Evidens i konteksten

af hjernerystelsesrehabilitering

Cervellos rehabiliteringsforløb, målrettet mennesker med senfølger efter hjernerystelse, bygger på et solidt forskningsbaseret fundament. Når man i sundhedsvidenskaben taler om evidens, bliver ordet evidens ofte brugt snævert – næsten som om evidens udelukkende betyder “et randomiseret kontrolleret studie (RCT) på præcis denne metode.” Men det er en misforståelse af, hvordan videnskab fungerer. RCT’er er vigtige, men de er kun ét led i en langt bredere proces. Her har vi samlet en række videnskabelige referencer, der udgør en del af fundamentet for Cervellos arbejde med hjernerystelsesrehabilitering.

Evidens findes i flere lag

Direkte evidens fra RCT’er er ét lag. Indirekte evidens – dvs. viden, der er afledt af veldokumenterede mekanismer, neuroanatomi, fysiologi, psykologi, metakognitive processer og konsistente observationer – er et andet. De to former er ikke modsætninger, men forudsætter hinanden. Uden den teoretiske forståelse og de indirekte beviser, ville et RCT slet ikke give mening. Historien giver os tydelige eksempler. Einsteins generelle relativitetsteori blev udviklet i 1915 og brugt som grundlag for hele vores forståelse af universet, længe før dens prædiktioner kunne måles direkte. Den var ikke “mindre evidensbaseret” af den grund – dens indirekte evidens var så robust, at man kunne bygge videre på den, indtil de direkte målinger kom hundrede år senere.

Det samme gælder i rehabilitering. En øvelse eller behandling kan bygge på veldokumenteret viden om muskler, reflekser, psykologiske mekanismer eller sensoriske systemer, og den evidens er ikke svagere, blot fordi der ikke findes et RCT på netop den øvelse. Den hviler på logiske og biologisk plausible mekanismer, som er en fuldgyldig del af evidensbegrebet.

Cervellos indsats bygger på solid evidens

Hos Cervello er vores screenings- og rehabiliteringsindsats udviklet ud fra netop denne forståelse. Vi har ikke opfundet ny viden, men deduktivt anvendt den eksisterende forskning i neuroanatomi, netværksvidenskab, sensorisk integration samt psykologiske og metakognitive processer i en sammenhængende model for hjernerystelsesrehabilitering.

Det betyder, at rehabiliteringsforløbet bygger på solid evidens, også selvom der endnu ikke findes et RCT på præcis denne samlede tilgang.

Samtidig er vi nu på vej ind i det direkte lag. Cervellos forskningsprojekt FYTECH (Jay et al. 2025, in review) – den indledende version af den nuværende Cervello-rehabilitering – er netop gennemført som et randomiseret kontrolleret studie (RCT) og ligger i øjeblikket i peer review.

Resultaterne viser, at målrettet visuel-vestibulær træning kombineret med aerob træning har en signifikant positiv effekt på senfølger efter hjernerystelse. Det er et af de første RCT-beviser for, at en sådan tilgang kan gøre en forskel. Siden FYTECH har Cervellos neurospecialister udbygget screeningsmodellen yderligere. Ved at integrere nye lag af komplekse neurofunktionelle teorier, psykologiske mekanismer og metakognitive observationer, kan vi nu målrette en rehabiliteringsindsats endnu mere præcist, end det var muligt i FYTECH. På den måde kombinerer vi et voksende fundament af direkte evidens med et bredt og robust teoretisk grundlag.

Vi har her samlet en række videnskabelige referencer, der udgør en del af fundamentet for Cervellos arbejde med hjernerystelsesrehabilitering. De viser, hvordan indirekte og direkte evidens tilsammen danner den videnskabelige basis for den tilgang, vi anvender i neuro-klinikken.

Af forskningschef Kenneth Jay Andersen, Cand. Scient, MSc, PhD
og ph.d.-studerende cand. psych Natasja Bojsen
Cervello, september 2025.

Download de videnskabelige referencer som pdf

Referencer – Cervellos tværfaglige hjernerystelsesprogram

Rehabiliteringsprogrammet er tværfagligt og har fokus på at øge funktionsevnen indenfor fem primære funktioner: Visuel funktion, vestibulær funktion, kognitiv funktion, mental funktion samt proprioceptiv funktion. Nærværende dokument gennemgår den forskning og litteratur, der har bidraget til udviklingen af den tværfaglige rehabiliteringsmodel. (Bemærk, at de angivne temaer er vejledende, og at enkelte artikler med fordel kan placeres under andre temaer).

A) Generelt / Tværfagligt (overordnede reviews, guidelines, metodologi, konsensusudtalelser)

Collins, M. W., Kontos, A. P., Reynolds, E., Murawski, C. D., & Fu, F. H. (2014). A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surgery, Sports Traumatology, Arthroscopy, 22, 235-246. https://doi.org/10.1007/s00167-013-2791-6
Graff, H. J. (2021). National Klinisk Retningslinje for non-farmakologisk behandling af længerevarende symptomer efter hjernerystelse. Dansk Center for Hjernerystelse. Tilgået d. 18.08.25, fra https://files.magicapp.org/guideline/adaee090-13ea-4f32-bcd6-c1ddb8bfe064/published_guideline_4774-0_5.pdf
Marshall S, Bayley M, McCullaugh S, et al. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Inj 2015;29(6):688–700; https://doi.org/10.3109/02699052.2015.1004755
McCrory, Paul, Willem Meeuwisse, Jiří Dvořák, et al. 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 51 (11): 838–47. https://doi.org/10.1136/bjsports-2017-097699
Patricios, Jon S., Kathryn J. Schneider, Jiri Dvorak, et al. 2023. Consensus Statement on Concussion in Sport: The 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Consensus Statement. June 1. https://doi.org/10.1136/bjsports-2023-106898
Rytter, H. M., Graff, H. J., Henriksen, H. K., Aaen, N., Hartvigsen, J., Hoegh, M., … & Callesen, H. E. (2021). Nonpharmacological treatment of persistent postconcussion symptoms in adults: a systematic review and meta analysis and guideline recommendation. JAMA network open, 4(11). doi:10.1001/jamanetworkopen.2021.32221
Silverberg, N. D., Iverson, G. L., Group, A. B. I. S. I., Cogan, A., Dams-O-Connor, K., Delmonico, R., … & Zemek, R. (2023). The American Congress of rehabilitation medicine diagnostic criteria for mild traumatic brain injury. Archives of physical medicine and rehabilitation, 104(8), 1343-1355. https://doi.org/10.1016/j.apmr.2023.03.036
Silverberg, N. D., Gardner, A. J., Brubacher, J. R., Panenka, W. J., Li, J. J., & Iverson, G. L. (2015). Systematic review of multivariable prognostic models for mild traumatic brain injury. Journal of neurotrauma, 32(8), 517- 526. https://doi.org/10.1089/neu.2014.3600

B) Visuel / Oculomotorisk (okulære funktioner, pupillerefleks, øjentræning)

Kontos AP, Collins MW, Holland CL, et al. Preliminary evidence for improvement in symptoms, cognitive, vestibular, and oculomotor outcomes following targeted intervention with chronic mTBI patients. Mil Med 2018;183(Suppl 1):333–338; https://doi.org/10.1093/milmed/usx172
McKee, Connor, Mark Matthews, Alan Rankin, and Chris Bleakley. 2024. “The Role of Concussion History and Biological Sex on Pupillary Light Reflex Metrics in Adolescent Rugby Players: A Cross-Sectional Study.” Sports (Basel, Switzerland) 12 (2): 56. https://doi.org/10.3390/sports12020056
Thiagarajan P, Ciuffreda KJ. Short-term persistence of oculomotor rehabilitative changes in mild traumatic brain injury (mTBI): a pilot study of clinical effects. Brain Inj 2015;29(12):1475–1479; https://doi.org/10.3109/02699052.2015.1070905

C) Vestibulær (balance, svimmelhed, vestibulo-okulær funktion, behandling)

Akin FW, Murnane OD, Hall CD, et al. Vestibular consequences of mild traumatic brain injury and blast exposure: a review. Brain Inj 2017;31(9):1188–1194; https://doi.org/10.1080/02699052.2017.1288928
Alsalaheen BA, Whitney SL, Mucha A, et al. Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion. Physiother Res Int 2013;18(2):100–108; https://doi.org/10.1002/pri.1532
Crampton, Adrienne, Elizabeth Teel, Mathilde Chevignard, and Isabelle Gagnon. 2021. “Vestibular-Ocular Reflex Dysfunction Following Mild Traumatic Brain Injury: A Narrative Review.” Neurochirurgie 67 (3): 231–37. https://doi.org/10.1016/j.neuchi.2021.01.002
Ellis, Michael J., John J. Leddy, and Barry Willer. 2015. “Physiological, Vestibulo-Ocular and Cervicogenic Post Concussion Disorders: An Evidence-Based Classification System with Directions for Treatment.” Brain Injury 29 (2): 238–48. https://doi.org/10.3109/02699052.2014.965207
Gard, Anna, Ali Al-Husseini, Evgenios N. Kornaropoulos, et al. 2022a. “Post-Concussive Vestibular Dysfunction Is Related to Injury to the Inferior Vestibular Nerve.” Journal of Neurotrauma 39 (11–12): 829–40. https://doi.org/10.1089/neu.2021.0447
Sadeghi NG, Sabetazad B, Rassaian N, et al. Rebalancing the vestibular system by unidirectional rotations in patients with chronic vestibular dysfunction. Front Neurol 2018;9:1196; https://doi.org/10.3389/fneur.2018.01196
Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med 2014;48(17):1294–1298; https://doi.org/10.1136/bjsports-2013-093267
Ueta Y, Matsugi A, Oku K, et al. Gaze stabilization exercises derive sensory reweighting of vestibular for postural control. J Phys Ther Sci 2017;29(9):1494–1496; https://doi.org/10.1589/jpts.29.1494

D) Proprioception & Sensorimotorik (nakkeproprioception, postural kontrol, motorisk træning)

Kristjansson, Eythor, and Julia Treleaven. 2009. “Sensorimotor Function and Dizziness in Neck Pain: Implications for Assessment and Management.” The Journal of Orthopaedic and Sports Physical Therapy 39 (5): 364-77. https://www.jospt.org/doi/10.2519/jospt.2009.2834
Nashner LM, Peters JF. Dynamic posturography in the diagnosis and management of dizziness and balance disorders. Neurol Clin 1990;8(2):331–349.
Pagnacco G, Carrick FR, Wright CH, et al. Between-subjects differences of within-subject variability in repeated balance measures: consequences on the minimum detectable change. Gait Posture 2015;41(1):136–140; https://doi.org/10.1016/j.gaitpost.2014.09.016
Pettorossi, Vito Enrico, and Marco Schieppati. 2014. “Neck Proprioception Shapes Body Orientation and Perception of Motion.” Frontiers in Human Neuroscience 8: 895. https://doi.org/10.3389/fnhum.2014.00895
Stephens JA, Davies PL, Gavin WJ, et al. Evaluating motor control improves discrimination of adolescents with and without sports related concussion. J Mot Behav 2020;52(1):13–21; https://doi.org/10.1080/00222895.2019.1570908
Treleaven, Julia. 2017. “Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain.” The Journal of Orthopaedic and Sports Physical Therapy 47 (7): 492–502. https://www.jospt.org/doi/10.2519/jospt.2017.7052

E) Mental / Psykologisk (psykoterapi, coping, metakognition, psykologiske profiler, identitetstab)

Aylett E, Small N, Bower P. Exercise in the treatment of clinical anxiety in general practice – a systematic review and meta-analysis. BMC Health Serv Res. (2018) 18:559. https://doi.org/10.1186/s12913-018-3313-5
Landau, J., & Hissett, J. (2008). Mild traumatic brain injury: Impact on identity and ambiguous loss in the family. Families, Systems, & Health, 26(1), 69–85. https://doi.org/10.1037/1091-7527.26.1.69
Losoi, H., Silverberg, N. D., Wäljas, M., Turunen, S., Rosti-Otajärvi, E., Helminen, M., … & Iverson, G. L. (2015). Resilience is associated with outcome from mild traumatic brain injury. Journal of Neurotrauma, 32(13), 942– 949. https://doi.org/10.1089/neu.2014.3799
Mikolic A, Klotz T, Brasher P, Yeates K, Vranceanu AM, Kendall KD, et al. Canadian traumatic brain injury research consortium (CTRC). Graded exposure therapy for fear avoidance behaviour after concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial. BMJ Open. (2024) 14:e086602. doi: 10.1136/bmjopen-2024-086602.
Minen, M., Jinich, S., & Vallespir Ellett, G. (2019). Behavioral Therapies and Mind-Body Interventions for Posttraumatic Headache and Post-Concussive Symptoms: A Systematic Review. Headache: The Journal of Head and Face Pain, 59(2), 151–163. https://doi.org/10.1111/head.13455
Noetel M, Sanders T, Gallardo-Gómez D, Taylor P, Del Pozo CB, van den Hoek D, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomized controlled trials. BMJ. (2024) 384:e075847. https://doi.org/10.1136/bmj-2023-075847
Scheenen, M. E., van der Horn, H. J., de Koning, M. E., van der Naalt, J., & Spikman, J. M. (2017). Stability of coping and the role of self-efficacy in the first year following mild traumatic brain injury. Social Science & Medicine, 181, 184–190. https://doi.org/10.1016/j.socscimed.2017.03.025
Snell, D. L., Siegert, R. J., Hay-Smith, E. J. C., & Surgenor, L. J. (2011). Associations between illness perceptions, coping styles and outcome after mild traumatic brain injury: preliminary results from a cohort study. Brain Injury, 25(11), 1126–1138. https://doi.org/10.3109/02699052.2011.607786
Stulemeijer M, Vos PE, Bleijenberg G, et al. Cognitive complaints after mild traumatic brain injury: things are not always what they seem. J Psychosom Res. 2007;63(6):637–645. https://doi.org/10.1016/j.jpsychores.2007.06.023
Sullivan, K. A., Kaye, S. A., Blaine, H., Edmed, S. L., Meares, S., Rossa, K., & Haden, C. (2020). Psychological approaches for the management of persistent postconcussion symptoms after mild traumatic brain injury: a systematic review. Disability and Rehabilitation, 42(16), 2243–2251. https://doi.org/10.1080/09638288.2018.1558292
Wells, A., McNicol, K., Reeves, D., Salmon, P., Davies, L., Heagerty, A., … & Fisher, P. (2018). Metacognitive therapy home-based self-help for cardiac rehabilitation patients experiencing anxiety and depressive symptoms: study protocol for a feasibility randomised controlled trial (PATHWAY Home-MCT). Trials, 19(1), 444. https://doi.org/10.1186/s13063-018-2826-x
Ziadni, M. S., Sturgeon, J. A., & Darnall, B. D. (2018). The relationship between negative metacognitive thoughts, pain catastrophizing and adjustment to chronic pain. European Journal of Pain, 22(4), 756–762. https://doi.org/10.1002/ejp.1160

F) Fysisk træning & Kondition (aerob træning, styrke, HRV, autonom regulering)

DeGroot A, Huber DL, Leddy JJ, Raff H, McCrea MA, Johnson BD, et al. Use of the Buffalo concussion treadmill test in community adult patients with mild traumatic brain injury. PM R. (2024) 16:826–35. https://doi.org/10.1002/pmrj.13132
Gall B, Parkhouse W, Goodman D. Heart rate variability of recently concussed athletes at rest and exercise. Med Sci Sports Exerc. (2004) 36:1269–74. https://doi.org/10.1249/01.mss.0000135787.73757.4d
Kurowski BG, Hugentobler J, Quatman-Yates C, Taylor J, Gubanich PJ, Altaye M, et al. Aerobic exercise for adolescents with prolonged symptoms after mild traumatic brain injury: an exploratory randomized clinical trial. J Head Trauma Rehabil. (2017) 32:79–89. doi: 10.1097/HTR.0000000000000238.
Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. (2010) 20:21–7. doi: 10.1097/JSM.0b013e3181c6c22c.
Leddy, J. J., Burma, J. S., Toomey, C. M., Hayden, A., Davis, G. A., Babl, F. E., … & Schneider, K. J. (2023). Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. British Journal of Sports Medicine, 57(12), 762–770. https://doi.org/10.1136/bjsports-2022-106676
Miller, Jordan, Anita Gross, Jonathan D’Sylva, et al. 2010. “Manual Therapy and Exercise for Neck Pain: A Systematic Review.” Manual Therapy 15 (4): 334–54. https://doi.org/10.1016/j.math.2010.02.007
Stratford, T., Meara, A., & Lal, S. (2014). Heart rate variability and the anxious client: cardiac autonomic and behavioral associations with therapeutic alliance. The Journal of Nervous and Mental Disease, 202(8), 613–619. doi: 10.1097/NMD.0000000000000163.
Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. (2015) 135:213–23. https://doi.org/10.1542/peds.2014-0966

G) Neurobiologi & Plasticitet (neuroimaging, neuroplasticitet, cerebellum, diaschisis, netværksdysfunktion)

Caeyenberghs K, Leemans A, Leunissen I, et al. Altered structural networks and executive deficits in traumatic brain injury patients. Brain Struct Funct 2014;219(1):193–209; doi: 10.1007/s00429-012-0494-2.
Chen H, Epstein J, Stern E. Neural plasticity after acquired brain injury: evidence from functional neuroimaging. PM R 2010;2(12 Suppl 2):S306–S312; https://doi.org/10.1016/j.pmrj.2010.10.006
D’Souza, Maria M., Mukesh Kumar, Ajay Choudhary, et al. 2020. “Alterations of Connectivity Patterns in Functional Brain Networks in Patients with Mild Traumatic Brain Injury: A Longitudinal Resting-State Functional Magnetic Resonance Imaging Study.” The Neuroradiology Journal 33 (2): 186–97. https://doi.org/10.1177/1971400920901706
Hillary, Frank G., Sarah M. Rajtmajer, Cristina A. Roman, et al. 2014. “The Rich Get Richer: Brain Injury Elicits Hyperconnectivity in Core Subnetworks.” PLoS ONE 9 (8): e104021. https://doi.org/10.1371/journal.pone.0104021
Turrigiano, Gina. 2012. “Homeostatic Synaptic Plasticity: Local and Global Mechanisms for Stabilizing Neuronal Function.” Cold Spring Harbor Perspectives in Biology 4 (1): a005736. https://doi.org/10.1101/cshperspect.a005736