rehabilitation in sport-related concussion: a randomized controlled trial
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.
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?
by: Christian Glaser, DO
by: Jeffrey Driban