Getting rehab earlier improves concussion outcomes

Even though most people naturally recover from concussions within four weeks, the study revealed people who delayed physical therapy had lingering deficits related to their reaction times for balance, motor function -- or body movements to perform tasks -- and the use of sensory information -- as in sight and touch -- for balance. The research published this week in the Physical Therapy & Rehabilitation Journal.

"It means they're balanced-challenged and don't react as quickly as someone with normal reaction times," said senior author Laurie King, Ph.D., PT, MCR, professor of neurology in the OHSU School of Medicine. "If you've had a concussion and you're not reacting as quickly with balance control, it's natural to avoid precarious situations."

That, in turn, could lead to people avoiding beneficial physical activities, including exercise and rehabilitation.

"We have people who come in and say they're fine," King said. "Then when we challenge them to turn their head while looking at a fixed point, they're like, 'Whoa, that makes me feel sick.'"

Earlier rehab seems to enable the brain to return a more normal state of balance, she said.

In contrast, when physical therapy is delayed, the brain may adapt to the injury by compensating for poor use of sensory information. In effect, patients become overly dependent on vision rather than relying on their vestibular system, the sensory organs in the inner ear that help maintain balance. Patients had "sloppier" balance control to compensate for delayed reaction times, King said, which may explain higher rates of re-injury after a first concussion.

"There seems to be a window of opportunity within two months," King said. "After that point, the brain compensates in a way that's not good. If vision is your strategy for maintaining balance and you're in a dark room, you're not going to function very well."

The randomized control trial included 203 people divided into an intervention group that received physical therapy a week after testing into the project, and a control group that started therapy six weeks after testing. Both groups were assessed for balance control after undergoing six weeks of rehabilitation with licensed physical therapists. Participants entered the study two to 12 weeks following their injury.

Although most people recover from concussion naturally within four weeks, an estimated 30% suffer from lingering issues -- and physical therapy may be most important for that group of people.

Correctly identifying that group is the challenge, King said.

Going forward, King said the research suggests two areas of improvement for health care professionals, especially in primary care settings:

• Clearer guidelines: When primary care physicians assess patients who have suffered a concussion, they should have clearer guidelines about when to refer them to physical therapy. If a patient still has symptoms four weeks after the injury, for example, she said they should get an immediate referral to a physical therapist.
• Better tests: Teasing out each patient's symptoms currently varies by practice, so developing better standards for testing is an important goal of the research that continues at OHSU.

King received $10 million in research grants from the U.S. Department of Defense to study concussions, also known as mild traumatic brain injuries.

The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702- 5014 is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health/Complex Traumatic Brain Injury Rehabilitation Research Program under Award No. W81XWH-17-1-0424. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.