Research Review By Dr. Brynne Stainsby©

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Background Information:

Summary:

• 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.

• 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).

• 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 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.

• 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.

• 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:

Study Methods:

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:

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