Feasibility of Early Physical Therapy for Dizziness After a Sports-Related Concussion: A Randomized Clinical Trial
Reneker JC, Hassen A, Phillips RS, Moughiman MC, Donaldson M, Moughiman J. Scand J Med Sci Sports. 2017; ahead of print.
Take Home Message: Closely supervised cervical and vestibular ocular therapy may help safely return concussed athletes to play.
Dizziness is one of the most common symptoms reported following a concussion. Clinicians can use rehabilitative techniques to treat dizziness; however, it remains unknown whether these techniques are safe and effective for patients suffering dizziness following an acute concussion. Therefore, the authors developed a double-blind, randomized control feasibility trial to assess treatment benefits, patient retention, protocol management, and participant safety between 2 treatment strategies. The researchers assessed 41 athletes aged 10-23 years old that suffered an acute sports-related concussion (within 14 days), and at least 1 of the following: 1) abnormal vestibular or cervical exam findings, 2) reported at least a 3 on a 7-point Likert Post Concussion Scale (PCS) for dizziness, and 3) scored 10 on the PCS across 9-items with a dizziness score of at least 1. Athletes were recruited at multiple centers from September 2014 to October 2015. All the athletes went to physical therapy twice a week for 30-60 minutes each for 8 visits (or once cleared) beginning at 10 days post concussion. Athletes were randomly allocated into 1 of 2 groups. Athletes in the experimental group (22 athletes) received individually tailored, pragmatically delivered progressive interventions. Specifically, athletes completed vestibular rehabilitation (e.g., habituation, adaptation), oculomotor control exercises, neuromotor control exercises (proprioceptive and kinesthetic awareness), and balance exercises as necessary. The clinicians modified dosage and progression at each session based on symptom provocation and remediation. Athletes also completed an individually tailored home exercise program and exercise education that was complimentary to the individualized treatment they received at each visit. Athletes in the control (19 athletes) received subtherapeutic and non-to-minimally progressive therapeutic techniques (smooth pursuit tracking, convergence exercises, supine to sit). The control group athletes performed a standardized home exercise program, which consisted of cervical isometric exercises, gentle range of motion exercises for the cervical spine, and vestibule-ocular reflection cancelation exercises. The authors followed the athletes to determine symptomatic recovery and date of medical clearance for return to play. Ninety-five percent of the experimental group and 74% of the control group completed the treatment protocol. Fourteen percent of the treatment group and 37% of the control group failed to attain PCS recovery. The treatment group’s symptoms recovered faster (13.5 days) and they returned to play faster (15.5 days to full medical clearance) compared to the control group (17 days symptom recovery, 26 days for full medical clearance).
This is an important study as it the first to address a number of rehabilitation exercises that may help accelerate healing and allow quicker medical clearance. The authors suggest that this study needs to be replicated in a larger cohort to further explore the effectiveness of this type of concussion intervention. Additionally, it should be noted that in each group there were athletes that reported symptom provocation. Hence, clinicians may need to modify these exercises before implementation. Currently, medical professionals should be aware that dizziness should be specifically addressed during the initial concussion assessment protocol. Furthermore, clinicians should also consider performing some of the rehabilitation exercises prescribed in this study if their athletes are complaining of dizziness following an acute concussion.
Question for Discussion: Are you currently utilizing any concussion rehabilitation techniques? If so, what are they, and how do believe they are working?
Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban