After a concussion, the most common symptoms are headache and dizziness, followed by nausea and neck pain. Although the majority of symptoms resolve in seven to 10 days, in approximately 30 per cent of athletes they persist. Post-concussion headaches have been reported as a predictor of longer time loss, while cervical spine trauma may cause prolonged post-concussion headache. Dizziness and balance dysfunction are also commonly reported following sport-related concussion.
|Study title: Cervicovestibular rehabilitation in sport-related concussion: A randomised controlled trial
Authors: Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al.
Publication information: British Journal of Sports Medicine 2014; 48(17): 1294–1298
The objective of this study was to determine if a combination of vestibular and cervical spine rehabilitation decreased the time until medical clearance in individuals with prolonged post-concussion symptoms of dizziness, neck pain and/or headaches.
The study was a randomized controlled trial with an eight-week study endpoint. The primary outcome of interest was time to medical clearance to return to sport (in days) determined by a sport medicine physician blinded to treatment grouping. Patients were randomly allocated to the control or intervention group. They were seen once weekly for eight weeks or until medical clearance to return to sport. Both groups performed non-provocative range of motion exercises, stretching, postural education and the current standard of care protocol for sport-related concussion. In addition, the intervention group received an individually designed combination of cervical spine physiotherapy typically before vestibular rehabilitation – which included habituation, gaze, stabilization, adaptation exercises, standing balance exercises, dynamic balance exercises and/or canalith repositioning maneuvers – determined by the findings of the experienced physiotherapist.
Thirty-one individuals (of the 58 referred) participated at the beginning of the study. Three individuals in the control group subsequently dropped out.
Clinical determination of vestibular involvement was evident in the majority of participants (12 out of 15 in the treatment group and 14 out of 16 in the control group).
All participants had cervical spine involvement. Eleven out of the 15 individuals in the treatment group were medically cleared to return to sport within eight weeks of treatment. By comparison, only one of 14 in the control group was medically cleared to return to sport within eight weeks.
Individuals in the treatment group were 10.27 (95 per cent CI: 1.51-69.56) times more likely to be medically cleared to return to sport in eight weeks than the control (X2 = 50.12, p < 0.001).
In the intervention group, individuals who were medically cleared to return to sport had a greater improvement in the SCAT2 total score (Wilcoxon rank-sum, p = 0.009) and the Dizziness Handicap Inventory Score (Wilcoxon rank-sum, p = 0.019) when compared to individuals who were not medically cleared to return to sport.
The addition of cervical spine treatment and vestibular training shows promise for better outcomes regarding medical clearance to return to sport in those with concussion symptoms lasting more than 10 days, compared to the stand alone use of a battery of interventions consisting of: non-provocative ROM exercises, stretching, postural education and standard care protocol for concussion in children and adults age 12 – 30 years.
This study utilized a treatment endpoint of eight weeks, with treatment provided once per week following initial assessment. This provides a reasonable framework for treatment frequency and duration, and when to anticipate medical clearance for return to sport in this population. However, we cannot comment on the potential for more frequent treatment to further improve outcomes based on the results of this study.
As our knowledge evolves on the recognition, assessment and management of concussions, it is becoming clear that victims often suffer concomitant neck and vestibular issues – two areas where evidence-informed manual medicine clinicians can certainly add value and improve patient outcomes.
The best treatment methods and programs of care still require more research, however.
Dr. Shawn Thistle is the founder and CEO of RRS Education (rrseducation.com), which helps busy clinicians integrate current research evidence rationally into practice. He also maintains a practice in Toronto, lectures at CMCC and provides chiropractic medicolegal consulting services. Reach him at: firstname.lastname@example.org
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