Clinical examination factors that predict delayed recovery in individuals with concussion.


Background:Risk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery (DR) in individuals with concussion diagnosis. A secondary aim explored the influence of early examination on individual prognosis. Methods:The study was a retrospective, observational cohort design that included 163 individuals seen at a concussion clinic who were followed longitudinally until cleared for sports activity. Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at initial evaluation. DR was calculated by taking the median value associated with time to clearance for activity. Bivariate logistic regression analysis was calculated to determine odds ratios (and 95% confidence intervals) for the odds of DR with presence or absence of each clinical finding. Multivariate analyses were used to define the best predictors of DR. Results:80 of 163 individuals were considered delayed in their clearance to activity. Cognitive impairments (OR = 2.72; 95%CI = 1.40, 5.28), visual exam findings (OR = 2.98; 95%CI = 1.31, 6.80), and vestibular exam findings (OR = 4.28; 95%CI = 2.18, 8.43) all increased the odds of a DR. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examination after injury was a mediator for DR. Conclusions:The clinical examination provides value in identifying individuals who are likely to exhibit a delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a DR to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.





Published Version (Please cite this version)


Publication Info

Martinez, Corina, Zachary Christopherson, Ashley Lake, Heather Myers, Jeffrey R Bytomski, Robert J Butler and Chad E Cook (2020). Clinical examination factors that predict delayed recovery in individuals with concussion. Archives of physiotherapy, 10(1). p. 10. 10.1186/s40945-020-00081-z Retrieved from

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.



Jeffrey Ryszard Bytomski

Professor in Family Medicine and Community Health

Chad E. Cook

Professor in Orthopaedic Surgery

Dr. Cook is a clinical researcher, physical therapist, and profession advocate with a long-term history of clinical care excellence and service. His passions include refining and improving the patient examination process and validating tools used in day-to-day physical therapist practice. Dr. Cook has authored or co-authored 3 textbooks, has published over 315 peer reviewed manuscripts and lectures internationally on orthopedic examination and treatment.

Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.