Multimodal impairment-based physical therapy for the treatment of patients with post-concussion syndrome: A retrospective analysis on safety and feasibility

Highlights

• An impairment-based approach for patients with post-concussion syndrome is safe.

• Patients improved on average 9 points on the post-concussion symptom scale.

• Patients improved with exercise tolerance and postural stability.

• Patients averaged 4 physical therapy visits over approximately 3 months.

• Classifications are proposed to guide patient education and treatment.

Abstract

Objective

Demonstrate implementation, safety and feasibility of multimodal, impairment-based physical therapy (PT) combining vestibular/oculomotor and cervical rehabilitation with sub-symptom threshold exercise for the treatment of patients with post-concussion syndrome (PCS).

Setting

University hospital outpatient sports medicine facility.

Participants

Twenty-five patients (12–20 years old) meeting World Health Organization criteria for PCS following sport-related concussion referred for supervised PT consisting of sub-symptom cardiovascular exercise, vestibular/oculomotor and cervical spine rehabilitation.

Design

Retrospective cohort.

Main measures

Post-Concussion Symptom Scale (PCSS) total score, maximum symptom-free heart rate (SFHR) during graded exercise testing (GXT), GXT duration, balance error scoring system (BESS) score, and number of adverse events.

Results

Patients demonstrated a statistically significant decreasing trend (p < 0.01) for total PCSS scores (pre-PT M = 18.2 (SD = 14.2), post-PT M = 9.1 (SD = 10.8), n = 25). Maximum SFHR achieved on GXT increased 23% (p < 0.01, n = 14), and BESS errors decreased 52% (p < 0.01, n = 13). Two patients reported mild symptom exacerbation with aerobic exercise at home, attenuated by adjustment of the home exercise program.

Conclusions

Multimodal, impairment-based PT is safe and associated with diminishing PCS symptoms. This establishes feasibility for future clinical trials to determine viable treatment approaches to reduce symptoms and improve function while avoiding negative repercussions of physical inactivity and premature return to full activity.

Introduction

The incidence of concussion is high, with estimates approaching nearly 4 million sports-related concussions annually in the United States (Langlois, Rutland-Brown, & Wald, 2006). This increasingly common injury is a substantial concern to both medical professionals and the general population worldwide (Finch et al., 2013, Lincoln et al., 2011). The majority of patients with sports-related concussion will recover within 7–10 days (McCrea et al., 2003); however, a significant proportion, with estimates ranging from 24% to 84%, will suffer from prolonged symptoms despite appropriate conservative care (Ryan & Warden, 2003). If symptoms persist after the initial injury, the constellation may be classified as post-concussion syndrome (PCS). The World Health Organization (WHO) defines PCS as a persistence of three or more of the following symptoms succeeding a traumatic head injury: 1) headache, 2) dizziness, 3) fatigue, 4) irritability, 5) insomnia, 6) concentration difficulty, 7) memory difficulty (Boake et al., 2005).

Traditional treatments for PCS include rest, education, cognitive behavioral therapy, neurocognitive rehabilitation, and medications (Davies & McMillan, 2005). Recent recommendations from the Concussion in Sport group's (CISG) 4th consensus statement acknowledged that a substantial number of patients do not spontaneously recover; however, they provided little guidance beyond recommending a multimodal approach in these difficult cases (McCrory et al., 2013). While cognitive and physical rest are effective for many individuals in the acute stage of recovery, evidence suggests they may not be effective or appropriate for patients with PCS (Jotwani and Harmon, 2010, Willer and Leddy, 2006). Physical inactivity alone can precipitate secondary symptoms of fatigue, depression, anxiety, and physical deconditioning (Alosco et al., 2012, Ariza-García et al., 2013, Bogdanis, 2012, Nishijima et al., 2013). These unintended consequences are more likely to occur when recovery from concussion is prolonged (Leddy et al., 2010, Makdissi et al., 2013). Contrary to the effects of inactivity, increasing evidence supports the hypothesis that cardiovascular exercise may help treat PCS (Baker et al., 2012, Gagnon et al., 2009, Leddy et al., 2010).

Published evidence to support exercise as a treatment option for patients with PCS is encouraging, but remains limited. Leddy and colleagues concluded that PCS may be safely and effectively treated with individualized progressive sub-symptom threshold aerobic exercise (Leddy et al., 2010). After treatment, patients were able to exercise longer, achieving peak heart rate (HR) and systolic blood pressure without symptom exacerbation; 8 out of 11 patients significantly reduced their symptoms. Similarly, Baker and colleagues found an exercise rehabilitation program to be effective in returning over 70% of patients with PCS to full daily functioning (Baker et al., 2012). Majerske and colleagues retrospectively analyzed the neurocognitive performance and activity levels of 95 athletes for up to 33 days after concussion (Majerske et al., 2008). They noted that individuals who performed some exercise performed better than those who either performed no activity or returned to sports participation early on.

While it appears that cardiovascular exercise may provide an overall benefit to individuals with PCS, the syndrome often includes a spectrum of distinct symptoms that require more than exercise, or any single treatment, alone. For example, individuals often have concurrent cervical spine disorders, vestibular and visual disturbances, and various biopsychosocial influences that must be considered (Alsalaheen et al., 2010, Browne, 2006, Silverberg and Iverson, 2011). Due to this complex presentation and etiology, PCS is thought to be best treated with an individualized, multidisciplinary, and flexible approach (Leddy et al., 2010, Makdissi et al., 2013, McAllister and Arciniegas, 2002, Meehan, 2011, Reddy, 2011). Support for multimodal rehabilitation of patients with PCS is very limited (Schneider et al., 2013). One recent trial investigating the efficacy of cervical and vestibular physical therapy (PT) showed promising results when compared to the CISG guidelines, with more individuals in the PT group returning to their sport 8 weeks after injury (Schneider et al., 2014). While studies have shown the individual merits of cervicovestibular physical therapy and cardiovascular exercise, no study has combined the treatments in a complementary, impairment-based approach. The aim of this study was to assess whether an approach combining sub-symptom threshold exercise with comprehensive PT in an impairment-based treatment plan could safely treat the symptoms of post-concussion syndrome, establishing feasibility for this approach in future clinical trials.