Sequencing and Integration of Cervical Manual Therapy and Vestibulo-oculomotor Therapy for Concussion Symptoms: Retrospective Analysis

Abstract

Background BackgroundAfter concussion many people have cervicogenic headache, visual dysfunction, and vestibular deficits that can be attributed to brain injury, cervical injury, or both. While clinical practice guidelines outline treatments to address the symptoms that arise from the multiple involved systems, no preferred treatment sequence for post-concussion syndrome has emerged. Purpose PurposeThis study sought to describe the clinical and patient-reported outcomes for people with post-concussion symptoms after a protocol sequenced to address cervical dysfunction and benign paroxysmal positional vertigo within the first three weeks of injury, followed by integrated vision and vestibular therapy. Study Design Study DesignRetrospective longitudinal cohort analysis Methods MethodsRecords from a concussion clinic for 38 patients (25 male 13 female, aged 26.9±19.7 years) with post-concussion symptoms due to sports, falls, assaults, and motor vehicle accident injuries were analyzed. Musculoskeletal, vision, and vestibular system functions were assessed after pragmatic treatment including early cervical manual therapy and canalith repositioning treatment-when indicated-integrated with advanced vision and vestibular rehabilitation. Patient-reported outcomes included the Post-Concussion Symptom Scale (PCSS) for general symptoms; and for specific symptoms, the Dizziness Handicap Index (DHI), Convergence Insufficiency Symptom Scale (CISS), Activities-specific Balance Confidence scale (ABC), and the Brain Injury Vision Symptom Survey (BIVSS). Paired t-tests with Bonferroni correction to minimize familywise error (p<0.05) were used to analyze the clinical and patient-reported outcomes. Results ResultsAfter 10.4±4.8 sessions over 57.6±34.0 days, general symptoms improved on the PCSS (p=0.001, 95%CI=12.4-30.6); and specific symptoms on the DHI (p<0.001, 95%CI=14.5-33.2), CISS (p<0.002, 95%CI=7.1-18.3), ABC (p<0.024, 95%CI=-.3 --.1), and BIVSS (p<0.001, 95%CI=13.4-28.0). Clinical measures improved including cervical range-of-motion (55.6% fully restored), benign paroxysmal positional vertigo symptoms (28/28, fully resolved), Brock string visual convergence (p<0.001, 95%CI=3.3-6.3), and score on the Balance Error Scoring System (p<0.001, 95%CI=5.5-11.6).

Short-Term Effect of Spinal Manipulation on the Magnitude of Exophoria in Adults Who Are Asymptomatic: A Randomized Controlled Trial

“…This positive effect can be sustained at 3 and 6 months 49 , although this latter trial lacked a control group, which detracts from its methodological quality. Wong et al 50 combined manual therapy, visual exercises, and vestibular rehabilitation in…”

A Novel Approach to Integrative Concussion Rehabilitation: A Pragmatic Study

“…During initial evaluation, patients completed the PCSS, BIVSS, and DHI. Patients were screened for cervicogenic complaints and referred to a PT team member specializing in cervical spine for further evaluation and treatment for the cervical-musculoskeletal domain [13,16]. Evaluations of the motor function and vestibulo-oculomotor domains were completed and structured therapies were based on identified impairment(s).…”

“…Cervical musculoskeletal and vestibulo-ocular PT care models have been proposed to address this gap. Multiple studies have concluded that addressing cervical spine limitations and Benign Paroxysmal Positional Vertigo (BPPV) symptoms, integrated with visual and vestibular rehabilitation, can improve clinical and patient-reported outcomes across all systems [13,14]. In addition, Ziaks et al 2021 proposed that phased primitive reflex integration therapy targeting complex movements and Brain-Body Integration (BBI) as a precursor to vision and vestibular therapy can have improved motor function postconcussion [15].…”

Cervical Spine and CranioVertebral region function in Elite Short Track Speed Skating Athletes

“…Concussions can lead to various symptoms that are usually short lasting and are not necessarily specific to concussions (Iverson et al, 2020). For instance, concussion-related symptoms can also be present with cervical or vestibular dysfunctions (Cheever et al, 2016;Leddy et al, 2015;Leslie & Craton, 2013;Wong et al, 2021). The four main domains of clinical symptoms described in the literature are cognitive (e.g.…”