Effectiveness of Early Physical Therapy Intervention for Patients With Dizziness After a Sports-Related Concussion
Condition: Brain Concussion; Dizziness
MeSH terms: Vertigo; Brain Concussion; Dizziness
Study type: Interventional

Summary: 
      Therefore, the purpose of this pilot study is to determine the feasibility of conducting a
      randomized clinical trial (RCT) on physical therapist treatment for dizziness after
      sports-related concussion. The specific research question for this pilot RCT is: What is the
      feasibility of conducting a RCT on athletes who have dizziness 10 or greater days after a
      sports-related concussion to explore the effectiveness of directed vestibular rehabilitation,
      neuromotor retraining, and/or manual physical therapy (PT) when compared to sham treatment?
      The findings of this study (for both feasibility and effect size) will be used to inform and
      direct revisions to the methods for a larger RCT on this population.

      Primary Aims:

      Specific Aim 1: Assess the feasibility of the following: recruitment and retention of
      participants, required resources for project management, and assessment of patient safety.

      Specific Aim 2: Estimate the size of the effect between skilled physical therapist
      intervention and a sham treatment for the recovery rate for athletes with a concussion who
      have dizziness 10 - 14 days post-concussion.
    

Detailed description: 
      Study design: This study will be a pilot feasibility study of a RCT, randomized at the
      individual level.

      Subjects:

      The population of interest includes athletes who are seen by the physicians from a Sports
      Medicine Center (on site at Akron Children's Hospital (ACH) or at proxy locations, e.g. Walsh
      University or North Canton Children's Hospital Clinic) with a sports-related concussion. The
      specific population of interest is concussed patients who present for a medical assessment
      with dizziness as measured by the Post-Concussion Symptom Scale (PCS).

      Sample Size and Sampling: Because this is a pilot study exploring the feasibility of the
      recruitment, retention and methods for a larger RCT, the sample is not intended to power a
      full scale study. It is standard for a pilot study to include at least 12 participants per
      arm of the study, however, because of the potential for loss to follow up the investigators
      plan to enroll 20 subjects per treatment group.

      Study Subject Selection and Definitions: All patients who present to a Sports Medicine Center
      after an acute concussion (defined as any time between the event causing the concussion and
      up to 14 days after concussion) will complete the PCS. Within this 22 item scale, 7 items
      specify physical symptoms as components of the migraine cluster. These symptoms include:
      headaches, visual problems, dizziness, noise-light sensitivity, nausea/vomiting, balance
      problems, numbness/tingling. Although dizziness is the primary patient complaint being
      targeted, these other symptoms within the migraine cluster may also be present in addition to
      dizziness and may implicate a cervical, proprioceptive, and/or vestibular injury. For this
      reason, patients who report symptoms in the migraine cluster with one of the following
      criteria will be asked to enroll in the study at the initial assessment:

        1. An initial score of at least 3 on the 7 point Likert scale for dizziness as a singular
           symptom OR

        2. A score of 10 across the 7 items within the migraine cluster including a complaint of
           dizziness with at a score of at least 1 on the 7 point Likert scale OR

        3. If findings from the objective assessment conducted by the physician indicate that
           postural/vestibular/ocular perception is abnormal.

      Methods Allocation: At day10 after concussion, patients who enrolled in the study at their
      initial medical visit will be contacted by e-mail through Qualtrics and will be asked to
      complete the PCS a second time (if the patient sees the medical provider from Sports Medicine
      between day 10 and day 14, this will done on that same day). If at day 10 - 14 after the
      concussion was sustained, the patient continues to report dizziness with a score of at least
      3 or a total score in the migraine cluster of at least 10 (including a score of at least 1
      for dizziness) he/she will be randomized into one of the treatment groups using a random
      allocation sequence generator. If the patient does not meet the threshold of symptoms at day
      10 - 14, they will receive standard medical care from the Sports Medicine physicians but will
      not be randomized into one of the PT treatment arms. One study investigator will be
      responsible for assignment into the treatment groups using a 1:1 allocation ratio.

      Blinding: This study will be conducted as a double-blind trial whereby the physicians in the
      sports-medicine center, the patient participants, and their families will be blinded to the
      treatment allocation (sham or skilled) of patients throughout the study time. Blinding here
      is important to limit study bias because the physicians will determine one key outcome, the
      timeframe for return to play, and the athletes will report on the second key outcome, symptom
      severity on the PCS. The PTs performing the assessment and treatments will not be blinded to
      the allocation of the patients as they will be delivering the intervention. The same
      therapists will deliver both treatments (sham and skilled) based on allocation. Because the
      PTs cannot be blinded to the allocation of treatment, they will not determine the timeframe
      for return to play.

      Patient follow-up: All patients allocated into one of the treatment arms will be followed for
      4 consecutive weeks or until they are released for return to play by the sports medicine
      physician. All patients will continue to be followed by physicians in the sports medicine
      practice (as that is the standard of care).

      Patient safety: Because this study is challenging the rest paradigm and using a progressive
      and active treatment to manage acute dizziness, it is not without risk. Patients will be
      carefully monitored during each visit to determine their response to treatment. Since the
      sham treatment incorporates no actual therapeutic activities, an exacerbation in symptoms is
      not expected. The skilled treatment group is pragmatic, allowing the treating therapists to
      determine the type and aggressiveness of each treatment session. This gives therapists the
      ability to modify the activity using their expert clinical judgment. For all subjects in the
      study, patient response between PT sessions will be monitored at the beginning of each PT
      treatment. If patient symptoms increase between therapy sessions, greater than the standard
      error of measure 6.3 points, treatment will be ceased and patients will be referred back to
      Sports Medicine for follow up. All adverse events will be recorded.
    

Intervention name(s): Physical Therapy Treatment
Intervention type(s): Other
Other intervention name(s): Vestibular rehabilitation; Manual Therapy; Neuromotor training
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Treatment