Feasibility
of Early Physical Therapy for Dizziness After a Sports-Related Concussion: A
Randomized Clinical Trial
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.
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.
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).
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.
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?
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
by: Jane McDevitt, PhD
Reviewed
by: Jeff Driban
by: Jeff Driban
Related
Posts:
Posts:
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
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.)
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.
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.
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.