatory styles and the Sports History
Questionnaire (SHQ) to collect information regarding sports participation history,
number of concussions, and duration of symptoms in college aged athletes. The
researchers found that explanatory style did not influence symptom duration for single

COMBINED CARE IN CONCUSSION TREATMENT

concussion events, but those who experienced multiple concussions and who had an
optimistic internal explanatory style experienced significantly longer time to return to
baseline symptomology than those with a pessimistic explanatory style (Shapcott et al.,
2007). This research suggests that there are numerous psychological factors that influence
recovery from concussion that must be considered when treating athletes.
There are unique challenges facing student athletes in their attempts to recovery
from both physical health injuries and brain injuries. Special considerations may need to
be taken in addressing their physical and psychological symptoms. Additionally, these
confounding issues may include psychological factors, age of first sports participation,
and racial factors. These additional factors may also influence recovery from complex
concussions, and treatment needs to reflect these individualized concerns.

Cognitive Behavioral Treatments
To treat concussions, clinicians may consider referrals to cognitive behavioral
therapy (CBT) or other mental health services to more adequately manage mental health
symptoms. It is noted that CBT can be useful in reducing symptoms. Other techniques
such as reframing, biofeedback, and neurofeedback can be used to regain bodily control.
Furthermore, cognitive rehabilitation training can teach athletes skills to manage
symptoms and injuries by teaching appropriate expectations, coping skills, goal setting,
and others (Conder & Conder, 2015).

COMBINED CARE IN CONCUSSION TREATMENT

Researchers studied patients at the Boston Sports Concussion Clinic who
presented within three weeks of a sports concussion. Data were collected using the PCSS
tool in addition to a cognitive activity scale that was developed for concussion patients.
The authors found that subjects who reported the most cognitive activity, experienced the
slowest self-reported time to recover from post-concussive symptoms. This issue may
present challenges especially for the high school or collegiate athlete who may be
pressured to return to school and complete tasks at the same rate as peers. Brown et al.
(2014) reported that cognitive rest following a concussion may help athletes return to a
symptom-free state more quickly than those who are more cognitively active. Because of
this, it may be necessary for clinicians to prescribe specific cognitive rehabilitation
therapy to address these symptoms.
Researchers at the Icahn School of Medicine in New York, New York
investigated the effects of cognitive rehabilitation programs on post-concussion
symptoms (Cantor et al., 2014). Subjects received twice weekly group therapies, and
individual therapy over twelve weeks. The intervention focused on teaching problemsolving skills, emotional regulation training, attention skills training, and use of personal
aides such as daily planners or to-do lists. Therapists specifically taught skill application
and generalization of techniques to current life stressors to improve use of coping skills.
After twelve weeks, those subjects receiving the short-term cognitive
rehabilitation program reported improved problem-solving skills and reported their
behavior to be more goal-directed than the control group. Subjects who received this

COMBINED CARE IN CONCUSSION TREATMENT

intervention also reported specific improvements in emotional regulation, self-awareness,
distress tolerance, ability to pay attention, participation in activities, and improved quality
of life. These results suggest that skill training is an important part of cognitive
rehabilitation for those experiencing post-concussive symptoms (Cantor et al., 2014).
Because of the positive effects of mental health skills training, additional research
has been conducted reviewing the specific CBT interventions and skill teaching for
individuals experiencing post-concussive symptoms. Thomas, Alves, Vaska, and
Magalhaes, (2017), in their review of the literature, noted that effective CBT skills
teaching programs prioritized improving performance on tasks and improving
individual’s sense of well-being, particularly when delivered early in concussion
recovery.
Specific skills taught during these interventions included mental health skills such
as reasoning and cognition skills, addressing maladaptive thoughts, reducing overly
critical thoughts, improving attention, use of personal electronics or scheduling systems,
and relaxation techniques. Physical skills were also taught during these interventions,
including breathing techniques, sleep hygiene improvements, and tips to reduce
headaches. Those individuals participating in these interventions showed reduced
anxiety, depression, and task performance (Thomas et al., 2017).
Some research has also suggested that targeted CBT treatment may reduce the
potential for developing post-concussion symptoms in high-risk populations (Silverberg

COMBINED CARE IN CONCUSSION TREATMENT

et al., 2013). In this randomized controlled pilot study, individuals who experienced a
head injury within the previous six weeks and reported at least one subjective symptom
of concussion were assigned to either treatment as usual, which involved a meeting with
an occupational therapist for a three-hour session, or to the intervention group consisting
of treatment as usual as well as a six-week CBT intervention. The CBT intervention
focused on reducing health anxiety, improving self-efficacy, improve coping skills and
their use, and reduction of a maladaptive negative thinking processes (Silverberg et al.,
2013).
Subjects in the study completed the Rivermead PostConcussion Symptoms
Questionnaire and HADS Depression and Anxiety assessment at baseline and at three
months after intervention to investigate the effects of the CBT intervention. The
researchers found that those receiving CBT scored lower for depression on their follow
up reporting and noted improved perceptions about themselves and their rehabilitations
(Silverberg et al., 2013). Members of the intervention group tended to rate their level of
disability as lower than those of the treatment as usual group and rated their satisfaction
with concussion treatment higher. Because of the increased belief in recovery, reduction
of symptoms, and potential for reduced change of chronic post-concussion syndrome,
early and targeted CBT approaches may reduce mental health symptoms commonly
associated with concussions (Silverberg et al., 2013).
The research presented clarifies several clinical issues for those treating student
athletes who have histories of concussive injury. Researchers note that it is important to

COMBINED CARE IN CONCUSSION TREATMENT

properly assess student athletes for their physical health history, concussion history, and
to be aware of athletes who have experienced both as they may experience unique
challenges in their recoveries. A comprehensive concussion treatment program needs to
also properly identify previous mental health history and current mental health history to
most appropriately recommend treatment. This also provides support for the idea of
collaborative care across physical and mental health realms to optimize benefit to student
athletes as they recovery.
Executive functioning training in CBT. For those recovering from a concussion,
a priority of treatment is typically to return to normalcy as quickly as possible. To return
to normalcy in their lives, patients who have experienced a concussion need to use their
executive functioning skills in an effective way; they need to be able to plan effectively,
exhibit goal-directed behavior, initiated desired tasks, and incorporate these skills into
their environments (Spikman et al., 2009).
The researchers investigated the ImPACT®s of an executive functioning training
on executive decision-making in patients experiencing brain injury. Spikman et al. (2009)
developed a randomized controlled trial featuring an executive function intervention
lasting up to 24 sessions. The intervention focused on providing specific skills training on
goal setting, task planning, and regulation skills while the control group received
cognitive-functioning skills training via computer featuring repetitive exercises consisting
of training for improved reaction time, memory, attention, and ability to plan.

COMBINED CARE IN CONCUSSION TREATMENT

There were 75 subjects in this randomized controlled trial (RCT) who were
randomized to either the intervention group or control group. Data collection occurred via
The Role Resumption List, Treatment Goal Attainment, and Executive Serial Task
measurements which were used at baseline, after treatment, and six months following
intervention. The researchers found that the experimental group made significant
progress in the assessment tools in areas such as return to work, participation in hobbies
and activities, and level of social participation (Spikman et al., 2009). Also shown to
improve were skills associated with daily life functioning such as organizing, planning
tasks, initiating actions, and self-monitoring.
Similarly, a 12-week skills training program enhanced executive functioning
skills in patients with a history of TBI and executive functioning problems in areas such
as emotional regulation, attention skills, and ability to use personal aides such as planners
or to-do lists. Skills were taught using group therapy twice weekly and individual therapy
once weekly over a period of twelve weeks. Subjects were taught executive skills during
the treatment period with the intent of generalizing skills to reduce difficulties in
educational, employment, or social functioning. Post-intervention, subjects showed
increased ability in problem-solving, planning and purposeful behavior, and scores on the
composite executive function measure (Cantor et al., 2014).
These findings suggest that it is possible to treat disabling mental and cognitive
symptoms of concussions. Executive dysfunction can make those experiencing
concussions dependent on others, unable to work or attend school, and be unable to make

COMBINED CARE IN CONCUSSION TREATMENT

skillful decisions and actions in their personal lives. Treatment of these symptoms
through specific skills teaching during mental health treatment may be a fundamental
aspect of concussion recovery, because injured athletes wish to return to baseline
symptomology and resume previous activities.

Psychiatric Referrals in Concussion Treatment
Researchers report that research is currently lacking regarding the efficacy and
best practice guidelines for prescribing psychotropic medications for athletes following a
brain injury (Reardon & Factor, 2010; Warden et al., 2006). Despite these limitations,
some general recommendations have been developed regarding prescribing psychotropic
medications specifically to athletes. (Reardon & Factor, 2010).
To treat depression after brain injury, the use of selective serotonin reuptake
inhibitors (SSRIs) has been shown to improve symptoms in 87% of patients studied
(Warden et al., 2006). Also of benefit, preliminary studies report that SSRIs most likely
do not negatively impact muscle strength, power output, or athletic capacity (Reardon &
Factor, 2010). Tricyclic antidepressants, such as amitriptyline, have been shown to be
somewhat less effective in studies reviewed by Warden et al. (2006), but more research
needs conducted in this area due to small sample size and lack of supporting evidence. To
treat anxiety symptoms after brain injuries, some research validates the use of serotonin
norepinephrine reuptake inhibitors (SNRIs) (Warden et al., 2006).

COMBINED CARE IN CONCUSSION TREATMENT

The researchers reported that despite a lack of studies completed on brain injury
patients regarding psychotropic medication’s effectiveness in reducing mental health
symptoms, the demonstrated effectiveness of these interventions in other populations
provides some evidence of their benefit across populations (Warden et al., 2006). When
treating concussion patients with psychotropic medications, prescribers must consider the
unique needs of the athlete, including compliance with anti-doping regulations in sport,
potential impacts on athletic performance, and potential physiological differences
between concussion patients and uninjured patients (Reardon & Factor, 2010; Warden et
al., 2006).
Another resource for clinicians treating concussions is the Concussion Care
Manual: A Practical Guide (Brody, 2015). The manual reports that along with a thorough
assessment and clinical history, care has to be given when scheduling appointments. The
manual states that if individuals present with major safety issues or active suicidal
ideation, then an admission into the hospital may be the most effective treatment. Other
factors that may require more immediate follow up include severe anxiety or depression,
professional status such as professional athlete or military staff, and prescription of new
psychoactive medications may require more immediate return to the clinic. These more
urgent needs may require a visit within one week or up to every three weeks, and less
urgent needs such as treating mood instability, moderate issues, and more easily tolerated
medications may need appointments scheduled between six weeks and six months,
depending on clinical presentation (Brody, 2015).

COMBINED CARE IN CONCUSSION TREATMENT

Physical and Mental Health Collaborative Care
Research has been conducted to support the combination of physical health and
mental health treatment. This approach is referred to as collaborative care. Makdissi et al.
(2017) used Medline, Sportdiscus, Cinahi, Cochrane Library, and Proquest to collect a
series of base studies investigating collaborative care and appropriate treatments for postconcussive symptoms. Studies were included if they included sports-related concussions
and focused on either assessment or treatment of concussion symptoms lasting longer
than 10 days. The researchers identified 25 eligible studies, 11 of which focused on
assessment, and 14 studies that were treatment focused. The authors found support for
detailed clinical assessments, limited aerobic exercise, physical therapy, and collaborative
treatment that has integrated cognitive behavioral therapy (Makdissi et al., 2017).
Further validation can be found via a randomized controlled trial conducted by
McCarty et al. (2016). These authors investigated the effects of a collaborative care
intervention compared to treatment as usual in a group of adolescents who were slow to
recover from concussion. Those adolescents randomized to the intervention group
received care management, CBT aimed at reducing depressive and anxious symptoms
through teaching of coping skills, positive thinking skills, sleep hygiene, advocacy within
the school, and coordination of care among mental health and physical health providers.

COMBINED CARE IN CONCUSSION TREATMENT

100

Those receiving treatment as usual received consultation with a rehabilitation specialist
including submaximal exercise as appropriate (McCarty et al., 2016).
The youth, as well as their participating parents, both reported statistically
significant improvements in post concussive symptoms at one month, three months, and
six months following implementation of collaborative care (McCarty et al., 2016).
Adolescents receiving collaborative care noted higher quality of life during and after
treatment when compared to those not receiving collaborative care. This research
suggests that adolescents and young adults who experience post-concussive symptoms
may recover more quickly when they receive physical health care as well as mental
health treatment simultaneously.
Behavioral health symptoms, such as disruptive behavior, attention-deficit
disorder (ADD), and substance use problems are often difficult behaviors to treat but
appear to benefit from collaborative care approaches as well (Asarnow et al., 2015). The
studies included in these authors’ review utilized evidence-based CBT for mental health
symptoms or behavioral health problems as well as an evidence-based medication
algorithm to manage symptoms. Other tactics that showed positive effects included
primary care physician (PCP) communication training for mental and physical health care
providers, motivational interviewing, phone coaching, and peer support services
(Asarnow et al., 2015).

COMBINED CARE IN CONCUSSION TREATMENT

101

Positive effects, though small to moderate, were seen in the collaborative care
interventions for substance use disorders. Other mental health symptoms, such as
depression and anxiety, showed larger effect sizes and suggest the efficacy of these
programs in reducing symptoms than can often be related to post-concussive symptoms.
The researchers suggest that the positive outcomes of integrating mental and physical
healthcare can be particularly beneficial for adolescents and young adults at reducing a
variety of mental health and behavioral health symptoms (Asarnow et al., 2015; McCarty
et al., 2006).

Psychoeducational Interventions in Collaborative Care
Further evidence has suggested the efficacy of mental health treatment in
concurrent treatment for those experiencing chronic symptoms (Belanger et al., 2015).
Researchers investigated the effects of a web-based psychoeducational program on postconcussive symptoms. A web-based psychoeducational program is a computer-delivered
educational program aimed towards helping those experiencing mental health symptoms
that provided information on different severity levels of head injuries, expected
symptoms during treatment and recovery, tips and tactics to alleviate post-concussive
symptoms, and attempted to normalize problems (Belanger et al., 2015).

COMBINED CARE IN CONCUSSION TREATMENT

102

The Neurobehavioral Symptom Inventory (NBI) was used to track symptoms in
the patients. The researchers failed to find significant interaction between the two groups.
However, upon subgroup analysis they found a positive effect on symptoms for those
receiving the intervention and participating in concurrent mental health treatment. At six
months post-intervention, the group receiving the psychoeducational intervention and
concurrent mental health treatment expressed symptomology similar to the control
group’s measure at baseline. This evidence suggests that psychoeducational interventions
and concurrent mental health treatment may more quickly reduce post-concussive
symptoms to baseline more effectively than either intervention alone, but the researchers
report there were not enough subjects to accurately assess whether concurrent treatment
varies based on time since injury (Belanger et al., 2015).
Collaborative care models may be effective in reducing high-risk behaviors such
as violent behaviors, weapon carrying, substance use, and symptoms of Post-Traumatic
Stress Disorder (PTSD) in individuals who have experienced physical injury or head
injury (Zatzick et al., 2014). Adolescents at a Level 1 Trauma Center who experienced a
traumatic injury, 47.5% of whom experienced head injuries, were randomized to either a
usual care group or a stepped collaborative care intervention group.
The stepped collaborative care group received case management, motivational
interviewing techniques, pharmacotherapy, and CBT to address PTSD symptoms,
depression, and high-risk behaviors for the 12 months following injury. The usual care
group received primary care physician treatment, any outpatient surgery needed to

COMBINED CARE IN CONCUSSION TREATMENT

103

recover from the injuries, and any specialty mental health services frequently offered to
injury patients. The GSC was used to assess patients, the National Longitudinal Study of
Adolescent Health was used to determine high-risk behaviors, and the Composite
International Diagnostic Index was used to determine alcohol use behaviors.
Additionally, the PTSD Reaction Index (PTSD-RI) was used to identify subjects who
experienced elevated levels of symptoms related to PTSD (Zatzick et al., 2014).
The researchers found the most support for reduced weapon carrying in the group
receiving stepped collaborative care. Analysis of the data showed consistently lower
follow up reports in depressive symptoms, PTSD, and substance use, though the effects
were not large enough in this study to be considered statistically significant (Zatzick et
al., 2014). However, this data suggests the possibility that collaborative care interventions
may be implemented to illicit improvements in difficult, high-risk behavior. These
benefits may be more readily seen in a population with a higher percentage of concussion
or head injury patients.

COMBINED CARE IN CONCUSSION TREATMENT

104

Conclusion

Concussions are injuries that affect numerous internal mental and physical
processes within an individual. As such, they are subjective experiences that researchers
and clinicians have struggled to adequately define, research, and treat. Researchers now
agree, however; that concussive events are the result of traumatic force to the head,
resulting in impaired brain functions and processes (McCrory et al., 2017). Despite the
subjective nature of concussions, is imperative that athletes be appropriately assessed and
diagnosed so they may receive adequate and timely treatment. Numerous assessment and
diagnostic tools, including balance testing using the Balance Error Scoring System
(BESS), visual and vestibular impairment assessment tools such as the VOMS (Mucha et
al., 2014; York et al., 2017), and cognitive assessments such as the Sports Concussion
Assessment Tool Third Version (SCAT-3) are commonly used. Also, the Glasgow Coma
Scale is frequently used to measure baseline symptoms and consciousness (McLernon,
2014), and ImPACT® and PCSS testing procedures have been shown to effectively
measure concussion symptoms (Merritt et al., 2017).
Once a concussion is diagnosed, treatment referrals can be made. Evidence
suggests that physical rehabilitation programs can be beneficial in reducing concussion
symptoms of poor balance, poor cognitive functioning, and reduced perceived quality of
life (Chan et al., 2018). Vestibular therapies and treatments have also been shown to

COMBINED CARE IN CONCUSSION TREATMENT

105

reduce post-concussive symptoms, particularly dizziness, nausea, poor confidence in
balance, gait problems, and sensory processing errors (Alsalaheen et al., 2010;
Kleffelgaard, 2016; Kontos et al., 2017). Visual therapies have also been shown to reduce
post-concussive symptoms (Alsalaheen et al., 2013; Fimreite, Willeford, & Ciuffreda,
2016) as well as optometry interventions such as implementing chromatic filters and
colored lenses to reduce photosensitivity (Clark et al., 2017).
Additionally, mental health treatments have been shown to reduce the effects of
post-concussion symptoms and allow individuals to be more functional in their daily lives
(Brown et al., 2014). Chrisman and Richardson (2014) and Vargas et al. (2015) have
demonstrated a link between athletes experiencing concussion and an increase in mental
health symptoms afterwards such as increased anxiety and depressive symptoms. CBT
and skills training have been shown to treat several of these common effects associated
with delayed recovery from concussion (Cantor et al., 2014; Conder & Conder, 2015).
Collaborative care models are those that implement and co-facilitate treatment
between physical healthcare and mental healthcare. These models have been shown to be
effective at reducing post-concussive symptoms (Makdissi et al., 2017; McCarty et al.,
2016). Collaborative care models have also shown promise in reducing high-risk
behavior such as weapon carrying and substance abuse (Asarnow et al., 2015).
These research findings provide direction for application in treating athletes who
experience concussions. Initial assessment and diagnosis is an important step to gauge

COMBINED CARE IN CONCUSSION TREATMENT

106

symptoms as well to collect baseline data. Clinicians can provide treatment comprised of
physical rehabilitation, vestibular and visual rehabilitation programs if symptoms are
present (Alsalaheen et al., 2013; Chan et al., 2018; Kleffelgaard et al., 2016) and
concurrent mental health treatment consisting of specific skills training for noted deficits
(Asarnow et al., 2015; Makdissi, 2017; McCarty et al., 2016). Treatment should be
monitored for effectiveness and for potential negative interactions such as increased
symptomology. Treatment should be routinely monitored and adjusted to meet the
client’s needs, and collaborative consultation with both physical health and mental health
providers is recommended for the most effective treatment. If symptoms do not improve,
physical and cognitive rest may be prescribed to reduce the cognitive and physical strain
on the individual. Careful counseling and support are necessary during the recovery to
allow patients to understand ways to cope with their stressors and to understand realistic
expectations for recovery.
Despite the strengths of the research and recommendations that are derived from
it, there is still a need for future research in concussion management. Areas of
consideration for future research include the application of collaborative therapy,
including CBT, skills training for improvements in executive functioning, and physical
treatment such as vestibular therapies and physical therapy to the high school and
college-age student population. Also, an identified barrier to implementation of programs
may be time of injury to time of initiation of treatment. This may be due to recruiting
requirements for subjects in the research, procedural barriers of research, failure of

COMBINED CARE IN CONCUSSION TREATMENT

107

injured athletes to report to treatment within the timeframe, lack of follow through on
treatment recommendations, or lack of knowledge about the importance of concussion
care.
Despite the barriers, additional research can be conducted on implementation of
interventions within 72 hours of injury. Many of the interventions reviewed were
implemented several days, weeks, or even months post-injury. Additionally, many
research studies investigated the effects of brief treatment interventions lasting six to
eight weeks, where these programs may demonstrate more effect over a longer period.
Lastly, these programs can be studied for individuals who experience multiple
concussions, because each population may experience different symptom clusters with
continued injury. By further investigating these areas, researchers can continue to
develop and recommend the most recent and relevant evidence-based practices to support
those recovering from concussions and head injuries.

COMBINED CARE IN CONCUSSION TREATMENT

Appendix B
Problem Statement

108

COMBINED CARE IN CONCUSSION TREATMENT

109

In treating concussions and post-concussion symptoms, research has supported
that physical rehabilitation programs (Chan et al., 2018) and visual and vestibular
rehabilitation programs (Kontos et al., 2017) can be effective in reducing common
symptoms such as cognitive problems, poor balance, and lowered quality of life.
However, rest and gradual return to activity is one of the most commonly prescribed
approaches (Thomas et al., 2018) but has shown little improvements in frequently
experienced symptoms such as cognitive function and balance (Gagnon et al., 2016;
Maerlender et al., 2015).
Mental health symptoms can be frequently seen in those recovering from
concussion injuries, including depression, memory problems, and problems concentrating
(Brown et al., 2014; Vargas et al., 2015; Wiese-Bjornstal et al., 2015). Additionally,
concussion symptoms may be more serious following repetitive concussions; children
who experienced multiple concussions may be 3.3 times more likely to experience
depression than those who experienced their first concussion (Chrisman et al., 2014).
Research also supports the efficacy of mental health treatment in reducing
symptoms associated with concussions and post-concussion using a specific
psychotherapy called CBT to manage symptoms (Cantor et al., 2014; Conder & Conder,
2015). Collaborative care treatment integrates collaborative cares and have been shown to
reduce concussion symptoms (McCarty et al., 2016). Adolescents receiving collaborative
care noted higher quality of life during and after treatment when compared to those not
receiving collaborative care, suggesting post-concussive symptoms may resolve more

COMBINED CARE IN CONCUSSION TREATMENT

110

quickly when they receive physical health care as well as mental health treatment
simultaneously (McCarty et al., 2016).
The purpose of this research was to investigate the effects of a collaborative care
intervention consisting of mental health treatment and physical health treatment on postconcussive symptoms in adolescents and young adult athletes aged 16 to 25 as measured
on ImPACT® and time to clearance to return to normal activity. The goal for this research
was to test the hypothesis that adolescent and young adult student athletes experiencing
concussion symptoms, as identified on ImPACT® and who have participated in a
collaborative care intervention, will experience improvement or resolution of symptoms
more quickly than those receiving a physical health intervention as measured by time to
clearance to return to normal activity.

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C
Additional Methods

111

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C1
ImPACT®

112

113

COMBINED CARE IN CONCUSSION TREATMENT

ImPACT®Clinical Report
JANE DOE

JANE DOE
Passport ID: X2M2-LQVS-076K

Organizat ion:

Episcopal Acade m y

Age:

Dat e of Birt h:

08/01/1999

Height :

Gender:

Fe m ale

Weight :

Nat ive count ry/region:

Skippe d

Second language:

Skippe d

Nat ive language:

Skippe d

Years of educat ion
complet ed excluding
kindergart en:

Skippe d

Repeat ed one or more
years of school:

Skippe d

Received speech
t herapy:

Skippe d

Diagnosed learning
disabilit y:

At t ended special
educat ion classes:

Skippe d

Problems wit h
ADD/hyperact ivit y:

Current sport :

Skippe d

Current level of
part icipat ion:

Skippe d

Primary
posit ion/event /class:

Skippe d

Years of experience at
t his level:

Skippe d

Handedness:

Number of t imes diagnosed wit h a concussion
(excluding current injury):

Skippe d

Concussions t hat result ed in loss of
consciousness:

Skippe d

Concussions t hat result ed in conf usion:

Skippe d

Concussions t hat result ed in dif f icult y
remembering event s t hat occurred immediat ely af
t er injury:

Skippe d

Concussions t hat result ed in dif f icult y
remembering event s t hat occurred:

Skippe d

T ot al games missed as a result of all concussions
combined:

Skippe d

Concussion hist ory:
T reat ment f or
headaches by physician:

Skippe d

Hist ory of meningit is:

Skippe d

T reat ment f or migraine
headaches by physician:

Skippe d

T reat ment f or
subst ance/alcohol
abuse:

Skippe d

T reat ment f or
epilepsy/seizures:

Skippe d

T reat ment f or
psychiat ric condit ion
(depression, anxiet y):

Skippe d

Hist ory of brain surgery:

Skippe d

Diagnosed wit h
ADD/ADHD:

Diagnosed wit h Aut ism:

Skippe d

Diagnosed wit h Dyslexia: Skippe d

St renuous exercise in
t he last 3 hours:

Skippe d

Page 1

10/07/2018

114

COMBINED CARE IN CONCUSSION TREATMENT

®
ImPACT Clinical Report
Exam T ype

Base line

Dat e T est ed

09/26/2018

JANE DOE

Last Concussion
Exam Language

English

T est Version

3.4.0

Composit e S cores
Me m ory com posite (ve rbal)

Me m ory com posite (visual)

Visual m otor spe e d com posite

41.20

Re action tim e com posite

0.63

Im pulse control com posite

T ot al S ympt om S core

Cognit ive Ef f iciency Index *

0.19

The Cognitive Efficiency Index meas ures the interaction between accuracy (percentage correct) and s peed
(reaction time) in s econds on the Symbol Match tes t. This s core was not developed to make return to play
decis ions but can be helpful in determining the extent to which the athlete tried to work very fas t on s ymbol
match (decreas ing accuracy) or attempted to improve their accuracy by taking a more deliberate and s low
approach (jeopardizing s peed). Low s cores (0 to .20) may in s ome cas es s ugges t a very poor performance
on this s ubtes t.
Scores in bold RED type exceed the Reliable Change Index (RCI) when compared to the bas eline s core.
However, s cores that do not exceed to RCI index may s till be clinically s ignificant. Percentile s cores if
available are lis ted in s mall type.
Hours slept last night

Skippe d

Medicat ion

Skippe d

ImPACT is not intended to provide a diagnos is or decis ion about the Tes t Taker. ImPACT res ults s hould
be interpreted only by qualified healthcare profes s ionals .

Page 2

10/07/2018

COMBINED CARE IN CONCUSSION TREATMENT

ImPACT®Clinical Report

115

JANE DOE

Word Memory
Hit s (Immediat e)

Correct dist ract ors (immed.)

Learning percent correct

96%

Hit s (delay)

Correct dist ract ors (delay)

Delayed memory % correct

100%

T ot al percent correct

98%

Design Memory
Hit s (Immediat e)

Correct dist ract ors (immed.)

Learning percent correct

50%

Hit s (delay)

Correct dist ract ors (delay)

Delayed memory % correct

54%

T ot al percent correct

52%

X's and O's
T ot al correct (memory)

T ot al correct (int erf erence)

116

Average correct RT
(int erf erence)

0.54

T ot al incorrect (int erf erence)

Average incorrect RT
(int erf erence)

0.34

S ymbol Mat ch
T ot al correct (visible)

Average correct RT (visible)

1.70

T ot al correct (hidden)

Average correct RT (hidden)

1.71

Color Mat ch
T ot al correct (visible)

Average correct RT (visible)

0.78

T ot al commissions

Average commissions RT

0.46

T hree Let t ers
T ot al sequence correct

T ot al let t ers correct

% of t ot al let t ers correct

100%

Average t ime t o f irst click

1.95

Average count ed

17.8

Average count ed correct ly

17.8

Page 3

10/07/2018

COMBINED CARE IN CONCUSSION TREATMENT

ImPACT Clinical Report
S ympt oms S cores
Headache

Nausea

Vomit ing

Balance Problems

Dizziness

Fat igue

T rouble f alling asleep

S leeping more t han usual

S leeping less t han usual

Drowsiness

S ensit ivit y t o light

S ensit ivit y t o noise

Irrit abilit y

S adness

Nervousness

Feeling more emot ional

Numbness or t ingling

Feeling slowed down

Feeling ment ally f oggy

Dif f icult y concent rat ing

Dif f icult y remembering

Visual problems

T ot al S ympt om S core

Page 4

10/07/2018

116

JANE DOE

117

COMBINED CARE IN CONCUSSION TREATMENT

®
ImPACT Clinical Report
Memory Composit e (Visual)

Memory Composit e (Verbal)
100

100

React ion T ime Composit e

Visual Mot or Composit e
60

1.0

0.8

0.6

0.4

0.2

41.20
09/26/18

Page 5

43
09/26/18

09/26/18

JANE DOE

0.63
09/26/18

10/07/2018

118

COMBINED CARE IN CONCUSSION TREATMENT

®
ImPACT Clinical Report

JANE DOE
Sympt om Score

Impulse Cont rol Composit e
25

125

100

2
09/26/18

Page 6

0
09/26/18

10/07/2018

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C2
VOMS

119

120

COMBINED CARE IN CONCUSSION TREATMENT

Vestibular/Ocular-Motor Screening (VOMS) for Concussion
Vestibular/Ocular Motor Test:
BASELINE SYMPTOMS:

Not
Tested

Headache
0-10

Dizziness
0-10

Nausea
0-10

Fogginess
0-10

Comments

N/A

Smooth Pursuits
Saccades – Horizontal
Saccades – Vertical
Convergence (Near Point)

VOR – Horizontal
VOR – Vertical
Visual Motion Sensitivity Test

Instructions:
Interpretation: This test is designed for use with subjects ages 9-40. When
used with patients outside this age range, interpretation may vary. Abnormal
findings or provocation of symptoms with any test may indicate dysfunction –
and should trigger a referral to the appropriate health care professional for more
detailed assessment and management.
Equipment: Tape measure (cm); Metronome; Target w/ 14 point font print.
Baseline Symptoms – Record: Headache, Dizziness, Nausea & Fogginess on
0-10 scale prior to beginning screening


Smooth Pursuits - Test the ability to follow a slowly moving target. The
patient and the examiner are seated. The examiner holds a fingertip at a
distance of 3 ft. from the patient. The patient is instructed to maintain focus
on the target as the examiner moves the target smoothly in the horizontal
direction 1.5 ft. to the right and 1.5 ft. to the left of midline. One repetition is
complete when the target moves back and forth to the starting position, and
2 repetitions are performed. The target should be moved at a rate requiring
approximately 2 seconds to go fully from left to right and 2 seconds to go
fully from right to left. The test is repeated with the examiner moving the
target smoothly and slowly in the vertical direction 1.5 ft. above and 1.5 ft.
below midline for 2 complete repetitions up and down. Again, the target
should be moved at a rate requiring approximately 2 seconds to move the
eyes fully upward and 2 seconds to move fully downward. Record:
Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 1)



Saccades – Test the ability of the eyes to move quickly between targets.
The patient and the examiner are seated.
 Horizontal Saccades: The examiner holds two single points
(fingertips) horizontally at a distance of 3 ft. from the patient, and 1.5
ft. to the right and 1.5 ft. to the left of midline so that the patient must
gaze 30 degrees to left and 30 degrees to the right. Instruct the

(Near Point in cm):
Measure 1: ______
Measure 2:______
Measure 3:______

COMBINED CARE IN CONCUSSION TREATMENT



121

Vertical Saccades: Repeat the test with 2 points held vertically at a distance of 3 ft.
from the patient, and 1.5 feet above and 1.5 feet below midline so that the patient
must gaze 30 degrees upward and 30 degrees downward. Instruct the patient to
move their eyes as quickly as possible from point to point. One repetition is
complete when the eyes move up and down to the starting position, and 10
repetitions are performed. Record: Headache, Dizziness, Nausea & Fogginess
ratings after the test. (Figure 3)



Convergence – Measure the ability to view a near target without double vision. The patient
is seated and wearing corrective lenses (if needed). The examiner is seated front of the
patient and observes their eye movement during this test. The patient focuses on a small
target (approximately 14 point font size) at arm’s length and slowly brings it toward the tip of
their nose. The patient is instructed to stop moving the target when they see two distinct
images or when the examiner observes an outward deviation of one eye. Blurring of the
image is ignored. The distance in cm. between target and the tip of nose is measured and
recorded. This is repeated a total of 3 times with measures recorded each time. Record:
Headache, Dizziness, Nausea & Fogginess ratings after the test. Abnormal: Near Point of
convergence ≥ 6 cm from the tip of the nose. (Figure 4)



Vestibular-Ocular Reflex (VOR) Test – Assess the ability to stabilize vision as the head
moves. The patient and the examiner are seated. The examiner holds a target of
approximately 14 point font size in front of the patient in midline at a distance of 3 ft.
 Horizontal VOR Test: The patient is asked to rotate their head horizontally while
maintaining focus on the target. The head is moved at an amplitude of 20 degrees
to each side and a metronome is used to ensure the speed of rotation is maintained
at 180 beats/minute (one beat in each direction). One repetition is complete when
the head moves back and forth to the starting position, and 10 repetitions are
performed. Record: Headache, Dizziness, Nausea and Fogginess ratings 10 sec
after the test is completed. (Figure 5)
 Vertical VOR Test: The test is repeated with the patient moving their head
vertically. The head is moved in an amplitude of 20 degrees up and 20 degrees
down and a metronome is used to ensure the speed of movement is maintained at
180 beats/minute (one beat in each direction). One repetition is complete when the
head moves up and down to the starting position, and 10 repetitions are performed.
Record: Headache, Dizziness, Nausea and Fogginess ratings after the test. (Figure
6)



Visual Motion Sensitivity (VMS) Test – Test visual motion sensitivity and the ability to
inhibit vestibular-induced eye movements using vision. The patient stands with feet
shoulder width apart, facing a busy area of the clinic. The examiner stands next to and
slightly behind the patient, so that the patient is guarded but the movement can be
performed freely. The patient holds arm outstretched and focuses on their thumb.
Maintaining focus on their thumb, the patient rotates, together as a unit, their head, eyes
and trunk at an amplitude of 80 degrees to the right and 80 degrees to the left. A
metronome is used to ensure the speed of rotation is maintained at 50 beats/min (one beat
in each direction). One repetition is complete when the trunk rotates back and forth to the
starting position, and 5 repetitions are performed. Record: Headache, Dizziness, Nausea &
Fogginess ratings after the test. (Figure 7)

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C3
Chart Abstraction Form

122

123

COMBINED CARE IN CONCUSSION TREATMENT

ID#
ID#__________
__________

Staff:_________
Staff:_________

Date:________
Date:________

Chart Abstraction Form
DOI:

Date of Visit:

MOI:

LOC

Yes
No

Hx of
Migraine

Yes
No

Anxiety hx

Yes
No

PTA

Yes
No

Hx
undiagnosed
migraine

Yes
No

Fam hx
anxiety

Yes
No

Disorientation

Yes
No

Hx family
migraine

Yes
No

Depression hx

Yes
No

Confusion

Yes
No

Motion
Sickness

Yes
No

Fam hx
depression

Yes
No

Ocular
disorder/dys

Yes
No

Concussion hx # previous:
Yes
Date:
No

ADHD/LD

Current Grade: _________

Returned to school (Y/N):_______

VOMS
Headache Dizziness Nausea Fogginess
Baseline
Smooth Pursuits
HOR Saccades
VER Saccades

Measure 1:
Measure 2:
Measure 3:

Convergence
Horizontal VOR
Vertical VOR
Visual Motor
Sensitivity
TOTALS
Date of next visit: __________________________________
Referred to vestibular: ______

Date of clearance: ___________

Clinical profile(s): ________________________

Treatment referrals:

Comments

_____________________

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C4
Data Collection Form

124

Baseline 1/10/2018 1 1/1/2018

Total Symptom Score
PCSS Total

Treatment Type

19 m 43 81 41 0.63 2
0
8
Intervention

Reaction Time Comp

Vis. Motor Speed Comp

Verb. Memory Comp

Vis. Memory Comp.

Sex

Impulse Control Comp

N/A

Age

Date of clearance

Date of Concussion

Exam #

Date of Exam

Exam Type

COMBINED CARE IN CONCUSSION TREATMENT
125

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C5
Sample Consent Forms

126

COMBINED CARE IN CONCUSSION TREATMENT

127

CONSENT TO PARTICIPATE IN A RESEARCH STUDY
TITLE: Emotional functioning and post-concussion outcomes among youths
PRINCIPAL INVESTIGATOR:

Anthony Kontos, Ph.D. Assistant Research Director
Telephone: (412) 432-3725
3200 South Water Street
Pittsburgh, PA 15203
UPMC Sports Medicine Concussion Program

CO-INVESTIGATORS:
Nathan Kegel, PhD
Clinical Neuropsychologist
UPMC Sports Medicine Concussion Program
3858 South Water Street
Pittsburgh, PA 15203
Telephone: (412) 904-1298

Natalie Sandel, PsyD
Neuropsychology Fellow
UPMC Sports Medicine Concussion Program
3858 South Water Street
Pittsburgh, PA 15203
Telephone: (412) 904-1298

Alicia Sufrinko, PhD
Clinical Neuropsychologist
UPMC Sports Medicine Concussion Program
3858 South Water Street
Pittsburgh, PA 15203
Telephone: (412) 904-1298

Daniel Charek, PhD
Neuropsychology Fellow
UPMC Sports Medicine Concussion Program
3858 South Water Street
Pittsburgh, PA 15203
Telephone: (412) 904-1298

Brandon Gillie, PhD
Neuropsychology Fellow
UPMC Sports Medicine Concussion Program
3858 South Water Street
Pittsburgh, PA 15203
Telephone: (412) 904-1298

Michael W. Collins, PhD
Clinical Neuropsychology
UPMC Sports Medicine Concussion Program
3858 South Water Street
Pittsburgh, PA 15203
Telephone: (412) 904-1298

Johnathan French, PsyD
Neuropsychology Fellow
UPMC Sports Medicine Concussion Program
3858 South Water Street
Pittsburgh, PA 15203
Telephone: (412) 904-1298

Concussion Program Research Staff:
UPMC Sports Medicine Concussion Program
3858 South Water Street, Pittsburgh, PA 15203
Telephone: (412) 904-1298

COMBINED CARE IN CONCUSSION TREATMENT

•
•
•
•
•

128

Cynthia Holland, MPH, Project Coordinator
Valerie Reeves, PhD, Research Coordinator
Hannah Bitzer, B.S., Research Assistant
Andrew Rosse, B.S., Research Assistant
Nick Blaney, B.S., Research Assistant

SOURCE: UPMC Rooney Sports Medicine Concussion
Program
Why is this research being done?
This research study will examine the relationships among pre-injury and concurrent emotional
functioning and several post-concussion outcomes including neurocognitive performance,
symptom report, vestibular-ocular functioning, and recovery time among concussed patients. We
will examine gender differences, differences among subjects with and without history of
concussion, recovery trajectories for neurocognitive data/symptom report/vestibular dysfunction.
140 people will participate in this study.
Who is being asked to take part in this research study?
Subjects eligible for participation in this study must be between the ages of 10-18 years of age.
You/your child must have been diagnosed with a concussion within the past 30 days as determined
by The University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program.
What procedures will be performed for research purposes?
The following measures will be completed at your/your child’s first visit:
• SCARED – Child Version (Screening for Child Anxiety Related Disorders):
Questionnaire designed to rate degree of anxiety symptoms experienced with the past
three months, prior to injury.
• SCARED – Parent Version (Screening for Child Anxiety Related Disorders):
Questionnaire designed to quantify a parent’s perception of their child’s anxiety
symptoms experienced with the past three months, prior to injury.
• Generalized Anxiety Disorder Screen – 7 Item: Questionnaire designed to rate degree
of anxiety/worry experienced with the past two weeks.
• Mood and Feelings Questionnaire – Short Version: Questionnaire designed to rate
degree of depression symptoms experienced with the past three months, prior to injury.
The following measures will be completed at your/your child’s follow-up visits:
• Generalized Anxiety Disorder Screen – 7 Item: Questionnaire designed to rate degree
of anxiety/worry experienced with the past two weeks.
• Mood and Feelings Questionnaire – Short Version: Questionnaire designed to rate
degree of depression symptoms experienced with the past three months, prior to injury.
We will also request your authorization to collect information from your/your child’s clinical
medical record. Study staff will only access your medical records until your/your child’s clinical
clearance visit This may include ImPACT® (Immediate Post-Concussion Assessment and

COMBINED CARE IN CONCUSSION TREATMENT

129

Cognitive Testing), PCSS (Post-Concussion Symptom Scale) scores, VOMS (Vestibular and
Ocular Motor Screening), Medical History information and other information regarding injury,
treatment and clearance. This information will allow research study staff to gain a better
understanding of the link between pre and post injury emotional functioning and injury/recovery
outcomes.

What are the possible risks, side effects, and discomforts of this research study?
Some people feel uncomfortable answering questions of a personal nature or become fatigued or
frustrated. Study subjects can refuse to answer any questions or questionnaires that make them
uncomfortable or take breaks at any time.
While all information about subjects and their participation in this research study will be handled
in a confidential (private) manner, a breach of confidentiality is a potential risk. To minimize this
risk, you/your child will be identified using a coded ID number on all documentation for the study.
The master list of coded numbers will be kept in locked file cabinets accessible only to the
researchers. All study data and information will be kept on a secure password protected database,
in a locked office.

What are possible benefits from taking part in this study?
There are no direct benefits for being in this study. However, the study will enhance our
understanding of concussion and may provide a better measure of concussion outcomes.
Will my/my child’s insurance provider or I be charged for the costs of any procedures
performed as part of this research study?
No, study subjects will not be billed for study measures. However, all study measures will be
completed at clinical visits which will be billed to you/your child’s health insurance company and
you will be responsible for paying any deductibles, co-payments or co-insurance that are a normal
part of the health insurance plan. If the child does not have health insurance, you will be
responsible for all clinic costs.
Will study subjects be paid to take part in this research study?
Study subjects will not be compensated for participation in this study.
How long will this study take?
This study should take 10-15 minutes of your time.
Who will know about my/my child’s participation in this research study?
Any information about you/your child obtained from this research will be kept as confidential
(private) as possible. All records related to your/your child’s involvement in this research study
will be stored in a locked file cabinet. Your/your child’s identity on these records will be indicated
by a coded ID number rather than by name, and the information linking these ID numbers with
participant identity will be kept separate from the research records in a locked file cabinet. All
electronic study records will be kept on secure, password protected computers, behind the UPMC

COMBINED CARE IN CONCUSSION TREATMENT

130

firewalls, in locked offices. You/Your child will not be identified by name in any publication of
the research results.
Any study data or information shared with other investigators will be de-identified and no linking
information will be provided.

Will this research study involve the use or disclosure of identifiable medical
information? If you/your child completed ImPACT®, PCSS, and VOMS during standard
clinical care, it is possible that the data could be retrieved from the medical file. The research
staff may also obtain information regarding medical history or information about this injury.
Information may be obtained from your medical records and used by this research team until
completion of the study.
Will information from this research study be placed in the medical record?
No, information from study participation will not be included into your/your child’s clinical
medical record.
Who will have access to identifiable medical record information related to participation
in this research study?
Authorized representatives of the University of Pittsburgh Research Conduct and Compliance
Office may review your/your child’s identifiable research information for the purpose of
monitoring the appropriate conduct of this research study.
In unusual cases, the investigators may be required to release identifiable information related to
your/your child’s participation in this research study in response to an order from a court of law.
If the investigators learn that you/your child or someone with whom they are involved is in serious
danger or potential harm, they will need to inform, as required by Pennsylvania law, the
appropriate agencies.
Authorized representatives of the UPMC hospitals or other affiliated health care providers may
have access to identifiable information related to your/your child’s participation in this research
study for the purpose of (1) fulfilling orders, made by the investigators, for hospital and health
care services (e.g., laboratory tests, diagnostic procedures) associated with research study
participation; (2) addressing correct payment for tests and procedures ordered by the investigators;
and/or (3) for internal hospital operations (i.e., quality assurance).
We will protect you/your child’s privacy and the confidentiality of your records, as described in
this document, but cannot guarantee the confidentiality of your research records, including
information obtained from your medical records, once your personal information is disclosed to
others outside UPMC

For how long will the investigators be permitted to use and disclose identifiable
information related to participation in this research study?

COMBINED CARE IN CONCUSSION TREATMENT

131

The investigators may continue to use and disclose, for the purposes described above, identifiable
information related to your/your child’s participation in this research all research records must be
maintained for at least 7 years following final reporting or publication of a project. For projects
involving children, records must be maintained for 5 years past age of majority (age 23 per PA
State law) after study participation ends.
You/your child’s participation in this research study, to include the use and disclosure of
identifiable information for the purposes described above, is completely voluntary. (Note,
however, that if you do not provide your consent for the use and disclosure of your/your child’s
identifiable information for the purposes described above, your child will not be allowed to
participate in the research study.) Whether or not you provide your consent for your/your child’s
participation in this research study will have no effect on your and your child’s current or future
relationship with the University of Pittsburgh. Whether or not you provide your consent for
your/your child’s participation in this research study will have no effect on current or future
medical care at a UPMC hospital or affiliated health care provider or his/her current or future
relationship with a health care insurance provider.
Your/Your child’s doctor may be involved as an investigator in this research study. As both
your/your child’s doctor and a research investigator, s/he is interested both in your/your child’s
medical care and the conduct of this research study. Before agreeing to participate in this research
study, or at any time during study participation, you may discuss your/your child’s care with
another doctor who is not associated with this research study. You are not under any obligation
to participate in any research study offered by your/your child’s doctor

Is participation in this research study voluntary?
Your/your child’s participation in this research study, to include the use and disclosure of their
identifiable information for the purposes described above, is completely voluntary. (Note,
however, that if you do not provide your assent for the use and disclosure of your/your child’s
identifiable information for the purposes described above, they will not be allowed to participate
in the research study.) Whether or not you provide your assent for participation in this research
study will have no effect on your you/your child’s current or future medical care at a UPMC
hospital or affiliated health care provider or current or future relationship with a health care
insurance provider.
May I withdraw, at a future date, consent for participation in this research study?
You/your child may withdraw, at any time, consent for participation in this research study, to
include the use and disclosure of your/your child’s identifiable information for the purposes
described above. (Note, however, that if you withdraw your/your child’s consent for the use and
disclosure of your/your child’s identifiable medical record information for the purposes
described above, you/your child will also be withdrawn, in general, from further participation in
this research study.) Any identifiable research or medical information recorded for, or resulting
from, your/your child’s participation in this research study prior to the date that you formally
withdrew your consent may continue to be used and disclosed by the investigators for the
purposes described above.

COMBINED CARE IN CONCUSSION TREATMENT

132

To formally withdraw your/your child’s consent for participation in this research study you
should provide a written and dated notice of this decision to the principal investigator of this
research study at the address listed on the first page of this form
Your decision to withdraw your/your child’s consent for participation in this research study will
have no effect on current or future relationship with the University of Pittsburgh. Your decision
to withdraw your/your child’s consent for participation in this research study will have no effect
on your/your child’s current or future medical care at a UPMC hospital or affiliated health care
provider or current or future relationship with a health care insurance provider.
*****************************************************************************
*
VOLUNTARY CONSENT (For subjects 18 years old and older)
The above information has been explained to me and all of my current questions have been
answered. I understand that I am encouraged to ask questions about any aspect of this research
study during the course of this study, and that such future questions will be answered by a
qualified individual or by the investigator(s) listed on the first page of this consent document at
the telephone number(s) given. I understand that I may always request that my questions,
concerns or complaints be addressed by a listed investigator.
I understand that I may contact the Human Subjects Protection Advocate of the IRB Office,
University of Pittsburgh (1-866-212-2668) to discuss problems, concerns, and questions; obtain
information; offer input; or discuss situations in the event that the research team is unavailable.
A copy of this consent form will be given to me.
By signing this form, I give my consent for participation in this research study and I authorize the
use of my medical records as indicated in this consent form.

______________________________
Participant’s Name (Print)

_____________________________
Participant’s Signature

___________________________
Date

CERTIFICATION of INFORMED CONSENT
I certify that I have explained the nature and purpose of this research study to the above-named
individual(s), and I have discussed the potential benefits and possible risks of study participation.
I further certify that no research component of this protocol was begun until after this consent form
was signed. Any questions the individual(s) have about this study have been answered, and we
will always be
available to address future questions as they arise.

COMBINED CARE IN CONCUSSION TREATMENT

___________________________________
Printed Name of Person Obtaining Consent

________________________
Role in Research Study

_________________________________
Signature of Person Obtaining Consent

_______________________
Date

133

******************************************************************************
******* PARENTAL PERMISSION (For subjects under 18 years old)
The above information has been explained to me and all of my current questions have been
answered. I understand that I am encouraged to ask questions about any aspect of this research
study during the course of this study, and that such future questions will be answered by a
qualified individual or by the investigator(s) listed on the first page of this consent document at
the telephone number(s) given. I understand that I may always request that my questions,
concerns or complaints be addressed by a listed investigator.
I understand that I may contact the Human Subjects Protection Advocate of the IRB Office,
University of Pittsburgh (1-866-212-2668) to discuss problems, concerns, and questions; obtain
information; offer input; or discuss situations in the event that the research team is unavailable.
A copy of this consent form will be given to me.

____________________________
Participant’s Name
I understand that, as a minor (age less than 18 years), the above-named child is not permitted to
participate in this research study without my consent. Therefore, by signing this form, I give my
consent for his/her participation in this research study and I authorize the use of his/her medical
records as indicated in this consent form.

______________________________
Parent’s Name (Print)

____________________________
Relationship to Participant (Child)

_____________________________
Parent’s Signature

___________________________
Date

134

COMBINED CARE IN CONCUSSION TREATMENT

CHILD ASSENT
By signing this form, I agree to participate in this research study.

____________________________

___________

Child’s Signature

Printed Name of Child

Date

VERIFICATION of EXPLANATION
I certify that I have carefully explained the purpose and nature of this research study to the
above-named participant in appropriate language. He/she has had an opportunity to discuss it
with me in detail. I have answered all his/her questions and he/she has provided affirmative
agreement (i.e., assent) to participate in this study.

___________________________________
Printed Name of Person Obtaining Assent

________________________
Role in Research Study

_________________________________
Signature of Person Obtaining Assent

_______________________
Date

CONSENT FOR CONTINUED RESEARCH PARTICIPATION
I understand that I am currently participating in a research study. I further understand that consent
for my participation in this research study was initially obtained from my parent or legal guardian
because I was a minor (under 18 years of age). I have now reached age 18, and I am able to provide
my own direct consent for participation and I authorize the use of my medical records as indicated
in this consent form.".
All of the above has been explained to me and all of my current questions have been answered. I
understand that I am encouraged to ask questions about any aspect of this research study during
the continuation of this study, and that such future questions will be answered by the researchers
listed on the first page of this form. I also understand that any questions I have about my rights as
a research participant will be answered by the Human Subject Protection Advocate of the IRB
Office, University of Pittsburgh (1-866-212-2668).
By signing below, I agree to continue my participation in this research study and I authorize the
use of my medical records as indicated in this consent form. A copy of this consent form will be
given to me.

COMBINED CARE IN CONCUSSION TREATMENT

______________________________
Participant’s Signature

135

____________
Date

CERTIFICATION of INFORMED CONSENT
I certify that I have explained the nature and purpose of this research study to the above-named
individual(s), and I have discussed the potential benefits and possible risks of study participation.
Any questions the individual(s) have about this study have been answered, and we will always be
available to address future questions as they arise.”

___________________________________
Printed Name of Person Obtaining Consent

________________________
Role in Research Study

_________________________________
Signature of Person Obtaining Consent

____________
Date

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C6
IRB Approval of Submission

136

COMBINED CARE IN CONCUSSION TREATMENT

137

Institutional Review Board
California University of Pennsylvania
Morgan Hall, 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Melissa Sovak, Ph.D.

Dear Patrick,

Please consider this email as official notification that your proposal
titled “The Effect of Collaborative Care in Concussion Treatment with
Adolescents and Young Adults as Measured on the ImPACT®”
(Proposal #18-069) has been approved by the California University of
Pennsylvania Institutional Review Board as amended.

The effective date of approval is 6/18/19 and the expiration date is
6/17/20. These dates must appear on the consent form.

Please note that Federal Policy requires that you notify the IRB
promptly regarding any of the following:

COMBINED CARE IN CONCUSSION TREATMENT

138

(1) Any additions or changes in procedures you might wish for your
study (additions or changes must be approved by the IRB before they
are implemented)

(2) Any events that affect the safety or well-being of subjects

(3) Any modifications of your study or other responses that are
necessitated by any events reported in (2).

(4) To continue your research beyond the approval expiration date of
6/17/20 you must file additional information to be considered for
continuing review. Please contact instreviewboard@calu.edu

Please notify the Board when data collection is complete.

Regards,

Melissa Sovak, PhD.
Chair, Institutional Review Board

139

COMBINED CARE IN CONCUSSION TREATMENT

University of Pittsburgh
Institutional Review Board Avenue

Human Research Protection Office 3500 Fifth
Suite 106 Pittsburgh, PA 15213
Tel (412) 383-1480 www.hrpo@pitt.edu

APPROVAL OF SUBMISSION (Exempt)
IRB:
PI:
Title:

STUDY19030400
Anthony Kontos
The Effect of Collaborative Care in Concussion Treatment with Adolescents And Young
Adults as Measured on the IMPACT®

Funding:
Date:

None
May 22, 2019

On 5/22/2019, the Institutional Review Board reviewed and approved the above
referenced application through the administrative review process. The study may begin
as outlined in the University of Pittsburgh approved application and documents.
Approval Documentation
Review type:
Approval Date:

Initial Study
5/22/2019

Exempt Category:
Determinations:

(4) Secondary research on data or specimens (no consent required)
• Waiver of HIPAA authorization

Approved
Documents:

• Chart Abstraction Form

As the Principal Investigator, you are responsible for the conduct of the research and to
ensure accurate documentation, protocol compliance, reporting of possibly study-related
adverse events and unanticipated problems involving risk to subjects or others. The HRPO
Reportable Events policy, Chapter 17, is available at http://www.hrpo.pitt.edu/.
Research being conducted in an UPMC facility cannot begin until fiscal approval is
received from the UPMC Office of Sponsored Programs and Research Support (OSPARS).
Contact OSPARS@upmc.edu with questions.
If you have any questions, please contact the University of Pittsburgh IRB Coordinator, Amy
Fuhrman.

COMBINED CARE IN CONCUSSION TREATMENT

Appendix C7
Certificates of IRB Training

140

COMBINED CARE IN CONCUSSION TREATMENT

141

COMBINED CARE IN CONCUSSION TREATMENT

142

COMBINED CARE IN CONCUSSION TREATMENT

143

COMBINED CARE IN CONCUSSION TREATMENT

144

COMBINED CARE IN CONCUSSION TREATMENT

145

COMBINED CARE IN CONCUSSION TREATMENT

146

References

Allen, B.J., & Gfeller, J.D. (2010). The immediate post-concussion assessment and
cognitive testing battery and traditional neuropsychological measures: A construct
and concurrent validity study. Brain Injury, 25(2), 179-191.
https://doi.org/10.3109/02699052.2010.541897
Alsalaheen, B., Stockdale, K., Pcchumer, D., &Broglio, S.P. (2016). Validity of the
immediate post concussion assessment and cognitive testing (ImPACT®). Sports
Med, 46, 1487-1501. https://doi.org/10.1007/s40279-016-0532-y
Alsalaheen, B.A., Mucha, A., Morris, L.O., Whitney, S.L., Furman, J.M., CamioloReddy, C.E…Sparto, P.J. (2010). Vestibular rehabilitation for dizziness and
balance disorders after concussion. Journal of Neurologic Physical Therapy,
34(2), 87-93. https://doi.org/10.1097/NPT.0b013e3181dde568
Alsalaheen, B.A., Whitney, S.L., Mucha, A., Morris, L.O., Furman, J.M., & Sparto, P.J.
(2013). Exercise prescription patterns in patients treated with vestibular
rehabilitation after concussion. Physiotherapy Research Institute, 18(2013), 100108. https://doi.org/10.1002/pri.1532
Asarnow, J.R., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated medicalbehavioral care compared with usual primary care for children and adolescent
behavioral health. Journal of the American Medical Association Pediatrics,
169(10). https://doi.org/10.1001/jamapediatrics.2015.1141

COMBINED CARE IN CONCUSSION TREATMENT

147

Belanger, H.G., Barwick, F., Silva, M.A., Kretzmer, T., Kip, K.E., & Vanderploeg, R.D.
(2015). Web-based psychoeducational intervention for postconcussive symptoms:
A randomized trial. Military Medicine, 180(2), 192-200.
https://doi.org/10.7205/MILMED-D-14-00388
Brent, D.A., & Max, J. (2017). Psychiatric Sequelae of Concussions. Current Psychiatry
Reports, 19(108), 1-8. https://doi.org/10.1007/s11920-017-0862-y
Brody, D.L. (2015). Concussion Care Manual. New York, Oxford University Press.
Brown, N.J., Mannix, R.C., O’Brien, M.J., Gostine, D., Collins, M.W., & Meehan, W.P.
(2014). Effect of cognitive activity level on duration of post-concussive
symptoms. The American Academy of Pediatrics, 133(2), 299-304.
https://doi.org/10.1542/peds.2013-2125
Bryan, M.A., Rowhani-Rahbar, A., Comstock, R.D., & Rivara, F. on behalf of the Seattle
Sports Concussion Research Collaborative (2016). Sports and recreation-related
concussions in US youth. Pediatrics, 138(1). https://doi.org/10.1542/peds.20154635
Cantor, J., Ashman, T., Dams-O’Connor, K., Dijkers, M.P., Gordon, W., Spielman, L.,
…Oswald, J. (2014). Evaluation of the short-term executive plus intervention for
executive dysfunction after traumatic brain injury: A randomized controlled trial
with minimization. Archives of Physical Medicine and Rehabilitation, 95(1), 1-9.
https://doi.org/10.1016/j.apmr.2013.08.005

COMBINED CARE IN CONCUSSION TREATMENT

148

Centers for Disease Control and Prevention (2019). Surveillance Report of Traumatic
Brain Injury-related Emergency Department Visits, Hospitalizations, and
Deaths—United States, 2014. Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services.
Chan, C., Iverson, G.L., Purtzki, J., Wong, K., Kwan, V., Gangnon, I., & Silverberg,
N.D. (2018). Original research: Safety of active rehabilitation for persistent
symptoms after pediatric sport-related concussion: A randomized controlled trial.
Physical Medicine and Rehabilitation, 99(2), 242-249.
https://doi.org/10.1016/j.apmr.2017.09.108
Chrisman, S., & Richardson, L.P. (2014). Prevalence of diagnosed depression in
adolescents with history of concussion. Journal of Adolescent Health, 54(5), 582586. https://www.doi.org/10.1016/j.jadohealth.2013.10.006
Clark, J., Hasselfeld, K., Bigsby, K., & Divine, J. (2017). Colored glasses to mitigate
photophobia symptoms posttraumatic brain injury. Journal of Athletic Training,
52(8), 725-729. https://doi.org/10.4085/1062-6050-52.4.04
Coleman, J. (2016). Concussion diagnosis and management best practices. Retrieved
from:http://www.ncaa.org/sport-science-institute/concussion-diagnosis-andmanagement-best-practices
Collins, M.W., Kontos, A.P., Okonkwo, D.O, Almquist, J., Bailes, J., Barisa, M., … &
Zafonte, R. (2016). Concussion is treatable: Statements of agreement from the

COMBINED CARE IN CONCUSSION TREATMENT

149

Targeted Evaluation and Active Management (TEAM) approaches to treating
concussion meeting held in Pittsburg, October 15-16, 2015. Neurosurgery, 79(6),
912-929. https://doi.org/10.1227/NEU.0000000000001447
Conder, R., & Conder, A.A. (2015). Neuropsychological and psychological rehabilitation
interventions in refractory sport-related concussive syndrome. Brain Injury, 29(2),
249-262. https://doi.org/10.3109/02699052.2014.965209
Covassin, T., Elbin, R.J., Stiller-Ostrowski, J.L., & Kontos, A.P. (2009). Immediate postconcussion assessment and cognitive testing (ImPACT®) practices of sports
medicine professionals. Journal of Athletic Training, 44(6), 639-644.
https://doi.org/10.4085/1062-6050-44.6.639
Cresswell, J. (2015). Collecting Quantitative Data. In G. Gottfired & C. Griscom (Eds.),
Educational Research (5th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Dachtyl, S.A., & Morales, P. (2017). A collaborative model for return to academics after
concussion: Athletic Training and speech-language pathology. American Journal
of Speech-Language Pathology, 26, 716-728. Retrieved from:
https://ajslp.pubs.asha.org/
Daneshvar, D.H., Nowinski, C.J., McKee, A., & Cantu, R.C. (2011). The epidemiology
of sport-related concussion. Clin Sports Med, 30(1), 1-17.
https://doi.org/10.1016/j.csm.2010.08.006

COMBINED CARE IN CONCUSSION TREATMENT

150

Elbin, R.J., Schatz, P., & Covassin, T. (2011). One-year test-retest reliability of the online
version of ImPACT® in high school athletes. The Journal of Sports Medicine,
39(11). 2319-2324. https://doi.org/10.1177/0363546511417173
Fimreite, V., Willeford, K.T., & Ciuffreda, K.J. (2016). Effect of chromatic filters on
visual Performance in individuals with mild traumatic brain injury (mTBI): A
pilot study. Journal of Optometry, 9, 231-239.
http://dx.doi.org/10.1016/j.optom.2016.04.004
Gagnon, I., Grilli, L., Friedman, D., & Iverson, G.L. (2016). A pilot study of active
rehabilitation for adolescents who are slow to recover from sport-related
concussion. Scandinavian Journal of Medicine and Science in Sports, 26, 299306.https://doi.org/10.1111\sms.12441
Guskiewicz, K.M., McCrea, M., Marshall, S.W., Cantu, R.C., Randolph, C., Barr, W., …
Kelly, J.P. (2003). Cumulative effects associated with recurrent concussion in
collegiate football players. Journal of the American Medical Association, 290(19),
2549-2555. https://doi.org/10.1001/jama.290.19.2549
Hecimovich, M., King, D., Dempsey, A.R., & Murphy, M. (2018). The King-Devick test
is a valid and reliable tool for assessing sport-related concussion in Australian
football: A prospective cohort study. Journal of Science and Medicine in Sport,
21(10), 1004-1007. https://doi.org/10.1016/j.jsams.2018.03.011

COMBINED CARE IN CONCUSSION TREATMENT

151

Hobbs, J.G., Young, J.S., & Bailes, J.E. (2016). Sports-related concussions: Diagnosis,
complications, and current management strategies. Neurosurgery Focus, 40(4), 114. https://doi.org/10.3171/2016.1.FOCUS15617
ImPACT® Applications, Inc. (2007). ImPACT® Interpretation Manual: User Manual.
Retrieved from:
http://images.pcmac.org/Uploads/PortageAreaSD/PortageAreaSD/Departments/D
ocumentsCategories/Documents/Interpreting_the_ImPACT®_Clinical_Report.pd
f
Kleffelgaard, I., Soberg, H.L., Bruusgaard, K.A., Tamber, A.L., & Langhammer, B.
(2016). Vestibular rehabilitation after traumatic brain injury: Case series. Physical
Therapy, 96(6), 839-848. https://doi.org/10/2522/ptj.20150095
Kontos, A.P., & Collins, M.W. (2018). Concussion: A clinical profile approach to
assessment and treatment. Washington, DC: American Psychological
Association.
Kontos, A.P., Deitrick, J.M., Collins, M.W., & Mucha, A. (2017). Review of vestibular
and oculomotor screening and concussion rehabilitation. Journal of Athletic
Training, 52(3), 256-261. https://doi.org/10.4085/1062-6050-51.11.05
Kontos, A.P., Elbin, R.J., Appaneal, R.N., Covassin, T., & Collins, M.W. (2013). A
comparison of coping responses among high school and college athletes with

COMBINED CARE IN CONCUSSION TREATMENT

152

concussion, orthopedic injuries, and healthy controls. Research in Sports
Medicine, 21, 367-379. https://doi.org/10.1080/15438627.2013.825801
Kontos, A.P., Sufrinko, A., Sandel, N., Amami, K., & Collins, M.W. (2019). Sportsrelated concussion clinical profiles: Clinical characteristics, targeted treatments,
and preliminary evidence. Current Sports Medicine Reports, 18(3), 82-92.
https://doi.org/10.1249/JSR.000000000000573
Langlois, J. A., Rutland-Brown, W., & Thomas, K. E. (2006). Traumatic Brain injury in
the United States: Emergency department visits, hospitalizations, and deaths.
Atlanta, GA: Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control.
Lee., Y.M., Odom, M.J., Zuckerman, S.L., Solomon, G.S., & Sills, A.K. (2013). Does
age affect symptom recovery after sports-related concussion? A study of high
school and college athletes. Journal of Neurosurgery: Pediatrics, 12. 537-544.
https://doi.org/10.3171/2013.7.PEDS12572
Lee, Y.M., Wu, A., Zuckerman, S.L., Stanko, K.M., LaChaud, G.Y., Solomon, G.S., &
Sills, A.K. (2016). Obesity and neurocognitive recovery after sports-related
concussion in athletes: A matched cohort study. The Physician and
Sportsmedicine, 44(3), 217-222. https://doi.org/10.1080/00913847.2016.1216718
Maerlender, A., Rieman, W., Lichtenstein, J., & Condiracci, C. (2015). Programmed
physical exertion in recovery from sports-related concussion: A randomized pilot

COMBINED CARE IN CONCUSSION TREATMENT

153

study. Development Neuropsychology, 40(5), 273-278.
https://doi.org/10.1080/8756564.10677
Makdissi, M., Schneider K.J., Feddermann-Demont, N., Guskiewicz, K.M., Hinds, S.,
Leddy, J.L., …Johnston, K.L. (2017). Approach to investigation and treatment of
persistent symptoms following sport-related concussion: A systematic review.
British Journal of Sports Medicine, 51(12), 958-968.
https://doi.org/10.1136/bjsports-2016-097470 . Epub 2017 May 8.
Matuseviciene, G., Eriksson, G., & DeBoussard, C.N. (2016). No effect of an early
intervention after mild traumatic brain injury on activity and participation: A
randomized controlled trial. Journal of Rehabilitation Medicine, 48, 19-26.
https://doi.org/10.2340/16501977-2025
McCarty, C.A., Zatzick, D., Stein, E., Wang, J., Hilt, R., & Rivara, F.P. (2016).
Collaborative care for adolescents with persistent postconcussive symptoms: A
randomized trial. Pediatrics, 138(4), 1-13. https://doi.org/10.1542/peds.20160459
McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., … & Vos, P.
(2017). Consensus statement on concussion in sport – the 5th international
conference on concussion in sport held in Berlin, October 2016. British Journal of
Sports Medicine, 0, 1-10. https://doi.org/10.1136/bjsports-2017-097699

COMBINED CARE IN CONCUSSION TREATMENT

154

McLernon, S. (2014). The Glasgow Coma Scale 40 years on: A review of its practical
use. British Journal of Neuroscience Nursing, 10(4), 179-184. Retrieved from:
http://aann.org/publications/journal
Merritt, V.C., Bradson, M.L., Meyer, J.E., & Arnett, P.A. (2017). Evaluating the testretest reliability of symptom indices associated with the ImPACT® postconcussion symptom scale (PCSS). Journal of Clinical and Experimental
Neuropsychology, 40(4), 377-388.
https://doi.org/10.1080/12803395.2017.1353590
Mittenberg, W., Tremont, G., Zielinski, R.E., Fichera, S., & Rayls, K.R. (1996).
Cognitive-behavioral prevention of postconcussion syndrome. Archives of
Neuropsychology, 11(2), 139-145. https://doi.org/0887-6177(95)00006-2
Mrazik, M., Brooks, B.L., Jubinville, A., Meeuwisse, W.H., & Emery, C.A. (2016).
Psychosocial outcomes of sport concussions in youth hockey players. Archives of
Clinical Neuropsychology, 31, 297-304. https://doi.org/10.1093/arclin/acw013
Mucha, A., Colling, M.W., Elbin, R.J., Furman, J.M., Troutman-Eneski, C., DeWolf,
R.M., …& Kontos, A.P. (2014). A brief vestibular/ocular motor screening
(VOMS) assessment to evaluate concussions. The American Journal of Sports
Medicine, 42(10), 2479-2486. https://doi.org/10.1177/0363546514543775
Neidecker, J.M., Gealt., D.B., Luksch, J.R., & Weaver, M.D. (2017). First-time sportsrelated concussion recovery: The role of sex, age, and sport. The Journal of the

COMBINED CARE IN CONCUSSION TREATMENT

155

American Osteopathic Association, 117(10). 635-642.
https://doi.org/10.7556jaoa.2017.120
Nelson, L.D., Guskiewicz, K.M., Barr, W.B., Hammeke, T.A., Randolph, C., Ahn, K.W.,
…McCrea, M.A. (2016). Age differences in recovery after sport-related
concussion: A comparison of high school and collegiate athletes. Journal of
Athletic Training, 51(2), 142-152. https://doi.org/10.4085/1062-6050-51.4.04
Ramanathan, D.M., Rabinowitz, A.R., Barwick, F.H., & Arnett, P.A. (2011). Validity of
affect measurements in evaluating symptom reporting in athletes. Journal of the
International Neuropsychological Society, 18, 101-107.
https://doi.org/10.1017/S1355617711001457
Reardon, C.L., & Factor, R.M. (2010). Sport psychiatry a systematic review of diagnosis
and medical treatment of mental illness in athletes. Sports Med, 40(11), 961-980.
https://doi.org/10/0011-0961/$49.95/0
Rees, R.J., & Bellon, M.L. (2007). Post concussion syndrome ebb and flow: Longitudinal
effects and management. Neurorehabilitation, 22, 229-242. Available from
https://www.iospress.nl/journal/neurorehabilitation/
Root, J.M., Zuckerbraun, N.S., Wang, L., Winger, D.G., Brent, D., Kontos, A., &
Hickey, R.W. (2016). History of somatization is associated with prolonged
recovery from concussion. The Journal of Pediatrics, 174, 39-44.
https://doi.org/10.1016/j.jpeds.2016.03.020

COMBINED CARE IN CONCUSSION TREATMENT

156

Sandel, N., Reynolds, E., Cohen, P.E., Gillie, B.L., & Kontos, A.P. (2017). Anxiety and
mood clinical profile following sport-related concussion: From risk factors to
treatment. Sport, Exercise, and Performance Psychology, 6(3), 304-323.
https://doi.org/10.1037/spy0000098
Schatz, P., Pardini, J.E., Lovell, M.R., Collins, M.W., & Podell, K. (2006). Sensitivity
and specificity of the ImPACT® test battery for concussion in athletes. Archives
of Clinical Neuropsychology, 21, 91-99. https://doi.org/10/1016/j.acn.2005.08.001
Shapcott, E.J.B., Bloom, G.A., Johnston, K.M., Loughead, T.M., & Delaney, J.S. (2007).
The effects of explanatory style on concussion outcomes in sport.
NeuroRehabilitation, 22(3), 161-167. Retrieved from:
https://www.iospress.nl/journal/neurorehabilitation/
Silverberg, N.D., Hallam, B.J., Rose, A., Underwood, H., Whitfield, K., … & Whittal,
M.L. (2013). Cognitive-behavioral prevention of postconcussion syndrome in atrisk patients: A pilot randomized controlled trial. Journal of Head Trauma
Rehabilitation, 28(4), 313-322. https://doi.org/10.1097/HTR.0b013e3182915cb5
Sinnott, A. M., Elbin, R.J., Collins, M.W., Reeves, V.L., Holland, C.L., & Kontos, A.P.
(2019). Persistent vestibular-ocular impairment following concussion in
adolescents. Journal of Science and Medicine in Sport, 22(2019), 1292-1297.
https://doi.org/10.1016/j.sams.2019.08.004

COMBINED CARE IN CONCUSSION TREATMENT

157

Spikman, J.M., Boelen, D.H.E., Lamberts, K.F., Brouwer, W.H., & Fasotti, L. (2009).
Effects of a Multifaceted treatment programme for executive dysfunction after
acquired brain injury on indications of executive functioning in daily life. Journal
of the International Neuropsychological Society, 16(1),118-129.
https://doi.org/10.1017/S1355617709991020
Steer, R.A., Cavalieri, T.A., Leonard, D.M., & Beck, A.T. (1999). The Beck Depression
Inventory for primary care accurately screened for major depressive disorders.
General Hospital Psychiatry, 21(2). 106-111. https://doi.org/10.1016/SO1638343(98)00070-X
TBI: Get the facts. (4/27/2017). Centers for Disease Control and Prevention. Retrieved
from: https://www.cdc.gov/traumaticbraininjury/get_the_facts.html
Thomas, D.G., Apps, J.N., Hoffmann, R.G., McCrea, M., & Hammeke, T. (2018).
Benefits of strict rest after acute concussion: A randomized controlled trial.
Pediatrics, 135(2), 1-13. https://doi.org/10.1542/peds.2014-0966
Thomas, R.E., Alves, J., Vaska, M.M., & Magalhaes, R. (2017). Therapy and
rehabilitation of mild brain injury/concussion: Systematic review. Restorative
Neurology and Neuroscience, 35, 643-666. https://doi.org/10.3233/RNN-170761
Vargas, G., Rabinowitz, A., Meyer, J., & Arnett, P.A. (2015). Predictors and prevalence
of postconcussion depression symptoms in collegiate athletes. Journal of Athletic
Training, 50(3), 250-255. https://doi.org/10.4085/1062-6050-50.3.02

COMBINED CARE IN CONCUSSION TREATMENT

158

Warden, D.L., Gordon, B., McAllister, T.W., Silver, J.M., Barth, J.T., Bruns, J., … &
Zitnay, G. (2006). Guidelines for the pharmacological treatment of
neurobehavioral sequelae of traumatic brain injury. Journal of Neurotrauma,
23(10), 1468-1501. https://doi.org/10.1089/neu.2006.23.1468
What Is Cognitive Behavioral Therapy? (2018). The American Psychological
Association. Retrieved from: http://www.apa.org/ptsd-guideline/patients-andfamilies/cognitive-behavioral.aspx
Wiese-Bjornstal, D., White, A.C., Russell, H.C., & Smith, A.M. (2015). Psychology of
sport concussions. Kinesiology Review, 4, 169-189.
https://doi.org/10.1123/kr.2015-0012
Williams, R.M., Puetz, T.W.. Giza, C.C., & Broglio. S.P. (2015). Concussion recovery
time among high school and collegiate athletes: A systematic review and metaanalysis. Sports Medicine, 45, 893-903. https://doi.org/10.1007/s40279-015-03258
Yorke, A. M., Smith, L., Babcock, M., & Alsalaheen, B. (2017). Validity and reliability
of the vestibular/ocular motor screening and associations with common
concussion screening tools. Sports Health, 9(2), 174-180.
https://doi.org/10.1177/194173816678411
Zatzick, D., Russo, J., Lord, S.P., Varley, C. Wang, J…Rivara, F.P. (2014). Collaborative
care intervention targeting violence risk behaviors, substance use, posttraumatic

COMBINED CARE IN CONCUSSION TREATMENT

159

stress and depressive symptoms in injured adolescents. Journal of the American
Medical Association Pediatrics, 168(6), 532-539.
https://doi.org/10/1001/jamapediatrics.2013/4784
Zuckerman, S.L., Yengo-Kahn, A.M., Buckley, T.A., Solomon, G.S., Sills, A.K., & Kerr,
Z.Y. (2016). Predictors of postconcussion syndrome in collegiate student-athletes.
Neurosurgery Focus, 40(4), 1-10. https://doi.org/10.3171/2016.1.FOCUS15593