Research on Sports Related Concussions

Current and Emerging Rehabilitation for Concussions: A Review of the Evidence

Authors

Steven P. Broglio, PhD, ATC1,2; Michael W. Collins, PhD3; Richelle M. Williams, MS, ATC1; Anne Mucha, DPT3,4; and Anthony Kontos, PhD3

1School of Kinesiology, University of Michigan, Ann Arbor, MI
2University of Michigan Injury Center
3Department of Orthopaedic Surgery/UPMC Concussion Program-University of Pittsburgh, Pittsburgh, PA
4UPMC Centers for Rehab Services-UPMC, Pittsburgh, PA

Abstract

Concussion is one of the most hotly debated topics in sports medicine today. Research surrounding concussions has experienced significant growth recently especially in the areas of incidence, assessment, and recovery. However, there is limited research on the most effective rehabilitation approaches for this injury. This review evaluates the current literature for evidence for and against physical and cognitive rest and the emerging areas targeting vestibular, oculomotor, and pharamocological interventions for the rehabilitation of sport-related concussion.

Introduction

The clinical signs and symptoms of sport concussions have long been recognized as (1, 2), brought about by an extrinsic force applied directly or indirectly to the head or body (3). Much of the scientific literature surrounding this injury has focused on injury incidence(4), assessment tools (5, 6), and recovery patterns among athletes (7). Absent from the literature are reviews of empirical studies assessing the effectiveness of different rehabilitation approaches for concussed patients. Therefore, this paper will review and evaluate the evidence supporting consensus-based standard of care (e.g., physical and cognitive rest) and emerging, targeted (e.g., vestibular, oculomotor, exertional, pharamocological) rehabilitation approaches for concussion based on an evolving model of clinical concussion care (8).

The concept of physical and cognitive rest as the cornerstone of concussion management was developed and by the International Concussion in Sport Group, and currently states “The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and return to play (3).” The rationale for rest asserts that during the acute (1-7 days – possibly longer in youth) post-injury period of increased metabolic demand and limited adenosine triphosphate (ATP) reserves, non-essential activity draws oxygen and glycogen away from injured neurons. The Concussion in Sport Group recommendation has been interpreted by many clinicians to mean that all concussed athletes should be
restricted from all physical and cognitive activity until symptoms resolve. At which point, the athlete could be cleared to begin a return to play progression. This “shut down” or “dark closet” approach following concussion is wrought with potential pitfalls for patients including hyperawareness of symptoms, somatization, social isolation, and other potential co-morbid concerns. Citing the risk for prolonged and exacerbated symptoms that may not be directly related to the concussive injury, other medical organizations have recommended that athletes be permitted to engage in limited physical and cognitive activity so long as it does not worsen symptoms(9).

These two perspectives regarding strict rest versus physical and cognitive activity as tolerated are seemingly at odds with each other, in part because there is no agreed upon definition of what constitutes rest following a concussion in the literature. Such recommendations are also limited as they do not take into account the individualized nature of the injury, potential risk factors that may influence outcomes, and differential responses to recovery. Moreover, and most importantly, there are no known prospective randomized control trials evaluating rest in concussed athletes immediately following a concussion(10). In fact, the evidence for physical and cognitive rest is limited, relying on observational studies and studies of patients from sports medicine clinics during the sub-acute stage (11, 12). With a dearth of literature to support clinical guidelines, expert consensus has been used in its place.

The premise that rest is the most effective management strategy for all concussed patients assumes that all concussions are alike, yet concussion recovery is known to be influenced by several modifying factors including sex(13), concussion history(14), and age(15). Even for injuries occurring within these populations, concussions manifest in varied symptoms (e.g., headache, dizziness, fogginess), cognitive (e.g., memory, reaction time, processing speed)(16), psychological (e.g., depression, anxiety)(16), and vestibular (e.g. dizziness, imbalance, gait, vestibulo-ocular) (17) impairments. As such, this highly individualized injury results in a varied injury presentation, indicating no single rehabilitation strategy will be effective for all patients following concussion necessitating distinct treatment(8).

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