Feasibility of concussion rehabilitation approaches tailored to psychological coping styles: A randomized controlled trial

Silverberg ND, Cairncross M, Brasher PMA, Vranceanu AM, Snell DL, Yeates KO, Panenka WJ, Iverson GL, Debert CT, Bayley MT, Hunt C, Baker A, Burke MJ; Canadian Traumatic Brain Injury Research Consortium (CTRC). Arch Phys Med Rehabil. 2021 Dec 28:S0003-9993(21)01732-9. doi: 10.1016/j.apmr.2021.12.005. Epub ahead of print. PMID: 34971596.


Take-Home Message

People with persistent concussion symptoms and fear or endurance (pushing through the pain) coping behaviors could benefit from psychological-based rehabilitation programs such as graded exposure therapy.


Athletes often experience psychological symptoms (e.g., anxiety, fear of reinjury) following a concussion, which may predict who will develop persistent symptoms. However, many studies evaluating psychological treatments only evaluate one type of treatment and fail to address which psychological factors should be addressed to meet a patient’s needs. Some patients may need to address their fear of pain and its consequences, which causes them to avoid situations that might cause pain. Alternatively, other patients may need treatments to address their endurance behavior – when they push through pain and exacerbate their symptoms.

Study Goal

Silverberg and colleagues conducted a randomized controlled trial to assess the feasibility of providing treatments designed to address fear avoidance or endurance coping.


The researchers recruited 73 patients (~43 years of age, 63 completed the treatment) from 2 concussion clinics. Researchers included patients who had persistent post-concussion symptoms (enrolled in study ~13 weeks post-injury) and reported high avoidance or endurance behaviors. Participants were randomized into either an endurance-coping group or an avoidance-coping group. Each participant completed 16 therapy hours over secure video conferencing with psychology trainees (graduate students, post-doctoral fellow, interns) supervised by a registered psychologist. All participants also completed the Working Alliance Inventory to measure patient-perceived therapeutic relationships. Patients in the avoidance coping group received graded exposure therapy, where patients were exposed to feared cognitively demanding activities (e.g., mental math exercises), physical exertion (e.g., jogging), and sensory stimulation (e.g., visual motion), in session and as homework. Patients in the endurance coping group completed Pacing+, where therapists employed activity quotas, alternating activities, and planning rest breaks to shift activity from symptom-dependent to goal-based. The authors assessed feasibility outcomes with credibility, treatment fidelity, adherence, and retention. Avoidance was measured with the Fear Avoidance Behavior after Traumatic Brain Injury questionnaire and endurance behavior with Behavioral Response to Illness Questionnaire. Concussion symptoms were assessed with the Rivermead Post concussion Symptoms Questionnaire.  


Overall, there was an 89% retention rate, and 71% of participants consistently attended sessions and completed their homework. More than 90% of participants perceived their treatment as credible. Furthermore, participants would likely recommend their treatment to a friend and were confident it would help. Ninety-seven percent of the therapist prescribed all entailed elements of the program. Patients that completed the graded exposure therapy reported a greater reduction in avoidance behavior than the Pacing+ group. The benefit of Pacing+ on endurance behavior was less pronounced.


The authors demonstrated that a psychologically informed rehabilitation program for those with avoidance or endurance coping strategies could be beneficial. Further, patients found the programs credible and generally reported a positive experience. Patients in the graded exposure therapy reduced their fear avoidance more than those who completed the Pacing+ therapy program. It would be interesting to see how these treatments perform in a larger study where those with high avoidance receive the graded exposure therapy. In contrast, those with endurance behavior could receive the Pacing+ approach. This would tell us if targeting these treatment approaches based on a patient’s needs improve outcomes more than just giving everyone one of these interventions.

Clinical Implications

Clinicians should work with a psychologist to modify their concussion rehabilitation approach to ensure patients with persistent concussion symptoms are evaluated for psychological factors affecting their recovery. Specifically, clinicians should be aware of psychological approaches that can address a patient’s needs during concussion rehabilitation.

Questions for Discussion

Do you work closely with a therapist or psychologist when your athlete is not recovering from an injury? Have you ever implemented a psychologically-based rehabilitation? If so, what was the injury, what did you perform, and what were the outcomes?

Related Posts

1. Athletes with a concussion have Less Fear of Reinjiury Than Athletes with an Orothpedic Injury
2. Beliefs Become Reality: A Patient’s Beliefs about Rest May Influence Their Concussion Recovery
3. Peer-Led Concussion Education May Enhance Concussion Knowledge and Reporting Behaviors

Written by: Jane McDevitt
Reviewed by: Jeffrey Driban

Evidence-Based Assessment of Concussion Course - 5 EBP CEUs