Frequency and duration guidelines for therapy based on trend data at Weisman Children’s Rehabilitation Hospital
In the past 10 years, concussions have doubled by 200% in children ages 14-19 and emergency department (ED) visits for children ages 8-13 have doubled for incidences of a concussion as reported by the American College of Pediatrics.1 1.6-3.8 million sports-related concussions have been estimated to occur within the United States each year.1
The average time to expect a recovery from a concussion is 7-10 days. This timeframe can be extended due to prior history of concussions, age and sex, which can lead to a diagnosis of Post-Concussion Syndrome (PCS).
It is also established that a persistence of at least three or more symptoms including – but not limited to – fatigue, sleep disturbance, dizziness, balance concerns, nausea, headache, sensitivity to light, sensitivity to sound, mood or personality changes and or irritability and cognitive deficits in memory and or attention beyond this time may be considered PCS and most often requires skilled-based therapy to recovery. 3 These include physical, occupational or cognitive therapies.
Specialized Team Approach
In 2013, Weisman Children’s Rehabilitation Hospital (WCRH) developed a post-concussive program due to an increased need in the community after being approached by a local referring physician who specializes in concussions. This need, coupled with WCRH’s expertise in brain injury rehabilitation, provided a foundation on which to establish a concussion program.
A comprehensive approach including speech-language pathologists (SLPs), occupational therapists (OTs) and physical therapists (PTs) was initiated in order to maximize outcomes and return the patient to prior activity levels as quickly and safely as possible. This program has been developed using the most current evidence to develop best practices by a team that is certified in brain injuries. Since the start of this program, more than 300 children have been treated.
If the patient requires cognitive therapy provided by a speech-language pathologist secondary to residual cognitive concerns after the initial 3 months of healing, 1x/week for 8 weeks is recommended at the plan of care.5,6 This also comes with the recommendation for a neuropsychologist evaluation in order to establish long-term accommodations if necessary for future academic success.
When the program at Weisman Children’s Rehabilitation (WCRH) was established, treatment frequencies and duration were determined based on best clinical judgment, continuing education courses and observation with physicians who specialize in concussion for this patient population. The clinical educators in each field collaborated and established a program in 2012. The program was officially launched in 2013 after staff at each location was trained based on current research.
Therapists treating in the program were all trained utilizing current evidence by a clinical educator in their discipline. In addition, outside continuing education courses focused on treatment for concussion, as well as detailed treatment for impaired system (i.e. vision and vestibular), were hosted at WCRH to further advance the staff in their education and knowledge of treatment in this area. This consistent education and training among staff has helped to support our overall outcomes.
Currently, there is still a lack of published recommendations for treatment frequency and duration for pediatric patients with a diagnosis of PCS. Therefore, this article seeks to begin to establish these guidelines for pediatric patients with post-concussive syndrome ages 8-18 for physical therapy intervention, occupational therapy intervention and cognitive therapy conducted by a speech therapist. This information was acquired and analyzed utilizing concussion diagnosis data trends at WCRH since 2013.
A patient who is referred to Weisman Children’s Rehabilitation with a diagnosis of post-concussive syndrome often comes with a referral for physical therapy and/or occupational therapy. Once the physical therapist conducts their evaluation, an in-house referral can be made for occupational therapy, if this was not initiated by the referring physician.
Tolerance regarding head/eye movement is determined by the number of repetitions that can be completed without rest due to increase in symptoms. These activities include, but are not limited to, the number of repetitions of saccades both horizontally and vertically, vergence and smooth pursuits. A referral is often made to a pediatric optometrist because of their expertise in the visual system and advance equipment and treatment protocols. Initiating vision therapy can significantly reduce the recovery time. This is most meaningful as the patient attempts to return to the classroom and learn as these skills are essential within their day and can limit their classroom time and ability to complete notes and or assigned work.
Until they return to the classroom full-time without symptoms, the return to play protocol cannot be completed and therefore can delay their timeline to full recovery. This is concerning as it has been found that recovery that is greater than 6 weeks can have an effect on athletes and their long term lifestyle and lifestyle choices.4Subsequently, if a patient presents with their vestibular system with the most impairments and their visual system with minimal impairments, then PT is the primary service and an OT referral may not be recommended.
Memory & Attention Concerns
Individuals with post-concussive syndrome may have memory and/ or attention concerns after a concussion which should resolve within the first 3 months after injury. This is consistent with mild traumatic brain injury literature that states that cognitive deficits resolve within 1-3 months in most patients.5, 6 Therefore, a speech therapy consult is recommended if symptoms are still present after the initial 12 weeks. In this case, a neuropsychologist evaluation is preferred in addition to the speech therapy evaluation recommendation to initiate cognitive therapy to aid in recovery and their return to their prior academic level.
Determining when a patient is demonstrating true residual concussion impairments and not an indication of a premorbid concern requires examining if the symptoms are worsened by a significant increase in activity. If these impairments are consistent with rest or even minimal activity, it can indicate a premorbid concern or frustration due to inactivity or inability to perform at their level prior to the concussion. Speech therapy then aids with helping a patient utilize strategies to maximize their success in the classroom.
In addition, WCRH offers a post-concussive support group. This group is designed to support individuals after a concussion during their rehabilitation. Since a concussion is viewed by the public as an “invisible injury” and this patient population is at risk for significant depression, a support group was developed for ages 11-19. This group meets once a month and is led by both a child life specialist and a pediatric social worker. It is open to the public and the individuals that attend do not have to be Weisman patients. Adolescents with concussions and their family members can connect with others in similar situations and gain resources and information to support their recovery.
Intensive therapy is most appropriate when the condition is changing rapidly and there is a need for frequent plan of care modification.8 In patients with PCS – due to the acute nature of the patient’s injury and the impact it has on their tolerance to school and school activities, personal interactions and their overall activity – intensive therapy frequency is recommended. The recommendation for weekly services is 2-3x/week – often twice weekly when only one service is recommended and three times as a combination of services when more than one service is recommended.
If the patient’s visual system is more impaired than their vestibular system, OT will have an increased frequency (2x/week) over PT (1x/week) until the patient has an increased tolerance to activity without an increase in baseline symptoms. However, if the vestibular system is more impaired, then PT will have an increased frequency (2x/week) as compared to OT (1x/week, if any at all), again, until the patient has an increased tolerance to activity without an increase in symptoms.
This frequency is also chosen to attempt to return the patient to activities as safely and quickly as possible to improve their emotional status and minimize any lifestyle changes which can begin to occur after 6 weeks and is a concern in this population in general. This also allows them some days to integrate their new level of activity in their everyday activities and lifestyle. Quicker recoveries have also been shown to aid in their overall feeling of depression.4
At the start of Weisman’s concussion program, 12 weeks were recommended for the duration of a patient’s plan of care. This was established with best evidence, which states that concussions that do not occur on the field often demonstrate a full recovery within the first 3 months.7 Concussions that result from athletic activity often recover faster. However, after analyzing the data from 2 years of our program, it was determined that the average duration to full recovery including a completed return to play protocol was 8 weeks with skills-based therapy.
For patients who had several systems significantly involved and needed to receive several therapies at the same time, they were still able to return to their prior activities at 8 weeks. This may be due to the collaboration that occurs between providers to provide integrated therapy sessions and to adjust their session progression off of the last session regardless of if it was within the same discipline. This data was based off of a total of 312 patients seen from first quarter of 2013 to the last quarter of 2015. This was also a consistent median when each year was analyzed separately. In 2013, 74 patients were analyzed, 102 in 2014 and 136 in 2015.
Since there is evidence that suggests that once 6 weeks have passed, there can be long-term lifestyle effects on athletes, 8 weeks stands as a significant timeframe for this population. While each concussion is unique, having this trend data can help guide the athlete in their overall recovery and long-term lifestyle choices.
At this time, based on the current WCRH Concussion Program data analysis and the evidence that is consistent with the concussion literature that is currently established, the recommendation for treatment frequency and duration is 2-3x/week, depending on the number of services needed, for 8 weeks.
If the patient requires cognitive therapy provided by a SLP secondary to residual cognitive concerns after the initial 3 months of healing, 1x/week for 8 weeks is recommended at the plan of care.5,6 This also comes with the recommendation for a neuropsychologist evaluation in order to establish long-term accommodations if necessary for future academic success.
- Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-8
- Boake C, McCauley SR, Levin HS, et al. Diagnostic Criteria for postconcussional syndrome after mild to moderate traumatic brain injury, J Neuropsychiatry Clin Neurosci. 2005;17(3):350-6
- Leddy J, Sandhu H, Sodhi V, Baker J, Willer B. Rehabilitation of Concussion and Post-Concussion Syndrome. Orthopaedic Surgery. 2012;4(2):147-154
- Al Sayegh A, Sandfor D, Caron AJ. Psychological approaches to treatment of postconcussion syndrome: a systemic review. J Neurol Neurosurg psychiatry. 2010; 81(10): 1128-1134
- Carroll LJ, assidy JD, Peloso PM, et al. Prognosis for mild traumatic brain injury: results of the WHO collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004;43(suppl):84-105
- Levin HS, Mattis S, Ruff RM, et al Neurobehavioral outcome following minor head injury: a three-center study. J Neurosurg, 1987;66(2):234-43
- A Bailies, R Reder, C Burch. Development of Guidelines for Determining Frequency of Therapy Service in a pediatric Medical Setting. Pediatric Physical Therapy. 2008: 194-198
- Vidal P, Goodman A, Colin A, Leddy J, Grady M. Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent Concussion. Pediatric Annals 2012;41(9): 1-7