Vestibular Rehabilitation & Post-Concussion Syndrome

Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurologic Physical Therapy. 2010 Jun;34(2):87-93. Alsalaheen BA, Mucha A, Morris LO, Whitney SL, Furman JM, Camiolo-Reddy CE, Collins MW, Lovell MR, Sparto PJ.

Abstract
BACKGROUND AND PURPOSE:
Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion.

METHODS:
A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8-18 years]; 47 adults older than 18 years [mean, 41 years; range, 19-73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures.

RESULTS:
The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P < .05). Children improved by a greater amount in dizziness severity (P = .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P < .025).

DISCUSSION:
Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults.

CONCLUSIONS:
Vestibular rehabilitation should be considered in the management of individuals post-concussion who have dizziness and gait and balance dysfunction that do not resolve with rest.

My comments:

The problem with this study is in the abstract it says vestibular rehabilitation is equally effective for both children and adults.  However, if you read the actual paper, the findings showed anything but. Adults showed no significant improvements in self reported dizziness, improving from a 21/100 pretreatment to only 20/100 post treatment, while children improved from 26/100 to a 7/100.  In testing for Dynamic Computerized Posturography children improved pretreatment to post treatment, while adults had zero improvement.  The text of the paper even says:

…there was no significant difference in dizziness for the adult group between pre- and post-treatment

The exercises described in the study were gaze stabilization in which the person maintained focus on a fixed object while they turned their head, standing balance on a foam roll with eyes open and closed, and walking with balance challenges to include head turning, tandem walking, and obstacle avoidance.  They did canalith repositioning in only a few cases and it was interesting that out of 114 patients with post-concussive syndrome dizziness only 5 were diagnosed with benign paroxysimal positional vertigo (BPPV). I think this helps to explain the lack of effect with vestibular rehabilitation in the adults.  In my physical therapy practice I have noticed canalith repositioning to be near miraculous for eliminating vertigo, and it’s well supported by research for that, but for other balance disorders I can’t say that I have noticed much of an effect from the other vestibular exercises, gaze stabilization etc.

So while this paper is a bit of downer with regards to vestibular exercise for post-concussive syndrome, it’s valuable in that helps to indicate some exercises patients and therapists probably shouldn’t waste their time on for adults with post concussive syndrome.  The good news is that in researching potential physical therapy programs for post concussion syndrome, I came across a number of papers finding very positive effects with the use of aerobic exercises, which I plan to do a few blogs on coming up. [edit to add research showing effectiveness of aerobic exercise on post-concussion syndrome]

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

2 thoughts on “Vestibular Rehabilitation & Post-Concussion Syndrome

  1. Hello, Chad!

    I just found your valuable information re vestibular rehabilitation. We were rear-ended
    by car doing 30 mph, no braking, was 6 months ago, gait and balance deteriorateded to
    point of looking drunk when I walk. I’m very interested in your suggestion re aerobic exercise
    and wonder what kinds you would recommend.

    I was playing pickleball almost every day, up to 4 months ago, can no longer play well or safely.

    THANK YOU.

    Elizabeth Haas

    • Hi Elizabeth,

      In the Leddy research, which found the beneficial effects of aerobic exercise with post concussion syndrome, they walked on a treadmill gradually increasing speed and duration as symptoms allowed (details here). So I usually use treadmill in my office. I think treadmill in this situation is better than just walking in the neighborhood because you can really control how fast and how long your are going on a treadmill, so you know if you are making progress. If a person’s balance is so bad that they aren’t safe on the treadmill, then I’ll usually have them wear a safety harness anchored above them, making falls impossible. That might not be something you can reproduce at home or a fitness center so be careful. If balance is too bad to safely start on a treadmill, or the impact of walking is irritating, a recumbent bicycle might be a good way to get started and still get the the heart rate up enough to do some good, but not so high as to do any harm.

      I hope that helps, and feel free to ask follow up questions.

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