Running Head: LITERATURE REVIEW

Literature Review of Concussions and Vestibular Rehabilitation Therapy

Cayla Williams

Immaculata University
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Literature Review

1.6 to 3.8 million concussions occur each year in the United States and the number of

individuals being treated for concussion has rose in the last couple of years ("Concussion Facts,"

n.d.). Although the injury is common, it remains one of the more complex injuries for medical

professionals. New research about sports-related concussions had become more readily available

to medical professionals (Valovich & Hale, 2014). Athletic trainers (ATs) are licensed medical

professionals that receive instruction and clinical training in sports injuries including concussion

management. They are typically the first to identify and evaluate an injured athlete and are an

essential part of concussion management and return to play (RTP). The National Athletic

Trainer’s Association (NATA) has made recommendations regarding sports concussion

management and “Without exception, ATs should be present at all organized sporting events at

all levels of play and should work in close collaboration with a physician or designate who has

specific training and experience in concussion management to develop and implement a

concussion management plan” (Broglio et al., 2014, p 246).

Vertigo, dizziness and balance issues are common problems after a concussion. Patients with

these prolonged symptoms have found it helpful to use vestibular rehabilitation therapy (VTR) to

help with the recovery from a concussion. Current studies are discussing ways to assess, manage,

and treat concussions, along with the best policies and procedures regarding them (Lynall,

Laudner, Mahalik, & Stanek, 2013). Although there is still little information about the effects of

VTR on concussions, studies have begun to show positive results when used on post-concussion

athletes (Han, Song & Kim, 2011).

Concussions
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The Zurich Guidelines define concussions as “ a complex pathophysiological process

affecting the brain, induced by biomechanical forces” (Starkey & Brown, 2015, p. 864). A

concussion involves a collection of symptoms that are related to the impact on the brain by

forces acting on the head, face, neck or somewhere else on the body (Aligene & Lin, 2013).

Concussions mechanism of injury varies but may occur either by a direct blow or indirect contact

to the head.

Loss of consciousness may or may not happen following a concussion. The following

signs and symptoms are possible after a concussion: dizziness, tinnitus, nausea, memory loss,

motor impairment, personality changes, fatigue, trouble sleeping, lethargy, depression, neck

pain, feeling “in a fog”, difficulty concentrating, blurred vision, unequal pupil sizes, and

nystagmus (Starkey & Brown, 2015). The first 24 hours following a concussion are crucial in

determining the severity of the concussion and if it has become a medical emergency. (Aligene

& Lin, 2013) No two concussions are the same. Some patients obtain more than one concussion

in their life and report that they are each different. Patients have signs and symptoms that have

unique ways of presenting themselves each time. From patient to patient and concussion-to-

concussion differences occur which may include different signs, symptoms, and mechanism of

injury. “Based on signs and symptoms, concussion management is individualized for each

patient” (Starkey & Brown, 2015, p. 864 ). Because each concussion is individualized so is the

management.

Assessment

Athletic trainers and physicians are trained to diagnose a concussion based on the signs and

symptoms of the athlete or patient. To effectively evaluate an athlete there are a variety of tests

to use. The most common methods used to assess and diagnose a concussion are: Standardized
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Assessment of Concussion (SAC), Balance Error Scoring System (BESS), Noncomputerized

neuropsychological testing, computerized neuropsychological testing (ex.ImPACT [Immediate

Post-concussion Assessment and Cognitive Testing], Sports Concussion Assessment Tool 2 or 3

(SCAT2,3, 4 or 5), clinical examination, grading scale, symptom checklist, and Romberg test

(Lynall, Laudner, Mahalik, & Stanek, 2013). Other tests may include the Glasgow Coma Scale,

sensory testing, and motor testing. The athlete is also functionally assessed in similar areas:

memory, cognitive function balance and coordination, eyes, motor function and vital signs. Their

eyes, nose, and ears are examined along with a general observation of the athlete (Starkey &

Brown, 2015). Medical professionals are looking for anything that would be abnormal for that

individual athlete. The most challenging part, for medical professionals, is diagnosing a

concussion. Lynall, Ludner, Mihalik, and Stanek (2013) found in their study, “ATs are using

more objective tools available to them, such as balance testing and neuropsychological testing,

but have significantly decreased their use of clinical examinations and symptom evaluations

when assessing and managing concussions” (p. #). As cited in Paddack, Dewolf, Covassin, and

Kontos (2016) “Ferra et al. reported that 17% of athletic trainers used the SAC” in 2001..

Currently there are more athletic trainers using multiple programs in combination to assist with

the diagnosis of concussions (Paddack et al., 2016).

ATs are using more methods to diagnose concussions, and concussions are becoming more of

a regular occurrence. This is because there is more education and research on concussions than

there has been in the past. Education, baseline testing and early detection have been part of the

increase in sports related concussions.

Baseline testing has begun to be slowly implemented in many sports programs as part of

managing concussions. Baseline testing is when an athlete completes a concussion test pre-
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concussion, meaning they do not currently have a concussion or concussion-like symptoms.

Baselines are used to compare to the post-concussion test results if the athlete sustains a

concussion in the future (Paddack et al., 2016). Paddack, Dewolf, Covassin, and Kontos (2016)

found that, of the athletic trainers they surveyed, “71% were not conducting baseline assessments

and there was a negative correlation between the number of years participating as an AT and

how often cognitive baselines were obtained” (p. 84). In the same study the researchers looked

at community college athletic trainers and found of the athletic trainers they surveyed only 44%

administered a baseline testing and 56% did not. If baselines were completed, they found that the

most common assessment tools were the BESS (56%), SAC (48%) ImPACT (44%) and SCAT2

(24%). Overall, in community colleges in California baseline testing is not being used as part of

their concussion management policies. A study done by Kelly, Jordan, Joyner, Burdette, and

Buckley (2014) found that athletic trainers, at the Division I level, were using baseline testing

and “high rates of multifaceted assessments (i.e., evaluations using at least 3 techniques) during

testing at baseline (71.2%), acute concussion assessment (79.2%), and return to participation

(66.9%)” (p. 665). Both studies looked at the use of baseline testing and found different results.

This shows the limited regimented protocol being implemented. Very few are implementing

baseline testing at the community college level in California, but other studies have shown that at

the NCAA Division 1 level baseline testing is applied and a widespread of multi-part assessment

techniques are used and are compliant with the NCAA Sports Medicine Handbook.

Return to Play Guidelines

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Return to Play (RTP) guidelines following a concussion have been recommended by the

National Athletic Trainers’ Association (NATA). To begin, athletes that are suspected to have

sustained a concussion are removed from play. Once the athlete is asymptomatic a graded return

to play (RTP), protocol begins. The Zurich guidelines recommend a gradual return to play that

follows this progression:

1) No activity (both physical and cognitive rest based on symptoms) 2) light aerobic

activity (moderate intensity exercise such as walking or stationary biking that is less than

70% of their maximum heart rate. 3) Sport specific exercise (gradual progression in sport

specific motion patterns and activities) 4) noncontact training drills (advanced sport/skill

progression relative to stage 3) 5) full contact practice (medical clearance to participate in

normal training activities) 6) Return to play (normal gameplay). (Starkey & Brown, 2015,

871)

Each stage has a minimum of 24 hours between them and as long as the athlete remains

asymptomatic he or she may continue to the next level. If the symptoms reoccur, they repeat the

stage before the one that caused them symptoms. Each RTP is different and followed on a case-

by-case system. It is typical that athletes will be held out of competition for a minimum of a

week (Broglio et al., 2014). In a study completed by Paddack, Dewolf, Covassin, and Kontos

(2016), they found that most participants (85.5%) were aware of the NATA position statement

on concussion RTP protocols but only 61.8% followed the recommended guidelines.

Researchers found that female athletes remain symptomatic longer than male athletes.

“82 of 110 male athletes (75%) experienced recovery of concussion symptoms by 3 weeks

compared with 43 of 102 female athletes (42%)” (Neidecker, Gealt, Luksch, Weaver 2017)
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Athletes that have lingering symptoms and not progressing through the steps tend to look to

other options to help with recovery. An area of concern with these athletes is that there now may

also be vestibular dysfunction or changes to the vestibular system. Symptoms including

headache, dizziness, difficulty focusing and/or trouble with eye tracking are a few that may

linger post concussion (Watson, Black, & Crowson, 2016).

Vestibular System

The vestibular system provides sensory information about motion, equilibrium and

spatial orientation to the brain. This information is provided by the vestibular components in the

ear, which includes the utricle, saccule, and three semicircular canals. The utricle and saccule

help with vertical orientation and linear movement (Watson, Black, & Crowson, 2016). As cited

in Aligene and Lin (2013), Guskiewicz (2001) states, “The vestibular system can be divided into

a peripheral component consisting of the semicircular canals, otoliths (utricles and saccule),

vestibular ganglia and the vestibular nerve and a central element composed of vestibular nuclei,

cerebellum, autonomic nervous system, thalamus and cerebral cortex (p. 549).

Some signs and symptoms of vestibular dysfunction include dizziness, imbalance, vertigo

symptoms, looking down to confirm location about the ground, the urge to hold something while

standing, sensitivity to surface changes, trouble focusing or with eye tracking, sensitivity to

lights, tinnitus, and cognitive difficulties. Many of these symptoms are similar to ones reported

by concussion athletes. Many patients with vestibular dysfunction seek physical therapy to

decrease these symptoms (Watson, Black, & Crowson, 2016).

Vestibular Rehabilitation Therapy

The basic concept of vestibular rehabilitation therapy (VRT) is to help restore function.

“Restoration of concussion-related vertigo or impaired balance” includes restoring function by

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“inducing neural plasticity within existing healthy neural systems to allow for adaptation and

compensation for functional deficits” (Aligene & Lin, 2013, p. 550). It involves the use of

exercises that are specifically targeted at vestibular symptoms and aimed to reduce symptoms

associated with vestibular dysfunction. Physical therapist use specific cognitive and sensorimotor

exercises to help restore function and increase sensitivity. A goal of VRT is to see an

improvement in symptoms and regain vestibuloocular control and reflexes, bettering posture and

motor control (Aligene & Lin, 2013). Aligene and Lin (2013) also state that other goals of

treatment include improvement of gaze stability and eye-head coordination and to provide a

sport specific program with progression to help with the rehabilitation process.

Rehabilitation Programing. VRT programing includes a multitude of different

exercises to address the different vestibular dysfunctions. Each program is customized for

patients to help them achieve their specific goals. There are three methods of exercise that can be

prescribed which are habituation, gaze stabilization and balance training. Habituation exercises

are implemented to help with dizziness symptoms that occur because of moving head too quickly

or when they bend over or look up (Vestibular Rehabilitation Therapy (VRT), 2017). An

example would be rapid cervical rotation while seated. They then may progress to different body

positioning. They could be lying down and/or standing (Clendaniel, 2010). Gaze stabilization is

used to improve eye control. There are different kinds of exercise and it depends on the patient’s

deficits, which one is used. An example of an exercise is having the patient fixed on one spot and

then have them rapidly move their head up and down or back and forth (Vestibular

Rehabilitation Therapy (VRT), 2017). Another type would have the patient move their eyes first

from one target to another and then their head (Han, Song, & Kim, 2011). Lastly, balance
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exercises are used. Like all of the other exercise, balance ones should be individualized for each

patient. Balance exercises are easy to create but must have at least one of the following features:

“Visual and/or somatosensory cues, stationary positions and dynamic movements, coordinated

movement strategies (movements from ankles, hips, or a combination of both), dual tasks

(performing a task while balancing)” (Vestibular Rehabilitation Therapy (VRT), 2017). By

manipulating these features it makes the exercises more challenging ("Vestibular Rehabilitation

Therapy (VRT)," 2017). An example of a balance exercise could be having the patient stand on a

foam pad on one foot (Houglum, 2016).

VRT and Concussions. As mentioned, vestibular dysfunction has similar signs and

symptoms to some concussions. Balance issues, dizziness, and eye tracking issues (nystagmus)

are all concussion signs and symptoms related to the vestibular system. “The majority of post

concussive balance impairments are mediated through dysfunctions in the peripheral vestibular

system” (Aligene & Lin, 2013, p. 549).

A study conducted by Gurley, Hujsak, and Kelly (2013) found that VRT is an effective

way to manage vestibular related symptoms for concussion athletes, including dizziness, vertigo,

and imbalance. Customized vestibular rehabilitation programs reported having success in

reducing dizziness and improving gait and balance in both children and adults following

concussion. The programs included gaze stabilization, standing balance, and walking balance.

Although researchers found that this study showed promise, they cautioned that is study did not

only focus on sports related concussions but also it used a mix of adults and children, and

included non-sports related concussions.

Future Use of VRT. Although the preliminary research is not focused on specifically

sports-related concussions, it does show promise in treating concussions that have vestibular
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dysfunction. There is a potential for concussions to affect the vestibular system and decrease

vestibular function. Preliminary research suggests that VRT is useful in reducing vestibular

symptoms and improving patient outcomes; however, there need to be more trials to determine

the best program (Mcleod & Hale, 2014). Most Physical Therapists are using VRT for their

vertigo and vestibular dysfunction patients and have seen much success. A study completed by

Alsalaheen et al. (2010) found that 84 of 114 patients that used VRT had improvements in “all

self-report, gait and balance performance measures when they were discharged” (p. 88) and

children in the study had improved by a larger amount in the severity of dizziness and did better

on the Sensory Organization Test. Evidence in current research, has begun to show the success

of VRT to treat concussions but the use of this type of therapy in the athletic training setting has

not been recorded.

Conclusion

Based on the current research, many athletic trainers have a system in place to return their

athletes to play following a concussion (Kelly et al, 2014). They follow NATA return to play

guidelines and most of the recommendations regarding sports concussions. However, there are

mixed results in the number of athletic trainers implementing baseline testing at the collegiate

level. Returns to play protocols produced by the NATA at minimum have athletes returning to

sport after 1 week of the graded return to play protocol. For some, it may take longer, which may

be due to lingering symptoms (Watson, Black, & Crowson, 2016). Many athletes present with

lingering concussion symptoms and some of these symptoms are related to the vestibular system.

Physical Therapists are using VRT for their vestibular dysfunction patients, and have found it

beneficial for their concussion patients (Watson, Black, & Crowson, 2016). Athletic trainers are

mostly involved with the concussion diagnosis and return to play process for their athletes, but
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there has been limited evidence showing the use of rehabilitation techniques, including VRT, in

the athletic training facility.

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References

Aligene, K., & Lin, E. (2013). Vestibular and balance treatment of the concussed athlete.

NeruoRehabilitation, 32(3), 543-553. doi:10.3233/NRE-130876

Alsalaheen, B. A., Mucha, A., Morris, L. O., Whitney, S. L., Furman, J. M., Camiolo-Reddy, C.

E., Sparto, P. J. (2010). Vestibular rehabilitation for dizziness and balance disorders after

concussion. Journal of Neurologic Physical Therapy, 34(2), 87-93.

doi:10.1097/npt.0b013e3181dde568

Broglio, S. P., Cantu, R. C., Gioia, G. A., Guskiewicz, K. M., Kutcher, J., Palm, M., & Mcleod,

T. C. (2014). National Athletic Trainers' Association position statement: Management of

sport concussion. Journal of Athletic Training, 49(2), 245-265. doi:10.4085/1062-6050-

49.1.07

Clendaniel, R. A. (2010, June). The effects of habituation and gaze-stability exercises in the

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2904475/

Concussion Facts. (n.d.). Retrieved from http://www.sanfordhealth.org/medical-

services/concussions/concussion-facts

Gurley, J. M., Hujsak, B. D., & Kelly, J. L. (2013). Vestibular rehabilitation following mild

traumatic brain injury. Neruorehabilation, 32(3), 519-528. doi:10.3233/NRE-130874

Han, B. I., Song, H. S., & Kim, J. S. (2011). Vestibular Rehabilitation Therapy: Review of

Indications, Mechanisms, and Key Exercises. Journal of Clinical Neurology, 7(4), 184.

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Houglum, P. A. (2016). Balance. In Editor (Ed.). Therapeutic exercise for musculoskeletal

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Kelly, K. C., Jordan, E. M., Joyner, A. B., Burdette, G. T., & Buckley, T. A. (2014). National

Collegiate Athletic Association Division I Athletic trainers' concussion-management

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49.3.25

Lynall, R. C., Laudner, K. G., Mahalik, J. P., & Stanek, J. M. (2013). Concussion assessment and

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844-850. doi:10.4085/1062-6050-48.6.04

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Neidecker J.M, Gealt D.B, Luksch J.R, Weaver M.D. First-Time Sports-Related Concussion

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Paddack, M., Dewolf, R., Covassin, T., & Kontos, A. (2016). Policies, procedures, and practices

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Starkey, C., & Brown, S. D. (2015). Head and Acute Cervical Spine Pathologies. In Editor (Ed.)

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Valovich Mcleod, T. C., & Hale, T. D. (2014). Vestibular and balance issues following sport-

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Watson, M., Black, F., & Crowson, M. (2016, May 05). The human balance system. Retrieved

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