While physical and cognitive rest in the period immediately after concussion is widely considered the cornerstone of concussion management, it may hinder recovery in those concussion patients experiencing dizziness from an injury to the cervical spine, who might, some argue, benefit more from early, aggressive and active treatment for their dizziness.
Writing in the British Journal Medicine, physical therapists Jennifer Reneker of Kent State University and Chad Cook of Duke University, suggest that, for some concussed patients who experience cervicogenic dizziness, a form of dizziness characterized by neck pain and an illusory sense of motion and disequilibrium, vestibular rehabilitation therapy (VRT) targeting the complex sensory system in the inner ear that controls movement and balance, and manual manipulation and motor-control retraining of the neck, might prove more effective than rest, which they note, while a well-established practice, is only supported by a very low-level of evidence.
VRT has been demonstrated to be a highly effective treatment for most individuals with vestibular or central balance system disorders. In a number of studies, customized vestibular rehabilitation programs have been reported to be significantly more effective in resolving symptoms than generic exercises, and especially medications, and has been found to reduce dizziness and improve gait and balance in children and adults after concussion.
A recent study suggests that the degree of dizziness right after a concussion may be indicative of the eventual length of recovery, with extreme dizziness suggesting a longer recuperation, i.e. post-concussion syndrome. The authors of that study urged follow-up vestibular assessments to further identify the cause of dizziness and guide subsequent therapy and treatment, and said that on-field identification of dizziness could lead to earlier implementation of vestibular rehabilitation and other modalities to treat dizziness, which may expedite recovery from concussion.
VRT was also found effective in treating chronic dizziness after concussion in three recent studies.
In the first, a combination of cervical and vestibular physiotherapy was found in a small, randomized, controlled trial to decrease time to medical clearance to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion. Both the control and intervention groups received weekly sessions with a physiotherapist for 8 weeks or until the time of medical clearance, and received postural education, range of motion exercises and cognitive and physical rest until asymptomatic, after which the patients followed the symptom-limited graded exertion protocol experts recommend before returning to play. The intervention group also received cervical spine and vestibular rehabilitation. In the treatment group, 73% of the participants were medically cleared within 8 weeks of initiation of treatment, compared with only 7% in the control group.
In the second, a retrospective study which included patients with persistent symptoms of dizziness after concussion found that those who were treeated only with vestibular therapy significant decreases in symptoms.
In the third, researchers, reviewing the charts of 53 pediatric patients who had completed a course of VRT after concussion, found improved tolerance of eye tracking and balance, and that all tolerated the therapy without significant exacerbation of symptoms. The results led the paper's authors to conclude that VRT may be helpful in treating persisting dizziness and balance problems after concussion in children and teens, but that further study was neeed to determine if VRT may improve prolonged symptoms of dizziness and balance disturbance in children with concussion.
Missing treatment option?
While recognizing that none of the studies explored the effectiveness of accute assessment and skilled treatment of dizziness by a physical therapist to prevent prolonged symptoms in concussed athletes, Reneker and Cook pointed to them as supporting further exploration of such a treatment approach.
They were, however, candid in recognizing potential challenges to widespread adoption of a more aggressive and active treatment approach early in the course of concussion recovery, including the lack of a standardized assessment approach for cervoceginic dizziness, its controversial nature as a clinical diagnosis, lack of acceptance among physicians (particularly medical doctors in sports medicine) and absence from medical school curricula and continuing medical education, and of funding for the comparative trials needed to examine the results of early therapeutic interventions.
"Until research convincingly demonstrates the safety and effectiveness of early, skilled and active management of dizziness," Reneker and Cook admitted that, "it is likely that the rest paradigm will retain its position as the treatment of choice [after concussion]." But it was their "impression that a dedicated treatment approach recognizing the contribution of the cervical spine to the sensation of dizziness may be the missing treatment option in cases that arise after sports-related concussion."
Sources:
Reneker JC, Cook CE. Dizziness after sports-related concussion: Can physiotherapists offer better treatment than just 'physical and cognitive rest'? Br J Sports Med 2015;49:491-492. originally published online July 17, 2014.
Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cerviovestibular rehabilitation in sport-related concussion: a randomized controlled trial. Br J Sports Med 2014;48:1294-8.
Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which On-Field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Am J Sports Med 2011;20(10) DOI:10.1177/0363546511410655 (published June 28, 2011 online ahead of print)(accessed November 5, 2011).
Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther. 2010;34(2):87-93
McCory, P. 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
Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80:2250-7.
Harmon KG, Drezner J, Gammons M, et al American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26.
Research paper. Vestibular Rehabilitation in Children Following Concussion. Storey E, et al. Presented at American Academy of Pediatrics National Conference and Exhibition, October 24, 2015. Washington, D.C.
Posted April 3, 2015. Updated November 24, 2015
