Sports Medicine Research: In the Lab & In the Field: Start at the Neck and Work Your Way Up: Concussion Rehabilitation (Sports Med Res)


Monday, June 16, 2014

Start at the Neck and Work Your Way Up: Concussion Rehabilitation

Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial

Kathryn J Schneider, Willem H Meeuwisse, Alberto Nettel-Aguirre, Karen Barlow, Lara Boyd, Jian Kang, Carolyn A Emery. Br J Sport Med. 2014 May 22. pii: bjsports-2013-093267. doi: 10.1136/bjsports-2013-093267. [Epub ahead of print]

Take Home Message: Cervical spine and vestibular rehabilitation may be beneficial for patients with persistent concussion symptoms.

Consensus statements suggest that treatment for concussions should consist of rest until resolution of symptoms followed by graded return to play, non-provocative range of motion exercises, and postural education. However, our understanding of the role of rehabilitation after a concussion is limited, which means there may be better treatment options. In this randomized trial, Schneider et al investigated if cervical spine and vestibular rehabilitation could shorten the time frame for medical clearance after a concussion. The authors recruited 30 athletes ranging from 12 to 30 years of age with persistent symptoms of greater than 10 days. The participants were randomly divided into a rehabilitation group (15 athletes) and a control group (15 athletes). Both groups received treatment in accordance with the current standard of care for sports-related concussions. The treatment plan in the rehabilitation group also incorporated cervical spine physiotherapy and vestibular rehabilitation. Therapy protocols consisted of joint mobilization techniques in the cervical and thoracic spine, retraining of the craniovertebral flexor/extensor mechanism, and vestibular rehabilitation. The primary outcome of this study was the number of days from the start of treatment to medical clearance (up to 8 weeks) and the secondary outcome was neurocognitive scores at baseline and at time of medical clearance. The study sports medicine physician, who was unaware of which group an athlete was in, cleared the participants for return to play. Participants in both study groups were similar in regards to age, sex, number of previous concussions, symptoms, and mechanism of concussion. Both groups had similar compliance with a daily home exercise program: 67% in the treatment group versus 64% in the control group. The rehabilitation group had more athletes (73.3%) cleared within 8 weeks compared with the control group (7.1%). Neurocognitive testing scores did not differ between the two groups at the end of the 8-week study period.

Cervicovestibular rehabilitation may be beneficial for patients with persistent concussion symptoms but the small sample size is a limitation to this study. Larger studies are needed to validate the current results and to establish the optimal period when to initiate rehabilitation protocols. An additional limitation is the elapsed time since injury, which varied greatly. The rehabilitation group started rehabilitation between 8 and 276 days after their last injury compared with the control group, which started their program between 31 and 142 days. This should also remind us that the study results are focused on treating chronic concussion symptoms and did not specifically demonstrate if the results are also applicable for acute concussion symptoms. Further research is needed to establish effectiveness of cervical and vestibular rehabilitation for varying times since injury and severities of concussions. Overall, this study provides a good starting point for additional research to address the issues above but also may indicate that cervicovestibular rehabilitation may have a role in the management of chronic concussion symptoms.

Questions for Discussion: Do you use cervicovestibular rehabilitation after concussions? If so, do you use it for chronic or acute symptoms?

Written by: Christian Glaser, DO
Reviewed by: Jeffrey Driban

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Maud Nerman, D.O. said...

One of the neurologists I refer to uses it, with mixed results. If the temporal bones are out of alignment after a blow to the head, problems in balance and dizziness can persist. I have found that cranial techniques for realigning the temporal bones, and also for realigning the occiput and cervical regions, are very successful in treating this kind of dysfunction. If the origin is ANS dysfunction, however, my approach is different.

Christian said...

Dear Dr Nerman
thank you very much for your response and you reporting success in treatment of concussions with cranial OMT. I can report the same experience that you and your colleague are having in the treatment of concussion and cranial techniques. It is most certainly an area that still needs more research but does have promising reports at this point

Tricia said...

This is a very important and interesting topic of concussion management. I was the athletic trainer for a high school and my athletes whose symptoms lasted longer than 2-3 weeks often experienced frustration with the current standard plan of care. Concussion symptoms are so nonspecific and multi-factorial that I believe it is extremely important to continue research such as this study to try and treat concussion symptoms as safely and efficiently as possible is extremely important. This study is also clinically meaningful in that I can take these results and implement them into my practice directly. I look forward to seeing more research build on this study!

Kaitlin Henderson said...

This is an extremely relevant article, especially with all of the many issues surrounding return to play after concussion. It is difficult and frustrating for athletes, coaches, and athletic trainers alike to just sit and wait for concussion symptoms to return to baseline. By implementing rehabilitation for concussions, I think that would help the athletes feel like they are taking a more active role in working towards their recovery. I think this would also help ease some coaches' frustrations with their players or the thinking that athletic trainers aren't doing enough to help speed concussion recovery. However, I do think this type of rehab should be more cautiously supervised by a neurologist or physician to be sure its being implemented in the proper conditions.

christian said...

Thank you very much for your comment. I agree with your thoughts that concussion rehab should be closely supervised by a physician who is trained in concussion treatment. This will also give the athletic trainers support in dealing with pressuring coaches and help guide the players through the recovery process.

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