Evidence-Informed Concussion Rehabilitation

Although I've taken several courses that address concussion assessment and treatment over the last few years, research is continually advancing our knowledge of  guidelines.  Here is a summary I've put together of some of the most recent literature which aims to answer the questions: Which patients require concussion rehabilitation and what does recent evidence suggest that concussion rehabilitation should include?

Assessment and Treatment Timelines

The most recent International Consensus Statement on Concussion in Sport (The Berlin Consensus Statement, April 2017) states that evidence-based treatment for persistent concussion symptoms includes cervical spine treatment, vestibular rehabilitation, psychological interventions, and controlled submaximal exercise (1). 

The diagnosis of a concussion is a clinical judgment, made by a medical professional (1). A multi-faceted treatment approach seems to be the most effective approach to rehabilitation, and should begin immediately by obtaining a comprehensive history, performing a neurological exam to rule out serious pathology related to traumatic brain injury (TBI) or vascular insufficiency, and screening the cervical spine for signs of trauma.  As a minimum, the health care team involved in the patient’s care should include a Family Physician and/or Sports Medicine Physician, and a Physiotherapist trained in concussion management.  As required, patients may also benefit from a referral to see a psychologist, optometrist or dietician trained in concussion management.
 
Recent evidence suggests that starting rehabilitation as early as 10 days after injury improves recovery time and decrease the risk of developing post-concussion syndrome (PCS) (2).  For individuals with PCS, a multifaceted assessment is needed to identify targeted treatments that may be of benefit (3).

Cervical, Vestibular, and Oculomotor Rehabilitation

The amount of force necessary to sustain a concussion is far greater than that which is needed to sustain a whiplash (4).  As a result, nearly every concussion sustains a whiplash as well.  The significance of this fact is that whiplash injuries can disrupt the vestibular system (causing dizziness and vision dysfunction), result in cervical joint and muscle tightness/inflammation (causing local pain, referred headaches, and contribute to a lack of concentration), and disrupt the reflexes between cervical-vestibulo-occular system.

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 control group that was given the usual protocol of rest followed by gradual exertion.  Both groups received treatment from a physiotherapist at least once per week for 8 weeks, and had an average age of 15 years. In the treatment group, 73% of the participants were medically cleared within 8 weeks of initiation of treatment, compared with 7% in the control group. Individuals in the treatment group were 3.91 (95% CI 1.34 to 11.34) times more likely to be medically cleared by 8 weeks (2,5).
 
In 2017, Reneker et al., published another randomized clinical trial comparing individualized treatment plans consisting of manual therapy of the neck, vestibular rehabilitation, oculomotor and neuromotor retraining, to a control group.  Subjects were permitted by a sports medicine physician to enroll in the trial if they had experienced concussive symptoms for at least 10 days, and were treated by a Physiotherapist for up to a maximum of 8 visits or until they were fully cleared to return to play by a blinded sport-medicine physician.   The progressive treatment group achieved symptom resolution and clearance to resume full sport activities significantly sooner than the control group: 15.5 days versus 26 days, respectively.  The authors concluded that a personalized treatment plan beginning as early as 10 days after concussion may be an effective option to shorten recovery time (6).

Exercise Recommendations Post-Concussion

Initiating physical activity within the first 7-14 days post-concussion has been associated with a decreased risk of developing PCS.  These results have been noted in adolescents and adults (7-12).  Several clinical trial have demonstrated significant improvements in symptoms, cerebral blood flow mechanics, and complete return to all pre-injury activities over a much faster timeline compared to control groups or sham therapies (i.e. stretching).  This is true for both acute concussions and PCS (7-10).  Research would suggest performing low-level aerobic exercise most days of the week, at 80% of their symptom-tolerated heart rate (13,14).

Summary: Providing Effective Treatment

In addition to a graduated ‘Return to Learn’, ‘Return to Work’, and/or ‘Return to Play’ protocol, patients recovering from concussions seem to benefit the most from specific therapies for the cervical spine, vestibular system, visual system, and cardiovascular system.  Research suggests that focused rehabilitation that begins within the first 7 to 10 days after injury can significantly improve outcomes and decrease long-term symptoms in both children and adults. 

References

1) McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Apr 26:bjsports-2017.
 
2) Schneider K, Meeuwisse W, Nettel-Aguirre A, Boyd L, Barlow KM, Emery CA. Cervico-vestibular physiotherapy in the treatment of individuals with persistent symptoms following sport-related concussion: a randomized controlled trial. Br J Sports Med. 2014 May 1;48:1294-8.
 
3) Feddermann-Demont N, Echemendia RJ, Schneider KJ, Solomon GS, Hayden KA, Turner M, Dvořák J, Straumann D, Tarnutzer AA. What domains of clinical function should be assessed after sport-related concussion? A systematic review. Br J Sports Med. 2017 Jun 1;51(11):903-18.

4) Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. The Physician and sportsmedicine. 2015 Jul 3;43(3):274-84.
 
5) Schneider KJ, Meeuwisse WH, Barlow KM, Emery CA. Cervicovestibular rehabilitation following sport-related concussion. Br J Sports Med. 2018 Jan 1;52(2):100-1.
 
6) 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. Scand J Med Sci Sports. 2017 Dec 1;27(12):2009-18.
 
7) 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. Rehab Res Pract. 2012.
 
8) Leddy JJ, Cox JL, Baker JG, Wack DS, Pendergast DR, Zivadinov R, Willer B. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehab. 2013 Jul 1;28(4):241-9.
 
9) 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. Sci and J Med Sci Sports. 2015; 26(3):299–306.
 
10) 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. J Sports Med. 2016.

11) Lal A, Kolakowsky-Hayner SA, Ghajar J, Balamane M. The Effect of Physical Exercise after a Concussion: A Systematic Review and Meta-Analysis. Am J Sports Med. 2017 Jun 1.
 
12) Zemek R, Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W. Relationship of early participation in physical activities to persistent post-concussive symptoms following acute paediatricpediatric concussion. Br J Sports Med. 2017 Jun 1;51(11):A20.
 
13] Schneider KJ, Leddy J, Guskiewicz K, Seifert TD, McCrea M, Silverberg N, Feddermann-Demont N, Iverson G, Hayden KA, Makdissi M: Rest and specific treatments following sport-related concussion: A systematic review. Br J Sports Med. 2017 Mar 24, 51:930-4.
 
14) Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010 Jan 1;20(1):21-7