Craniosacral therapy
Craniosacral therapy (CST) is a 20th century offshoot of cranial osteopathic medicine, a philosophy and system of healing first proposed by Dr. A. T. Still in 1874. The goal of CST is to improve cranial flexibility and restore normal brain function. It is fundamentally an approach that encourages the body to heal itself, but it is not a quick fix. Just like every other aspect of concussion, the body and brain need time to do the work of healing in response to CST.
Although CST is considered somewhat outside the mainstream, some leading sports physicians treating concussion (and the various symptoms of concussion such as vertigo, headache, musculoskeletal pain, vision and hearing changes to name a few) now refer patients to CST, sometimes with impressive results.
Vestibular rehabilitation therapy
Vetibular dysfunction (e.g. dizziness) is commonly associated with concussion and other traumatic brain injury. [5,9] A recent study [4] 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 also urged follow-up vestibular assessments to further delineate the cause of dizziness and inform subsequent therapy and treatment. Citing a 2010 study finding that patients who had at least 2 rehabilitation visits for persistent dizziness after a concussion showed improvement on tests for dizziness, [5] the study 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.
A 2015 study [24] by Canadian researchers found that nearly two-thirds (62.5%) of young athletes diagnosed with PCS had vestibular-ocular dysfunction or VOD (e.g. they complained of intermittent blurred or double vision, visual disturbance, gaze instability or difficulty focusing, dizziness, difficulty reading, or motion sensitivity and were found on clinical examination to have more than one abnormality in eye movements or vestibulo-ocular reflexes).
The findings led the study authors to conclude that the presence of VOD may be predictive of a prolonged recovery from sports-related concussion. Writing in the Journal of Neurosurgery: Pediatrics, lead author Michael Ellis of the Canada North Concussion Network in Manitoba, said that, "Future research is needed to confirm the findings of this study, identify clinical predictors of vestibulo-ocular dysfunction, and evaluate the effects of targeted vestibular and oculomotor rehabilitation on the objective findings responsible for persistent concussion symptoms."
Vestibular rehabilitation therapy (VRT) has been demonstrated to be a highly effective treatment for most individuals with vestibular or central balance system disorders. [5,22] 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. [9,14]
In one small randomized controlled trial [23], a combination of cervical and vestibular physiotherapy was found 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 followed by a protocol of graded exertion. The intervention group also received cervical spine and vestibular rehabilitation. In the treatment group, 73% (11/15) of the participants were medically cleared within 8 weeks of initiation of treatment, compared with only 7% (1/14) in the control group. Put another way, individuals in the treatment group were almost 4 times more likely to be medically cleared by 8 weeks.
A second retrospective study[5], including patients with persistent symptoms of dizziness after concussion, found that treatment with vestibular therapy only reported significant decreases in symptoms.
In a third retrospective study, [26] 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.
The basis for the success of a vestibular rehabilitation program is the use of already existing neural mechanisms for adaptation, plasticity, and compensation in the human brain. Compensation and adaptation have been demonstrated to be closely related to the direction, duration, frequency, and magnitude of the stimulus. Specifically designed VRT exercise protocols take advantage of this plasticity of the brain to increase sensitivity and restore symmetry, which results in an improvement in vestibular-ocular control, an increase in the gain of the vestibuloocular reflex (VOR), better postural strategies, and increased levels of motor control for movement.
Aerobic exercise therapy
When an athlete is unable to transition back into an active lifestyle, they are at risk for secondary problems such as physical deconditioning, anxiety and stress, mild depression, and irrritability. Over time, the strength of the relation between the original injury and ongoing symptoms very likely diminishes, and the pre-existing, current and contextual factors increasingly contribute to causing, maintaining, or exacerbating symptoms. [9]
The accepted wisdom that PCS should be treated with rest, reassurance and anti-depressants, and that physical activity should be avoided, however, is now being questioned, with the authors of a 2013 systematic review of the literature on the effects of rest and treatment following sport-related concussion [9] noting that "[c]onverging lines of diverse, albeit indirect, medical and scientific evidence [now] support the use of exercise as a core component of treatment for children, adolescents, and young adults who are slow to recover from concussion."
In a landmark 2012 study published in the Clinical Journal of Sports Medicine, [6] researchers at the State University of New York at Buffalo (SUNY-Buffalo) reported that a program of progressive exercise developed individually for each participant and performed at levels just below the onset of symptoms was safe and relieved nearly all PCS symptoms.
The SUNY-Buffalo regimen is based on the hypothesis that the regulatory system responsible for maintaining cerebral blood flow, which may be dysfunctional in people with concussion, [7] can be restored to normal by controlled, graded, symptom-free exercise. A 2013 pilot study by the same researchers provided preliminary evidence to support that hypothesis.
"Perhaps the most exciting aspect of this study is that all of the subjects that participated, both athletes and non-athletes, got better eventually, although the athletes certainly improved the fastest," said Barry Willer, PhD, UB professor of psychiatry and rehabilitation sciences and senior author on the study, in a January 2010 SUNY-Buffalo press release. [8]
"It also was reassuring to discover that the use of exercise was safe and did not prolong symptoms, a worry expressed by other practitioners."
Physicians in UB's Sports Medicine Concussion Clinic initially used their approach only with athletes from UB teams, but word spread, and they now have assessed and treated many professional athletes, especially those from the National Hockey League.
"One of the advantages we offer to professional teams is a more precise test of post-concussion syndrome," says John J. Leddy, MD, associate professor of orthopaedics and co-director of UB's Sports Medicine Institute. "If the patient does not develop symptoms during the exercise test, then the cause of their difficulties is likely to be another source. Most commonly it is neck strain, which tends to cause headaches that mimic post-concussion headache."
"The data suggest that some PCS symptoms are related to disturbed cerebral autoregulation, and that after this treatment, the brain was able to regulate blood flow when the blood pressure rose during exercise," says Leddy. "We think progressive stepwise aerobic training may improve cerebral autoregulation by conditioning the brain to gradually adapt to repetitive mild elevations of systolic blood pressure."
"Although each concussion should be considered a 'unique injury,' a randomized trial that included a PCS control group should be conducted to address the possibility that PCS symptoms would have resolved spontaneously without intervention, said study co-author Karl Kozlowski, PhD, UB clinical instructor of exercise and nutrition sciences, who developed the exercise protocol.
"All of our subjects had been symptomatic for months before treatment and were not getting better on their own," says Kozlowski, "so we are pretty convinced that the regulated exercise program did the trick."
Most recently, researchers presenting at the American of Academy of Pediatrics National Conference and Exhibition in Washington, D.C. in October 2015, [25] reported that aerobic therapy may lessen the symptoms experienced by children and adolescents suffering from post-concussion syndrome and allow them to return to baseline.
Researchers, led by William R. Johnson of the Perelman School of Medicine at the University of Pennsylvania, reviewed the charts of 57 pediatric patients with post-concussion syndrome presenting to a specialty sports medicine concussion program at a large children's hospital from 2011-2013 who were referred to physical therapy (PT) for post-concussion symptoms.
Extracting data from each PT visit with AT, along with the number of symptoms, symptom severity, exercise time, completed exercise, and symptoms with exercise, they found that the percentage of patients who reported concussion symptoms dropped from 93% at their first PT visit to 42% at discharge from physical therapy.
Two-thirds of the patients were able to complete AT during their initial PT session, with exercise inducing post-concusive symptoms in slightly more than half (54%). At their final PT session, nine out of ten were able to complete the exercise, with exercise inducing post-concussion symptoms in only 9%.
While conceding that further study was needed to prospectively compare outcomes in post-concussion syndrome patients treated with and without AT, the authors concluded that exersise appeared to be both tolerated by pediatric patients with post-concussion syndrome and to result in a reduction of symptoms.
