Research Review By Dr. Brynne Stainsby©


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Date Posted:

October 2019

Study Title:

Concussion – Part II: Rehabilitation – The need for a multifaceted approach


Schneider KJ

Author's Affiliations:

Sport Injury Prevention Research Centre, Faculty of Kinesiology, Hotchkiss Brain Institute, Alberta Children’s Hospital Research Institute, University of Calgary, Alberta, Canada.

Publication Information:

Musculoskeletal Science and Practice 2019; 42: 151-161. doi: 10.1016/j.msksp.2019.01.006.

Background Information:

Concussion is one of the most common injuries in sport and recreation (1). A multifaceted assessment including history, neurological evaluation, balance tests, cervical spine exam and cognitive assessment (1, 2) should be conducted. In most cases, an initial period of physical and cognitive rest will be followed by a gradual return to sport and activity (3). While most patients will recover through this initial phase, in 20-30% of cases, symptoms will persist. In these patients, multidisciplinary rehabilitation may facilitate recovery (3, 4).

The purpose of this narrative review was to outline evidence-informed rehabilitation strategies which may benefit those recovering from concussion.


Typical Treatment and Recovery Path:
  • A short (24-48 hour) period of physical and cognitive rest is the typical first stage of treatment for concussion (3). Prolonged rest and avoidance of activities of daily living (ADL) is not recommended (3).
  • A gradual return to ADL and a strategy to increase physical and cognitive exertion should be integrated before returning to school/work or sport (5).
  • For return to sport, athletes should progress through six steps (symptom-limited activity, light aerobic exercise, sport-specific exercise, non-contact training drills, full contact practice, return to play) with medical clearance prior to participation in full contact practice (6). Clinicians should be aware of return to play criteria for specific leagues to ensure athletes receive appropriate clearance. Each step should take a minimum of 24 hours and should symptoms recur, the athlete must move back to the previous step for an additional 24 hours (6). If symptoms are persistent, further evaluation is warranted.
  • Return to school or occupation also requires a stepwise process to accommodate for the increased cognitive demands and challenges associated with processing sensory input (5, 7, 8). The four steps for return to school are: daily activities that do not cause symptoms, school activities (at home), return to school part time, return to school full time (6).
  • Although the majority of athletes will experience resolution of their symptoms within 10 days (5), studies have indicated that 14-30% of young athletes may experience prolonged symptoms (9-11). Given that concussions have a heterogeneous clinical presentation (particularly when symptoms persist), it is challenging to know which treatment will be most appropriate for a given patient, and often multi-intervention or multidisciplinary programs are used (12). Thorough evaluation of the symptom pattern should inform the plan of management.
Management of Post-Traumatic Headache:
  • Headaches (HA) are one of the most common symptoms following concussion, and it is generally accepted that a multifaceted approach addressing the contributing factors to the HA is appropriate (13-16). Differential diagnosis is important to identify the type of HA in order to appropriately direct care.
  • Pharmacological management may be indicated for migraine or tension-type HA, however, medication overuse can also cause HA (13, 16, 17).
  • Physical therapies are an effective intervention for HA, particularly cervicogenic HA (18), migraine and perhaps tension-type HA (this is where spinal manipulation and mobilization come into play).
  • Occipital nerve blocks have also shown benefit for posttraumatic HA in adult and child populations (19, 20).
Cervical Spine Treatment and Rehabilitation:
  • Although neck pain (NP) and alterations in cervical spine function/motion have been reported following concussion, evidence for treatments in populations with NP related to concussion is limited (21), though there large body of evidence for the management of NP in general.
  • The evidence suggests a role for mobilization or manipulation, in addition to exercise and active therapies. In patients with NP following concussion, clinicians may consider sensorimotor exercises to assist with the improvement of pain, function and quality of life (18, 22, 23).
  • Specific neck muscle retraining may be helpful in the population with neck pain following concussion, such as combining cervical and vestibular rehabilitation with the aim of improving craniocervical neuromuscular control (24). Exercises focused on activating the deep cervical flexors, extensors and axio-scapular muscles may be beneficial (25).
  • While there is a paucity of evidence evaluating cervical interventions specifically in populations with concussion, one trial suggests that including neuromuscular retraining exercises as part of a multifaceted treatment may demonstrate a positive effect in those with ongoing symptoms following concussion (24).
Vestibular Rehabilitation:
  • Vestibular rehabilitation refers to exercises aimed at facilitating central vestibular reorganization, which is normally required to address one or more specific deficits.
  • If a patient has been diagnosed with benign paroxysmal positional vertigo (BPPV) following concussion, canalith repositioning maneuvers may be indicated, and evidence suggests these are safe and effective interventions (26, 27). If the symptoms are not alleviated within three treatments, other diagnoses should be considered (this applies to non-concussion cases as well, in general) (26).
  • Adaptation exercises to train the vestibulo-ocular reflex may be prescribed following concussion (24, 28, 29). The patient is instructed to focus on a target and then rotate the head while remaining focused on the target. These exercises should be progressed to be context-specific and trained in the direction and environment in which the athlete will be required to function. A mild and brief increase in symptoms is acceptable, however, prolonged or intense symptoms should not occur.
  • Habituation exercises repetitively expose the patient to movements that provoke a small amount of dizziness (30). As with adaptation exercises, a mild and brief increase in symptoms is acceptable, however, prolonged or intense symptoms should not occur.
  • Postural stability and balance exercises are another critical component of vestibular rehabilitation (30). Depending on the ability of the athlete/patient, exercises should be used to safely challenge balance (a spotter or supports may be required initially). Typically, standing balance will progress from double leg stance to tandem stance to single leg stance, and altered sensory input (closing eyes) may also be incorporated (31). Dynamic balance exercises may be incorporated depending on the abilities of the athlete and the demands of his/her sport (turning head, using equipment, etc.). In patients with concurrent pain and balance difficulties, pain-free and adequate control of the head on the neck is desirable, and clinicians should consider addressing pain complaints (NP, HA, etc.) before beginning balance exercises.
Low-Level Aerobic Exercise:
  • There is some evidence that low-level aerobic exercise may facilitate recovery in youth and adults with persistent symptoms following concussion (32-35).
  • In adolescents and adults, a protocol of training at 80% of maximum, sub-symptom heart rate five to six times per week (until symptoms no longer increase with exercise) has been found to be safe and beneficial to recovery (35).
  • In children, a protocol of exercising at 60% of maximum heart rate (calculated using 220-age) for 15 minutes in combination with coordination exercises, mental imagery and reassurance demonstrated positive results in a case series (36-38).
  • Further research regarding the optimal frequency, intensity, timing and type of aerobic exercise is required.
Other Considerations:
  • Postural education, particularly for return to work or school, may be of benefit (39).
  • Some patients may experience sensitivity to visual stimulus following concussion (40) and wearing tinted glasses or avoiding incandescent (or other bothersome) lighting may be beneficial for a period of time (41). This literature is limited and co-management with an optometrist or ophthalmologist would be warranted.
  • Patients may experience difficulties with divided attention following concussion, and clinicians should aware of this as rehabilitation programs progress to more complex tasks including multiple systems concurrently (12, 42).
  • Evidence regarding pharmacological therapy for the management of concussions is limited. If symptoms are persistent, screening for mood, psychological, cognitive and sleep disorders should be considered, with appropriate referral if warranted. In these more complex cases, multidisciplinary collaborative care (including psychological intervention, pharmacotherapy) is suggested (43, 44).

Clinical Application & Conclusions:

The initial management of a concussion should include a brief (24-48 hour) period of physical and cognitive rest. A gradual, step-wise return to learn/work and return to sport program should be followed, with careful assessment at each stage to ensure that symptoms have not returned.

While most patients will experience an uncomplicated recovery, if symptoms persist beyond 10 days, a detailed, multifactorial (and possibly multidisciplinary) assessment is required. Treatment should be individualized based on the symptom presentation. Clinicians must be aware that there is limited high-quality evidence in concussion populations specifically, so they may need to rely on evidence in the general population, with the need for careful monitoring of recurrent symptoms throughout the treatment plans. In these cases, referrals to specialists with experience in managing concussions will likely be indicated. Cervical spine and vestibular rehabilitation should be considered, in addition to treatment of NP or HA. Clinicians should also consider screening for concurrent mental health diagnoses, which may be aggravated by a concussion. A multidisciplinary team with experience managing concussions will facilitate optimized care of these complex cases. Future research is required to better understand the optimal plan of management for patients dealing with persistent symptoms following concussion.

Study Methods:

This paper was a narrative review and as such, the methodology was not described.

Study Strengths / Weaknesses:

  • This review provides an overview of the expected recovery and return to learn/return to play strategies to be used in patients with concussion.
  • It also highlights potential types of interventions which may be beneficial for patients suffering from persistent symptoms following concussion.
  • This review identifies the limitations in research, and suggests that clinicians look to related evidence in the general population to guide treatment decisions.
  • This review appropriately emphasizes the need for and value of collaborative care for concussion patients.
  • The primary limitation of this paper is the lack of a description of the methods employed.
  • The author does not include statements regarding the research question, search strategy or if/how the quality of the included evidence was appraised.
  • The references with respect to cervical rehabilitation are relatively dated, and a significant body of evidence (the subsequent updates of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (NPTF)) was not included.
  • While this review presents a number of possible interventions, not all have been assessed in concussion populations, and thus, clinical utility and generalizability may be limited, pending further evidence.

Additional References:

  1. McCrory P, Meeuwisse W, Dvorak J et al. Consensus statement on concussion in sport - the 5th international conference on concussion in sport held in Berlin, October 2016. BJSM 2017; 51: 838–847.
  2. Patricios J, Fuller GW, Ellenbogen RG et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. BJSM 2017; 51: 888–894.
  3. Schneider KJ, Leddy J, Guskiewicz K et al. Rest and specific treatments following sport-related concussion: a systematic review. Br. J. Sports Med 2017b; 51: 930–934.
  4. Marshall S, Bayley M, McCullagh S et al. Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Can Fam Physician 2012: 58: 257–267 e128-40.
  5. McCrory P, Meeuwisse WH, 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: 250–258.
  6. Echemendia RJ, Meeuwisse W, McCrory P et al. The sport concussion assessment tool 5th edition (SCAT5). BJSM 2017; 51: 848–850.
  7. Davis GA, Anderson V, Babl FE et al. What is the difference in concussion management in children as compared with adults? A systematic review. BJSM 2017a; 51: 949–957.
  8. Davis GA, Purcell L, Schneider KJ et al. The child sport concussion assessment tool 5th edition (child SCAT5): background and rationale. BJSM 2017bb; 51: 859–861.
  9. Barlow KM, Crawford S, Stevenson A et al. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics 2010: 126: e374–e381.
  10. Schneider K, Nettel-Aguirre A, Palacios-Derflingher L et al. Concussion burden, recovery and risk factors in elite youth ice hockey players. BJSM 2017a; 51: E103.
  11. Zemek R, Barrowman N, Freedman SB et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. J Am Med Assoc 2016; 315: 1014–1025.
  12. Schneider K. Sport-related concussion: optimizing treatment through evidence-informed practice. JOSPT 2016; 46: 613–616.
  13. Blume HK. Headaches after concussion in pediatrics: a review. Curr Pain Headache Rep.2015; 19.
  14. Pinchefsky E, Dubrovsky AS, Friedman D et al. Part I - evaluation of pediatric post-traumatic headaches. Pediatr Neurol 2015a; 52: 263–269.
  15. Pinchefsky E, Dubrovsky AS, Friedman D et al. Part II – management of pediatric post-traumatic headaches. Pediatr Neurol 2015b; 52: 270–280.
  16. Zasler ND. Sports concussion headache. Brain Inj 2015; 29: 207–220.
  17. Heyer GL, Idris SA. Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients? Pediatr Neurol 2014; 50: 464–468.
  18. Jull G, Trott P, Potter H et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27: 1835–1843, discussion 43.
  19. Hecht J. Occipital nerve blocks in postconcussive headaches: a retrospective review and report of ten patients. J. Head Trauma Rehabil 2004; 19: 58–71.
  20. Seeger T, Rajapakse T, Bodell L et al. Response to occipital nerve block after traumatic brain injury in adolescents. Brain Inj 2014; (in press).
  21. MacGregor K, Atkins C, Blake TA et al. Clinical characteristics, referral patterns and time to recovery in youth and adults following a sport related concussion. BJSM 2017; 51: E126.
  22. Gross A, Hoving J, Haines T et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 2004; 29: 1541–1548.
  23. Hurwitz E, Carragee EJ, van der Velde G et al. Treatment of neck pain: Noninvasive interventions: results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine 2008; 15: S123–S152.
  24. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A et al. Cervicovestibular physiotherapy in the treatment of individuals with persistent symptoms following sport related concussion: a randomised controlled trial. Br J Sports Med 2014b; 48: 1294–1298.
  25. O'Leary S, Falla D, Elliott JM et al. Muscle dysfunction in cervical spine pain: implications for assessment and management. JOSPT 2009; 39: 324–333.
  26. Bhattacharyya N, Gubbels SP, Schwartz SR et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg 2017b; 156: S1–S47.
  27. Ouchterlony D, Masanic C, Mchalak A et al. Treating benign paroxysmal positional vertigo in the patient with traumatic brain injury: effectiveness of the canalith repositioning procedure. J. Neurosci. Nurs 2016; 48: 90–99.
  28. Alsalaheen BA, Whitney S, Mucha A et al. Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion. Physiother Res Int 2013; 18: 100–108.
  29. Schneider K, Meeuwisse W, Barlow K et al. Cervicovestibular rehabilitation following sport-related concussion. BJSM 2018; 25: 100–101.
  30. Herdman SJ, Clendaniel R. Vestibular Rehabilitation Fourth Edition. F.A. Davis Company, Philadelphia, PA 2014.
  31. Hall CD, Herdman SJ, Whitney SL et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline. J Neurol Phys Ther 2016; 40: 124–154.
  32. Gagnon I, Galli C, Friedman D et al. Active rehabilitation for children who are slow to recover following sport-related concussion. Brain Inj 2009a; 23: 956–964.
  33. Gagnon I, Grilli L, Friedman D et al. A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scand J Med Sci Sports 2016a; 26: 299–306.
  34. Leddy JJ, Cox JL, Baker JG et al. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehabil 2013; 28: 241–249.
  35. Leddy JJ, Kozlowski K, Donnelly JP et al. A preliminary study of subsymptom threshold exercise training for refractory postconcussion syndrome. Clin J Sport Med 2010; 20: 21–27.
  36. Dobney D, Grilli L, Kocilowicz H et al. Evaluation of an active rehabilitation program for concussion management in children and adolescents. Brain Inj 2017: 31(13-14): 1753–1759.
  37. Gagnon I, Galli C, Friedman D et al. Active rehabilitation for children who are slow to recover following sport-related concussion. Brain Inj 2009b; 23: 956–964.
  38. Gagnon I, Grilli L, Friedman D et al. A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scand J Med Sci Sports 2016b; 26: 299–306.
  39. Kim D, Cho MJ, Park Y et al. Effect of an exercise program for posture correction on musculoskeletal pain. J Phys Ther Sci 2015; 27.
  40. Digre K, Brennan K. Shedding light on photophobia. J Neuro Ophthalmol 2012; 32: 68–81.
  41. Clark J, Hasselfeld K, Bigsby K et al. Colored glasses to mitigate photophobia symptoms posttraumatic brain injury. J Athl Train 2017; 52: 725–729.
  42. Kleiner M, Wong L, Dube A et al. Dual-Task Assessment protocols in concussion assessment: a systematic literature review. J Orthop Sports Phys Ther 2018; 42(2): 87–103.
  43. Makdissi M, Schneider KJ, Feddermann-Demont N et al. Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med 2017; 51, 958–968.
  44. McCarty CA, Zatzick DF, Stein E et al. Collaborative care for adolescents with persistent postconcussive symptoms: a randomized trial. Pediatrics 2016; 138.

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