Cervicovestibular Rehabilitation in Sport-Related Concussion: RCT +MP3 (Sample)
Research Review By Dr. Keshena Malik©
- 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:
- 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.
- 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)
- Neurological conditions
- Musculoskeletal injuries other than the cervical spine that restrict activity
- Medications that affect neural adaptation
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:
- 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.
- 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.
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