Rehabilitation in Sport-related Concussion
Rehabilitation in Sport-related Concussion
Sport-related concussion is a commonly occurring injury in sport and recreation. The majority of individuals recover in the initial 7-10 days following injury but in up to 30% of cases, symptoms may persist. In many cases, ongoing symptoms can limit participation in activities of daily living, school, occupation and sport. Thus, evaluation to inform optimal management strategies following concussion will decrease the public health burden to Canadians from this commonly occurring injury.
The current guidelines for treatment following sport-related concussion are largely based on a consensus of expert opinion. Some of the most common symptoms following concussion are dizziness, neck pain and headaches. Previous work by our group has identified that youth and young adult athletes treated with a combination of cervical and vestibular rehabilitation were 10 times more likely to be medical cleared to return to sport when compared to the standard of rest followed by a protocol of graded exertion. Case series suggest that low-level aerobic exercise may be of benefit following concussion. There is a gap in the literature comparing a combination of cervical and vestibular rehabilitation and aerobic exercise to either treatment in isolation.
The objectives of our research program are to evaluate if cervical and vestibular rehabilitaton (CVPT) reduce time to medical clearance to return to sport and improve quality of life compared to low level aerobic exercise (LLAE) in individuals with persistent symptoms of dizziness, neck pain and/or headaches following concussion. Secondary objectives are to determine if a combination of CVPT and LLAE reduce time to medical clearance to return to sport and improve quality of life compared to CVPT or LLAE alone.
We hypothesize that the proportion of individuals who are medically cleared to return to sport in an 8-week time period following treatment initiation will be greater in the CVPT group than in the LLAE group. Improvements in quality of life will be greater in the CVPT group than in the LLAE group. The proportion of individuals who are medically cleared and improvements in quality of life will be greatest in the combination group (CVPT and LLAE).
Design: This is a single blind, 3 arm randomized controlled trial (RCT). Participants will include youth (ages 10-18 years) diagnosed with a sport-related concussion and who have ongoing symptoms of dizziness, neck pain and/or headaches (>10 days and < 1 year post injury). Participants must also have clinical examination findings suggesting cervical spine and/or vestibular involvement. All participants will undergo a physiotherapy assessment at inclusion into the study, time of medical clearance to return to sport (if less than 8 weeks) or at 8 weeks following initiation of treatment. Interventions: Participants will be randomized into a cervicovestibular physiotherapy intervention (CVPT) group, a low level aerobic exercise group (LLAE), or a combination of CVPT and LLAE group (combination). All study participants will follow-up weekly with a study physiotherapist (30 minute appointment) for 8 weeks (or until medical clearance to return to sport if clearance occurs prior to 8 weeks). Outcome measures: The primary outcomes of interest are: 1) Medical clearance to return to sport by 8-weeks (as per the 4th International Consensus Guidelines on Concussion in Sport) and 2) Quality of Life (Pediatric Quality of Life Inventory). Data collection and management: will occur at the Sport Injury Prevention Research Centre, University of Calgary. Sample Size: Based on previous work performed by our group, we require 32 participants per group for a total of 96 participants (10% drop out rate, 80% power). Analysis: Primary objectives: 1) The primary outcome of interest is medical clearance to return to sport by eight weeks (dichotomous outcome: yes/no). For the CVPT and LLAE groups, crude proportions will be calculated and compared using survival analysis. 2) Health Related Quality of Life (PedsQL): Independent samples t-tests will be used to evaluate the mean difference in PedsQL score.
Secondary research questions: Crude proportions will be calculated for the combined treatment group (CVPT+LLAE). Pairwise comparisons between groups will be performed. Specifically, we will examine differences between i) CVPT and combined treatment (CVPT+LLAE), and ii) LLAE and combined treatment (CVPT+LLAE). 2) Health Related Quality of Life (PedsQL): Independent samples t-tests will be used to evaluate the mean difference in PedsQL score.
Expected results and potential significance: The results from this RCT will inform future multifaceted RCTs as well as best practice in rehabilitation post-concussion. Identification of optimal rehabilitation strategies will lead to a reduction in persistent symptoms and functional improvements in youth suffering from this common injury.
This RCT is currently under review with the Conjoint Health Research Ethics board at the University of Calgary. It is anticipated that the RCT will begin in July 2016 and be complete by December 2017. This study is funded through the Vi Riddell Paediatric Rehabilitation Research Program, Alberta Children’s Hospital Foundation, Canadian Foundation for Innovation and the Faculty of Kinesiology at the University of Calgary.