WHEN DO CONCUSSION PATIENTS REQUIRE REHAB?
Proven, evidence-based treatments for persistent concussion symptoms include cervical spine treatment, vestibular rehabilitation, psychological interventions, and controlled sub- symptom-threshold, submaximal exercise.1 This information is according to the most recent international consensus statement on concussion in sport (also known as the Berlin Consensus Statement), published in April 2017.
But, when should a patient be referred for these treatments? And, where should they go?
The Berlin Consensus Statement defines persistent symptoms as those lasting more than 10-14 days in adults, and more than 1 month in children.1 The good news is that recent evidence suggests that starting rehabilitation as early as 10 days after injury may improve recovery time and decrease the risk of developing post-concussion syndrome (PCS).3
The trick for success seems to be a multi-faceted treatment approach versus rehabilitation focused on one specific area (for example, only vestibular rehabilitation).
CERVICAL, VESTIBULAR & OCULOMOTOR REHABILITATION
In 2014, Schneider et al., published one of the first randomized clinical trials comparing a group receiving a combination of cervical and vestibular rehabilitation versus a group that was given the usual treatment approach (i.e., wait and see until symptoms subside and gradually return to activity). The average age of subjects was 15 years old, and all experienced symptoms beyond 10 days. Both groups received treatment from a physiotherapist at least once per week for 8 weeks. After the 8- week trial, 73% of subjects receiving treatment fully recovered and returned to sport compared to only 7% of subjects receiving the usual, wait and see treatment approach.2
Another randomized clinical trial published in 2017 looked at concussion patients between ages 10 to 23 years old who experienced symptoms beyond 10 days after injury. These patients were randomized to either receive an individualized and progressive treatment plan consisting of manual therapy of the neck, vestibular rehabilitation, oculomotor and neuromotor retraining, or a sub-therapeutic treatment approach consisting of sham, sub-therapeutic, and non-progressive therapeutic techniques. All subjects were seen up to a maximum of 8 visits or until they were fully cleared to return to play by a blinded sport-medicine physician (whichever came first).
The progressive treatment group achieved symptom resolution and clearance to resume full sport activities significantly sooner than the sub-therapeutic treatment group. The authors, Reneker et al., concluded that a personalized treatment plan consisting of manual therapy, vestibular rehabilitation, oculomotor and neuromotor retraining delivered to patients while still symptomatic, beginning as early as 10 days after concussion, may be an effective option to shorten recovery time.3
CONTROLLED, SUB-SYMPTOM THRESHOLD EXERCISE
For more than 10 years, researchers at the University of Buffalo have been studying the effects of utilizing a controlled exercise program to improve persistent PCS. Several trials demonstrate significant reductions in symptoms, meaningful improvements in cerebral blood flow mechanics, and complete return to all pre-injury activities in as little as 6 to 10 weeks over sham therapies (i.e., stretching).4,5,6,7 A recent systematic review found that physical exercise appears to improve symptom scores in patients with concussion.8 Further, a large, Canadian multi-centre study found that initiating physical activity within 7 days post-concussion was associated with a lower risk of developing persistent symptoms in children.9
HOW TO APPLY THESE FINDINGS
There are several therapeutic options for patients with concussion and most are centered around specific therapies for the cervical spine, vestibular system, visual system, and cardiovascular system. Evidence shows that a focused rehabilitation approach that begins within the first 7 to 10 days after injury can significantly improve outcomes and decrease long-term symptoms in children and adults.3 As most concussion cases have symptom resolution within the first week, it is recommended that patients with symptoms beyond this time point be referred to a multidisciplinary clinic with advanced training in the management and rehabilitation of concussion.
1. McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine. 2017.
2. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, Barlow K, Boyd L, Kang J, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal of Sports Medicine. 2014; 48(17):1294–8.
3. Reneker JC, Hassen A, Phillips RS, Moughiman MC, Donaldson M, Moughiman J. Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial. Sc and J Med Sci Sports. 2017.
4. Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to Full Functioning after Graded Exercise Assessment and Progressive Exercise Treatment of Postconcussion Syndrome. Rehabilitation Research and Practice. 2012; (2):1–7.
5. Leddy JJ, Cox JL, Baker JG, Wack DS, Pendergast DR, Zivadinov R, et al. Exercise Treatment for Postconcussion Syndrome. Journal of Head Trauma Rehabilitation. 2013; 28(4):241–9.
6. Gagnon I, Grilli L, Friedman D, Iverson GL. A pilot study of active rehabilitation for adolescents who are slow to recover from sport- related concussion. Sc and J Med Sci Sports. 2015; 26(3):299–306.
7. Imhoff S, Fait P, Carrier-Toutant F, Boulard G. Efficiency of an Active Rehabilitation Intervention in a Slow-to-Recover Paediatric Population following Mild Traumatic Brain Injury: A Pilot Study. Journal of Sports Medicine. 2016; (2):1–11.
8. Lal A, Kolakowsky-Hayner SA, Ghajar J, Balamane M. The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2017.
9. Zemek R, Grool AM, Aglipay M, Momoli F. Relationship of early participation in physical activities to persistent post-concussive symptoms following acute paediatric concussion. Br J Sports. 2017.