Abstract
Corresponding Author(s)
Address correspondence to: Craig Chappell, DO, Ohio University Team Physician and Assistant Clinical Professor Department of Family Medicine OU-HCOM, Athens, Ohio. Email: cc50cal@hotmail.com
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INTRODUCTION
Concussion has become an increasingly common and pervasive injury associated with high energy sports such as football and soccer. Large numbers of athletes who participate in such sports at the professional, collegiate, or even high school level- suffer from concussive injury. The Centers for Disease Control and Prevention reported that out of the 2.5 million concussions that occurred in the United States in the year 2010, 300,000 occurred from sports and recreational activities.1, 2 Sport-related concussions present clinicians with unique challenges regarding diagnosis, treatment and return to play decisions.3, 4
Numerous factors unique to the patient, such as age, gender, prior history of concussion and other preexisting neurological or psychosocial conditions, can affect diagnosis, prognosis and treatment.5 A current deficit in the medical community is that no gold standard has been established concerning the diagnoses and management of concussion.6 The Standardized Concussion Assessment Tool (SCAT) is currently used by sports clinicians for the diagnosis and management of sport related concussion. The second edition of the SCAT (SCAT2) is divided into eight components that assess severity of symptoms, cognition, balance, neurological signs and the Glasgow Coma Scale.6 The symptom assessment portion is comprised of 22 symptoms measured by a 7 point Likert scale. Most commonly reported symptoms following concussion include headache, dizziness, neck pain and nausea.7 The 4th international conference on concussion in Zurich, Switzerland stated that a concussion is caused by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.8 Impulsive impacts transmitted through the body to the head or from the head to the body can result in an array of somatic and vestibular dysfunction.
Treatment of vestibular dysfunction and dizziness with osteopathic manipulation and vestibular rehabilitation has been shown to be helpful at improving impairments in eye-head coordination, standing static balance, and ambulation.9 Dizziness is also a common complaint without history of impact or concussion and has been treated successfully with osteopathic manipulative therapy (OMT). 10, 11, 12 OMT has been shown to be useful at treating cervical somatic dysfunction, neck pain, and balance difficulties, which are all commonly reported symptoms following concussion.10 Conceivably, OMT could be useful at treating symptoms related to concussion.
Presently, the recommended management of concussion includes a period of physical and cognitive rest immediately following the injury and a graded program of physical exertion once symptoms have subsided.5 No consensus has been reached on whether rest and light exercise are beneficial to the athlete’s return to play progression. However, recent literature suggests that individualized treatment of symptoms may reduce time lost due to concussion.5 The majority of concussions (80%-90%) resolve in 7-10 days with 10%-15% persisting longer.6 It has been recommended that sport related concussions in which symptoms persist longer than 10 days be managed in a multidisciplinary manner.6 OMT has the potential to be easily integrated into existing concussion treatment and management plans. Thus the question explored in this study became: Did OMT reduce symptom burden? If symptom burden prevents progression to a graduated return to play protocol then reduction of that burden may result in a quicker return to play.
OBJECTIVE
To examine the effectiveness of OMT at reducing concussive symptoms in athletes who were diagnosed with a concussion.
HYPOTHESIS
OMT is effective at reducing symptoms related to concussion
MATERIALS AND METHODS
DESIGN
This study was a retrospective chart review of cross-sectional medical information collected on symptomatic athletes diagnosed with concussion during a visit to the physician’s sports medicine practice. Institutional Review Board (IRB) permission was obtained to review patient records.
SETTING
All charts contained data on patients who were evaluated at the physician’s main office and the athletic training facility at Ohio University. Both are located in Athens, Ohio.
POPULATION/SAMPLE
Each patient whose chart was selected was a high school or collegiate athlete in a small Midwestern community. These athletes were involved in high energy sports and diagnosed with concussion. Twenty-six charts were extracted from the spring sport season of 2013 and fall sport season of 2013.
INCLUSION AND EXCLUSION CRITERIA
All data from charts are representative of athletes who were evaluated and treated for a sports-related concussion. In order to be considered, the patient must have completed the SCAT2 symptom checklist prior to physician evaluation, received osteopathic manipulation and filled out another SCAT2 symptom checklist following the physician encounter.
All chart data without a completed pre and post-treatment SCAT2 symptom checklist or a non-sports related concussion were excluded from the review.
INSTRUMENTS
The SCAT2 was used to assess concussion symptoms. The SCAT2 is a standardized assessment tool that measures self-reported symptoms and neurocognitive functioning following a suspected concussion. Each patient evaluated was asked to complete the symptom log that contains 22 symptoms commonly seen in concussed individuals. The log prompts the patient to rank each symptom on a 0-6 scale with 0 being no symptoms and 6 being severe symptoms. Self-reported scores were obtained as literature suggests that self-reported scores are more consistent than if the patient were asked about their symptoms in an interview style.13, 14 The SCAT2 symptom list is shown in Appendix 1 (page 34).
PROCEDURE
Each patient chart contained a subjective portion of the SCAT2 that was completed upon arrival for an appointment with the physician. During the course of the evaluation, each patient was treated with osteopathic manipulation by the physician or by one of two OMM/NMM Plus-One Residents under the direct supervision of the physician. Osteopathic treatments were individualized based upon the patient’s complaint and location of somatic dysfunction. Osteopathic techniques used to treat somatic dysfunction was left to the discretion of the treating practitioner but included both direct and indirect technique. At the close of the appointment the patient was asked to fill out another SCAT2 symptom checklist which was placed in the chart. Once data was collected the pre-treatment scores were compared to post-treatment scores to determine whether osteopathic manipulation had an effect on the participants’ SCAT2 scores.
DATA ANALYSIS
Summary descriptive statistics (mean, standard deviation, and range) were generated for continuous variables such as age and the number of days post-injury treatment occurred. Furthermore, descriptive statistics were generated for SCAT2 scores pre and post OMT. Frequencies were generated for the categorical variable, gender. Paired sample t-tests were used to determine pre-post differences in the SCAT2 scores for each of the symptoms as well as an overall summative SCAT2 symptom score. Where appropriate a chi-square test of proportions was used. Statistical significance was set at p < .05.
RESULTS
In all, 26 records of athletes met the inclusion criteria. Complete data on gender was available on 25 patients—there was one missing data point for gender. Out of the 25, 16 (64%) were male while 9 (36%) were female. Participants’ average age was 19.56 (± 2.873 s.d.) years with a range of 15 to 26 years. Post-injury to treatment period was on average 6.50 (± 4.926 s.d.) days with a range of 1 to 19 days (Table 1). When post-injury period was categorized for the 20 records for which data was recorded, 12 (60%) had post injury time of seven days or less and 8 (40%) had higher than seven days. However, these proportions of patients were not significantly different with respect to the post-injury time categories, p= .371.
All the SCAT2 score differences (post minus pre) of the 22 symptoms had a negative sign indicating that the self-reported pre-treatment scores were higher than the reported post-treatment scores. This suggested that treatment (OMT) provided improvement for all symptoms. However, statistically significant improvements were observed in 10 out of the 22 (45.4%) symptoms as well as the overall summative symptoms score of the SCAT2 listed in Table 2. Table 2 provides a summary of the statistically significant (p<.05) SCAT2 symptoms scores.
TABLE 1
Age and Number of Days Post-Injury of Patients
N | Min | Max | Mean | Standard Deviation | |
Age | 25 | 15 | 26 | 19.56 | 2.873 |
Number of days post injury | 20 | 1 | 19 | 6.50 | 4.926 |
Table 2
Mean Differences, Standard Errors, Confidence Intervals, and p-Values of the Statistically Significant SCAT2 Symptom Scores
Symptom | Mean Difference (post - pre score) | Standard Error of Mean Difference | 95% Confidence Interval | p-value (2-tailed) | |
Lower | Upper | ||||
Headache | -0.731 | 0.226 | -1.196 | -0.266 | .003 |
Pressure in head | -0.615 | 0.229 | -1.087 | -0.143 | .013 |
Balance problems | -0.462 | 0.194 | -0.861 | -0.062 | .025 |
Sensitivity to noise | -0.615 | 0.193 | -1.012 | -0.218 | .004 |
Feeling like in a fog | -0.731 | 0.219 | -0.280 | -3.340 | .003 |
Don’t feel right | -0.615 | 0.272 | -1.176 | -0.055 | .033 |
Difficulty concentrating | -0.808 | 0.309 | -1.444 | -0.171 | .015 |
Fatigue or low energy | -0.615 | 0.208 | -1.044 | -0.187 | .007 |
Irritability | -0.462 | 0.194 | -0.861 | -0.062 | .025 |
Sadness | -0.500 | 0.224 | -0.961 | -0.039 | .035 |
Overall symptom | -10.846 | 3.769 | -18.608 | -3.085 | .008 |
Conversely, the non-statistically significant pre-post differences in symptom scores are shown in a table in Appendix 2 (page 35). While the differences were not statistically significant, they all had a negative sign, which implied that there was a reduction in the severity of the symptoms reported following OMT. The SCAT2 scale ranged 0-6 where 0 signified no symptom and 6 signified severe symptoms. Hence, a negative difference between post- and pre- scores would suggest a diminution in reported severity of symptoms following the use of OMT as a treatment intervention.
COMMENT
To our knowledge, this is the first reported study of its kind to examine the effects of OMT on concussive symptoms. Many symptoms listed on the SCAT2 are common to other medical conditions and have been shown to be treated effectively with OMT. In this study, all 22 symptoms trended toward improvement immediately following OMT. There was a subset of symptoms that showed significant improvement as shown in Table 2.
Our hypothesis that OMT results in a reduction of concussion related symptoms as recorded by concussed athletes on the SCAT2 was substantiated by the data. Furthermore, OMT significantly improved a subset of 10 symptoms as reported by the SCAT2 scores. Therefore, it is feasible that stratification of patients into treatment groups, such that those patients presenting with symptoms most responsive to osteopathic manipulation, would receive the greatest benefit from OMT. Patients with symptoms that do not show significant improvement with OMT could then be effectively managed by standard treatment protocols.
Although encouraging, this retrospective study had the limitation of a small data set. It did not take into account patient randomization into a treatment group, a control group or a sham treatment group. As there was not a control group that did not receive OMT, we cannot conclude that the positive changes observed were secondary to OMT. Furthermore, this study also involved the results from multiple treating physicians. The multiple physicians involved in providing the OMT could provide variability in the treatments that was not accounted for. Future studies should have a single osteopathic physician to reduce variability in OMT techniques. Although a formal protocol would have created a uniform treatment, it is important to note that variability coincides with the theories of osteopathic medicine, which is to resolve structural imbalances to improve overall function of the body.10 In future studies, it may be useful to record the location and severity of somatic dysfunction in order to determine patterns as they relate to concussion. This could potentially help determine treatment protocols, which could then be implemented by clinicians treating concussion.
Results suggest that a certain subset of concussive symptoms can be immediately reduced with individualized OMT. One encouraging outcome was the fact that quite a number of symptoms were significant despite the small sample size. Notably, it would be expected that a higher number of symptoms to be significant with a larger sample size. Although, there are certainly limitations, the results appear promising and should provide a starting point for further research on OMT as an option in the concussion treatment repertoire. Such studies are becoming increasingly more important and necessary secondary to the paucity of recommended treatment options for concussion.
CONCLUSION
The use of OMT following concussion had a positive impact on symptoms as measured by SCAT2 symptom scores. The impact of OMT in reducing the burden of concussive symptoms was significant for 10 of the 22 symptoms on the SCAT2. Future prospective studies are needed to provide more compelling evidence of the effectiveness of OMT in the management of concussive symptoms. Implementing OMT into the management of concussive symptoms decrease the overall symptom burden experienced by the athlete, which may result in a timely return to activity.
REFERENCES
National Hospital Discharge Survey (NHDS), 2010; National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010; National Vital Statistics System (NVSS), 2010. All data sources are maintained by the CDC National Center for Health Statistics.
McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport. 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Clin J Sport Med. 2013;23:89– 117.
Alsalaheen BA , Whitney SL , Mucha A , Morris LO , Furman JM , Sparto PJ . Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion. Physiother Res Int. 2013 ; 18 ( 2 ): 100
– 108.
Fraix, M, Gordon, A, Graham V, Hurwitz E, Seffinger, M. A. Use of the SMART balance master to quantify the effects of osteopathic manipulative treatment in patients with dizziness. J Am Osteopath Assoc. 2011;113(5):394-403.
Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 2010.
Fraix M. Osteopathic manipulative treatment and vertigo: a pilot study. PM&R. 2010;2(7):612-618.
Lopez D, King H, Knebl J. Effects of comprehensive osteopathic manipulative treatment on balance in elderly patients: a pilot study. J Am Osteopath Assoc. 2011;111(6):382-388.
Schneider KJ, Iverson GL, Emery CA, et al. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;24:91–92.
Iverson GL, Brooks BL, Ashton VL, et al. Interview versus questionnaire symptom reporting in people with the postconcussion syndrome. J Head Trauma Rehabil. 2010;25:23–30.
Krol AL, Mrazik M, Naidu D, et al. Assessment of symptoms in a concussion management programme: method influences outcome. Brain Inj. 2011;25:1300–1305.
Mayers LB. Outcomes of sport-related concussion among college athletes. J Neuropsychiatry Clin Neurosci. 2013;25(2):115119.
Institute of Medicine. Sports-related concussions in youth: Improving the science, changing the culture. Report Brief. 2013. Available
at http://www.iom.edu/~/media/Files/Report%20Files/2013/ Concussions/concussions-RB.pdf
Guskiewicz K, Register-Mihalik J, McCrory P, et al. Evidence-based approach to revising the SCAT2: introducing the SCAT3. Br J Sports Med. 2013;47(5):289–93.
Benson BW, Meeuwisse WH, Rizos J. A prospective study of concussions among National Hockey League players during regular season games: the NHL-NHLPA Concussion Program. CMAJ 2011;183:905–11
APPENDIX 1
SCAT2 Symptom Evaluation List
None | Mild | Moderate | Severe | ||||
Headache | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
“Pressure in head” | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Neck Pain | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Nausea or vomiting | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Dizziness | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Blurred vision | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Balance problems | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Sensitivity to light | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Sensitivity to noise | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Feeling slowed down | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Feeling like you’re in a fog | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Don’t feel right | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Difficulty concentrating | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Difficulty remembering | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Fatigue or low energy | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Confusion | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Drowsiness | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Trouble falling asleep | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
More emotional than usual | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Irritable | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Sadness | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Nervous or Anxious | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
APPENDIX 2
Table of Statistically Non-Significant SCAT2 Pre-Post Scores Differences
Symptom | Mean Difference (post – pre score) | Standard Error of Mean Difference | 95% Confidence Interval | p-value (2-tailed) | |
Lower | Upper | ||||
Neck pain | -0.538 | 0.320 | -1.197 | 0.120 | .105 |
Nausea or vomitting | -0.308 | 0.173 | -0.665 | 0.049 | .088 |
Dizziness | -0.500 | 0.243 | -1.001 | 0.001 | .051 |
Blurred vision | -0.269 | 0.197 | -0.674 | 0.136 | .183 |
Sensitivity to light | -0.269 | 0.239 | -0.761 | 0.223 | .271 |
Feeling slowed down | -0.308 | 0.247 | -0.816 | 0.200 | .224 |
Difficulty remembering | -0.462 | 0.310 | -1.100 | 0.177 | .149 |
Confusion | -0.462 | 0.237 | -0.949 | 0.026 | .063 |
Drowsiness | -0.462 | 0.243 | -0.963 | 0.039 | .069 |
Trouble falling asleep | -0.385 | 0.222 | -0.843 | 0.073 | .096 |
More emotional | -0.308 | 0.222 | -0.761 | 0.146 | .175 |
Nervous or anxious | -0.423 | 0.243 | -0.923 | 0.077 | .094 |