Sports Medicine Research: In the Lab & In the Field: Don’t Let Your Concussed Athletes Spin Out of Control; PT is Feasible! (Sports Med Res)
Monday, April 3, 2017

Don’t Let Your Concussed Athletes Spin Out of Control; PT is Feasible!

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

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Reneker JC, Hassen A, Phillips RS, Moughiman MC, Donaldson M, & Moughiman J (2017). Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial. Scandinavian Journal of Medicine & Science in Sports PMID: 28211600

4 comments:

Landon Lempke said...

This research study highlights an important aspect of concussion-based research that I have never thought too much about. Typically, physical therapy is utilized in cases where post-concussion syndrome is the pathology in focus, but I never really thought about utilizing it as an early intervention.

That being said, I would be interested to see neurocognitive, balance, and patient-reported outcomes related to activities of daily living utilized in a cohort receiving early physical therapy compared to a control group who is receiving limited physical/mental activity followed by a 5-step return to play protocol. I think a limitation of this study is the utilization of a “control” group that actually received an intervention. The idea that the “control” group was going to a physical therapy clinic to receive treatment still and not progressing exercises makes me wonder if a psychological aspect comes into play where the subject’s may have felt as if they weren’t actually recovering with a result of increased likelihood to report symptoms. Additionally, the “control” group’s return to play median value appears to be longer than a typical return to play timeline.
My thoughts on this topic is that the use of early physical therapy may help with early symptom resolution and thus allow quicker return to play, but does this mean they are actually “healed”? If you treat the symptoms are you truly treating the pathophysiology or the sequalae of a concussion? Additionally, it doesn’t appear that the intervention group (15.5 days) in this study is too far away from a normal recovery time to that of current treatment practices. This drives the question of is this clinically meaningful, and if so is it worth the additional time and expenses to conduct early physical therapy?

My question to you is: Hypothetically, if a larger study was conducted and found physical therapy to help reduce symptom presence and return to play times by 5 days, how would you see this being implemented clinically and do you think that this could potentially have long-term consequences? (I understand there isn’t enough evidence out there currently to answer, but just curious as to what your thoughts are.)

Jane McDevitt said...

Great question,
I think a larger cohort will really open the door for introducing rehab for concussed athletes. Think about an anterior talofib sprain, no matter grade 1 or grade 3 they are getting some treatment, doing exercises, and staying up with their conditioning via bike and/or pool. What do we do with our concussed athletes? We basically tell them to sit and wait. Even if they are quick to recover like the 5 day s/s free is the 5 day progression enough to return them to play? How long do really test them functionally with intense sport specific training? Also, how many of our tests are performed dynamically in the acute and subacute stage to see if they are still able to progress? I think adding these rehab tools will really get the athlete ready to return to play better than some rest and light activity. As far as the long term consequences we could end up pushing an athlete to far to quick, but I think this day by day progression will help see what we can do with them. Just remember our simple there ex principles...avoid aggravation, timing, try and keep compliance, individualize the program, add sport specific training.

Abbis Haider said...

Hi, I think this is an interesting study. Where two things are dealt at the same time. 1) Early physical intervention has been given to the athletes who suffered from concussion 2) a well-tailored exercise program is developed to target the symptom of dizziness that is kind of a major symptom in decreasing functionality of an athlete. I think in my clinical practice ( in Pakistan) I have seen that people who suffer from concussion are restricted to bed rest with minimal physical activity let alone any physical exercise protocol utilized for treatment. Rest forms the mainstay of the treatment post-concussion in the acute phase. This also goes along with the recommendations on treatment of concussion given in Zurich and then also in Berlin. However, I think developing a tailored program that can be target symptoms is very important. I think what I will like to see more is what effect this exercise protocol was having on other symptoms like visual memory, reaction time etc. ? that will be interesting to look that whether this exercise program is helping with other symptoms or is making them worse.

Jane McDevitt said...

Abbis,
I think you bring up a great point that returning athletes to play using a more tailored approach rather than the more broad 5 stage progression may be better. Assessing the s/s and tailoring the program to how the athlete feels I think is a great start to this individualization.

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