Research Review By Dr. Keshena Malik©

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Date Posted:

October 2015

Study Title:

Cervicovestibular rehabilitation in sport-related concussion: A randomised controlled trial

Authors:

Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al.

Author's Affiliations:

Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Alberta; Faculty of Medicine, Alberta Children’s Hospital Research Institute for Child and Maternal Health, University of Alberta; Department of Community Health Sciences, Faculty of Medicine, University of Calgary; Department of Physical Therapy and Brain Research Centre, UBC Hospital, University of British Columbia, Vancouver, Canada.

Publication Information:

British Journal of Sports Medicine 2014; 48(17): 1294–1298.

Background Information:

After a concussion, the most common symptoms are headache (1-4) and dizziness (5), followed by nausea and neck pain (6, 7). Although the majority of symptoms resolve in 7-10 days, in approximately 30% of athletes they persist (6, 8). Post-concussion headaches have been reported as a predictor of longer time loss (8), while cervical spine trauma may cause prolonged post-concussion headache (9). Dizziness and balance dysfunction are also commonly reported following sport-related concussion, likely resulting from dysfunction of the vestibular, proprioceptive or central systems (3, 5, 10-12). Dysfunction of these systems may persist and may also alter risk of future concussion (13, 14). Currently, there is a paucity of evidence evaluating interventions targeting the vestibular system and cervical spine as treatment for post-concussion symptoms of dizziness, neck pain and headache (15). Therefore, 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.

Pertinent Results:

  • 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 (12/15 in the treatment group and 14/16 in the control group)
  • All participants had cervical spine involvement (not surprising!)
  • 11 of 15 (73.3%) of individuals in the treatment group were medically cleared to return to sport within 8 weeks of treatment.
  • By comparison, only 1 of 14 (7.1%) of the control group was medically cleared to return to sport within 8 weeks.
  • Individuals in the treatment group were 10.27 (95% CI: 1.51-69.56) times more likely to be medically cleared to return to sport in 8 weeks than the control (Х2 = 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.

Clinical Application & Conclusions:

Take home messages:
  • 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 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 (rest until symptom free and graded exertion) in children and adults age 12 – 30 years.
  • This study utilized a treatment endpoint of 8 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 have 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.

Study Methods:

The study was a randomized controlled trial with an 8 week study endpoint.

Inclusion Criteria:
  • Age 12-30 years
  • Diagnosis of sport-related concussion based on the Third International Consensus Conference on Concussion in Sport
  • Persistent symptoms (greater than 10 days) of dizziness, neck pain and/or headaches reported on the Sport Concussion Assessment Tool 2 (SCAT2)
  • If clinical examination suggested vestibular and/or cervical spine involvement, individual were referred to a study physiotherapist for assessment of secondary outcomes (i.e. Numeric Pain Rating Scale score, Activities-specific Balance Confidence Scale, Dizziness Handicap Index, SCAT2, Dynamic Visual Acuity, Head Thrust Test, modified Motion Sensitivity Test, Functional Gait Assessment, Cervical Flexor Endurance and Joint Position Error test)
Exclusion Criteria:
  • Fracture
  • Neurological conditions
  • Musculoskeletal injuries other than the cervical spine that restrict activity
  • Medications that affect neural adaptation
Intervention:
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. Patients were seen once weekly for eight weeks or until medical clearance to return to sport. Both groups performed non-provocative range of motion (ROM) exercises, stretching, postural education and the current standard of care protocol for sport-related concussion (i.e. rest until symptom free, followed by graded exertion) (16). In addition to the above, the intervention group received an individually designed combination of cervical spine physiotherapy (i.e. joint mobilization techniques, craniovertebral flexor and extensor exercises and sensorimotor retraining exercises) typically before vestibular rehabilitation (which included habituation, gaze, stabilization, adaptation exercises, standing balance exercises, dynamic balance exercises and/or canalith repositioning manoeuvres) determined by the findings of the experienced physiotherapist (so, a pragmatic treatment approach) (17—19).

Study Strengths / Weaknesses:

Strengths:
  • This study provides insight into treatment frequency and duration following concussion to anticipate medical clearance to return to sport in this population only.
  • The sports medicine physician that evaluated medical clearance to return to sport was blinded to treatment group.
  • Secondary outcomes measured at baseline and at medical clearance were measured by a blinded physiotherapist.
Weaknesses:
  • Eight weeks was arbitrarily chosen as the study endpoint without any rational or evidence to support the treatment frequency. This could reflect the lack of established precedent in the literature to date.
  • Expectation bias may have been a factors, meaning the intervention group may perceive they were in the optimal treatment group.
  • The authors did not provide a description of cervical and vestibular training exercises, which unfortunately makes it difficult to replicate in clinical practice.
  • Formal vestibular testing was not performed in this study.

Additional References:

  1. McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47(5): 250–8.
  2. Kirkwood M, Yeates K, Wilson P. Pediatric sport-related concussion: A review of the clinical management of an oft-neglected population. Pediatrics 2006; 117(4): 1359–71.
  3. Pellman E, Powell JW, Viano DC, et al. Concussion in professional football: Epidemiological features of game injuries and review of the literature. Part 3. Neurosurgery 2004; 54: 81–97.
  4. McCrory P, Ariens T, Berkovic SF. The nature and duration of acute concussive symptoms in Australian football. Clin J Sport Med 2000; 10(4): 235–8.
  5. Benson BW, Meeuwisse WH, Rizos J, et al. A prospective study of concussions among National Hockey League players during regular season games: The NHL-NHLPA Concussion Program. CMAJ 2011; 183(8): 905–11.
  6. Rahman MI, Raveendran S, Kaliaperumal C, et al. Pseudotumor cerebri following traumatic brain injury in a 29-year-old man. J Nat Sci Biol Med 2012; 3: 105–7.
  7. Ponsford J, Willmott C, Rothwell A, et al. Cognitive and behavioural outcome following mild traumatic head injury in children. J Head Trauma Rehabil 1999; 14(4): 360–72.
  8. Asplund CA, McKeag DB, Olsen CH. Sport-related concussion: factors associated with prolonged return to play. Clin J Sport Med 2004; 14(6): 339–43.
  9. Treleaven J, Jull G, Atkinson L. Cervical musculoskeletal dysfunction in post-concussional headache. Cephalalgia 1994; 14(4): 273–9.
  10. Mallinson A, Longridge NS. Dizziness from whiplash and head injury: differences between whiplash and head injury. Am J Otol 1998; 19(6): 814–18.
  11. Ernst A, Basta D, Seidl RO, et al. Management of posttraumatic vertigo. Otolaryngol Head Neck Surg 2005; 132(4): 554–8.
  12. Goldberg L, Dimeff RJ. Sideline management of sport-related concussion. Sports Med Arthrosc 2006; 14(4): 199–205.
  13. Schneider KJ, Emery CA, Kang J, et al. Are clinical measures of cervical spine strength and cervical flexor endurance risk factors for concussion in elite youth ice hockey players? Br J Sports Med 2014; 48: 659.
  14. Schneider KJ, Emery CA, Kang J, et al. Are clinical measures of cervical flexor endurance, divided attention and computerized dynamic visual acuity different in elite youth ice hockey players who report a previous history of concussion compared to those who do not? Br J Sports Med 2014; 48: 658.
  15. Schneider KJ, Iverson GL, Emery CA, et al. The effects of rest and treatment following sport-related concussion: A systematic review of the literature. Br J Sports Med 2013; 47(5): 304–7.
  16. McCrory P, Johnson K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005; 39(4): 196–204.
  17. Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: Implications for assessment and management. J Orthop Sports Phys Ther 2009; 39(5): 364–77.
  18. Alsalaheen B, Much A, Morris L, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther 2010; 34(2): 87–93.
  19. Herdman S. Vestibular rehabilitation. 3rd ed. Philadelphia, PA: FA Davis Company, 2007.