Osteopathic manipulative treatment for concussions and postconcussive syndrome in athletes: a literature review

Manipulative treatment of concussions by osteopathic physicians

After searching the literature, five articles were found demonstrating the use of OMT to treat concussions and PCS in athletes: two randomized control trials, one retrospective review, and two case reports. Each study employed a personalized treatment plan, as opposed to a standardized protocol, that appears to be a key component of concussion management. Only the randomized control trials reported statistical analyses, whereas the other studies tracked the lone participant’s scores across multiple treatments, with only the retrospective review utilizing a standardized scoring tool. In addition, both randomized control trials focused on treating an initial injury, whereas the case reports and retrospective review focused on PCS. The randomized control trial and case reports were included in the review because the injury occurred in a sports setting, but the retrospective review detailed the results of OMT to treat a 16-year-old girl with a history of multiple head injuries who was involved in a head-to-head collision on a school bus [23]. All four of the following studies were conducted from the same research group.

Yao et al. [24] performed a randomized control trial (n=31) that investigated the difference in symptom severity and quantity between two groups of student-athletes, one of which received OMT and the other receiving a detailed, physician-led concussion education discussion. A total of 71 patients were screened to participate in the study, although only 31 were chosen to participate, and one was excluded due to having incomplete data. The average age of the patients was 19.9 years (range, 18–27 years), and there was a predominance of males (n=19). All participants in the OMT arm were treated with the following techniques: thoracic inlet release, rib raising, occiptoatlantal (OA) decompression, V spread, balanced membranous tension for cranial strain patterns, cranial lifts, and compression of the fourth ventricle. These techniques aimed to improve lymphatic drainage, while also addressing other common dysfunctions found in concussion patients. Other techniques chosen were picked based on the patient’s specific evaluation. In order to evaluate symptom severity and progression, the SCAT, 5th edition (SCAT5) was utilized. The severity of symptoms was not found to be statistically significant between the OMT group (n=16; M[SD]=14.38[5.04]) and the education group (n=15; M[SD]=13.07[5.00]) in the pre-intervention setting. There was also no statistical significance between the initial severity of symptoms when comparing the OMT group (M[SD]=38.21[22.20]) and the education group (M[SD]=31.00[16.03], p=0.196). However, they were found to be statistically significant following treatment, with the OMT intervention group reporting a decrease in the severity of symptoms (M[SD]= −3.93[3.92], p=0.001) and a decrease in the number of overall symptoms (M[SD]= −17.33[17.38], p=0.001]).

A pilot study (and randomized control trial) from Mazzeo et al. [25] looked at how sleep quality in athletes postconcussion could benefit from OMT vs. concussion education counseling (CEC). Athletes (n=30) were recruited into the study 2 weeks after a sports-related head injury and exhibiting concussive symptoms. One group (n=16), the controls, received CEC, whereas the other group (n=14) was to undergo OMT over a series of three visits. Three treating physicians utilized techniques such as OA decompression, venous sinus drainage, cranial lifts, CV4, thoracic inlet release, rib-raising, and abdominal diaphragm doming. If these participants exhibited any additional dysfunctions that were contributory to their presentation, those were also treated. The primary outcome measure was the comparison of scores on the SCAT5 “trouble falling asleep” subset section, which was obtained prior to sessions 1, 2, and 3. Overall, a medium-strength yet significant correlation existed for the “trouble falling asleep” items with the total SCAT5 symptom score across all participants (Y=7.233x + 22.278, r²=0.302, p=0.001). For visits 2 and 3, there were large, significant correlations for visit 2 (Y=12.673x + 8.819, r²=0.645, p<0.001) and visit 3 (Y=8.956x + 5.268, r²=0.471, p<0.001). Between groups, the OMT group had scores of 1.33, 0.27, and 0.36 for the “trouble falling asleep items” from each visit, whereas the CEC group had scores of 1.00, 0.64, and 0.54. This correlated to an 80.0 % improvement in sleep symptom severity between visits 1 and 2 for the OMT group, whereas the CEC group only showed a 36.0 % improvement between those same visits (p=0.24). From the second to the last visit, the OMT group experienced 73.0 % improvement compared to the CEC group 46 % improvement (p=0.24). There was no significant difference when comparing groups. Although there was no statistically significant difference in interventions, these authors posited that there was a greater trend toward clinical improvement when OMT was utilized vs. standard educational practices.

Among the two case reports, one addressed PCS while the other treated more immediate symptoms. Yao [26] (n=1) presented the case of a 17-year-old girl who was referred to his clinic for OMT after two months of persistent headaches following a head injury during a soccer game, whereas Guernsey et al. [27] (n=1) detailed the treatment of a 27 year-old male who was experiencing concussive symptoms after a snowboarding accident. Yao utilized techniques with the goal of improving the circulatory and lymphatic flow and restoring proper proprioceptive input. Success of treatment was based off the patient’s pain scale. He employed a variety of techniques such as OA decompression and balanced membranous tension (BMT) to the cranium, myofascial release (MFR), facilitated positional release (FPR), and high-velocity, low-amplitude (HVLA) to the cervical and thoracic spines, and BLT to the lumbosacral and sacroiliac junction. After her initial treatment, the patient reported an improvement from 5/10 to 2/10. She also returned for multiple treatment sessions (of unknown length), which improved her symptoms and allowed her to return back to her baseline activity level. Guernsey et al. [27] did not have a specific focus when selecting their techniques, but utilized balanced ligamentous tension, muscle energy, MFR, and HVLA to multiple spinal segments and cranial bone lifts. Their patient’s treatment response was evaluated with the sensory organization test (SOT) and SMART Balance Master before and after treatment. Sessions were consistently 25 min long, and after the session, the patient reported immediate relief of his symptoms. His SOT showed an increase in the composite equilibrium from 76 prior to treatment to 81, and the testing conditions associated with the visual and vestibular aspects of balance improved the most.

Manipulation performed by nonosteopathic medical providers with similar techniques

Five articles were included in this subsection, each of which identified as having an aspect of their study that involved manipulative techniques that were in line with osteopathic principles: one case report, three case series (one single-blinded, one as part of a review), and one retrospective study. Overall, the primary focus of the majority of these articles was PCS, with only Hugentobler and colleagues [32] examining how the treatment provides immediate concussion-symptom relief.

Marshall et al. [28] authored a review with associated case series (n=5), in which three cases were sport-related (one sparring and two hockey-related injuries) and two were due to other nonathletic causes. They found that although not much is known about the pathophysiology of PCS, skilled manual therapy–related assessment and rehabilitation of cervical spine dysfunction should be considered for chronic symptom management following concussion injuries [28]. Their conclusions were based on the subjective reports from those five cases in which the subjects had various mobilization modalities and manipulations performed by chiropractors during their assessment of the subjects’ deficits due to their concussions. In the 25-year old sparring athlete, eight treatments led to resolution of symptoms including headache, dizziness, and noise sensitivity. The 19-year old hockey athlete experienced an 80.0 % reduction of symptom severity after four treatments over a 21-day period; his symptoms included headache, dizziness, visual problems, fatigue, sensitivity to light, mental fogginess, concentration difficulties, and memory difficulties. In a 51-year old hockey athlete, there was full resolution of symptoms after three treatments over 6 weeks including headache and neck pain.

In their single-blinded case series, Wetzler et al. [29] worked with retired NFL players (n=11) who were experiencing long-term symptoms from repetitive head trauma. The techniques they utilized included craniosacral techniques as well as visceral and neural manipulation, and the therapy sessions took place twice a day for 5 days. These researchers found statistically significant improvements in overall pain reduction (p=0.0448), especially cervicogenic (p=0.0486) and increased active ROM (p=0.0377). Qualitatively, a doubling of sleep time was also reported. Most importantly, average memory performance increased (p=0.0156), allowing for less difficulty with learning, reading, and making appropriate decisions. Compared to the other studies, these participants experienced multiple years of high-velocity, head-to-head impacts that had a cumulative affect in their presentation. However, the uniqueness of this patient population bodes well for long-term concussion research by highlighting how successful manipulation was in improving sustained, chronic symptoms.

In a 2017 retrospective study by Grabowski and colleagues [30], participants (n=25) were sorted into PCS subgroups (physiologic, vestibular/oculomotor, cervicogenic, or some mix thereof) based on a subjective interview from their self-reported PCSS [30]. Each subgroup underwent a physical therapy (PT) modality that corresponded to the deficit characterizing the subgroup and sport-specific training; however, only the cervicogenic PCS subgroup (n=3) received soft-tissue and joint mobilization. Six patients were assigned to subgroups with mixed presentations that included cervicogenic PCS: physiologic-cervicogenic (n=3) and cervicogenic-vestibular (n=3). For all 25 patients in the study, the mean PCSS scores (SD) at the initial PT visit were 18.2 (14.2). At the final PT visit, the mean PCSS score was 9.1 (10.8). There was a significant decreasing trend of total scores (p<0.01) after supervised PT. Overall, 88.0 % (n=22) of the study’s total participants reported improvement in symptom scores, while 24.0 % (n=6) achieved a symptom-free state by the end of treatment. Only the primary outcome measure of PCSS was utilized to assess the cervicogenic group’s response to manipulation, and the data were not reported for each individual subgroup within this study to determine to what effect each subgroup benefited from their respective targeted treatment plan.

An occupational therapist credentialed in craniosacral therapy was able to successfully treat a collegiate athlete (n=1) experiencing 18 months of symptoms following a sports-related head injury [31]. Over the course of 11 treatments, the patient was able to improve his scores on the Post-Concussion Symptom Checklist (0–126, higher numbers indicate greater severity, reported in a range). The patient’s initial intake range was 81–92 (borderline moderate-severe) and decreased before the fourth session to 63–68 (moderate). The patient’s scores continued to decrease as obtained before the sixth session, 41–47 (borderline mild-moderate), to 24–32 (mild) after the eighth session, to 12–14 (none-mild [activity-related]) after the 11th session. In addition, the patient had an improvement on the Headache Impact Test (HIT-6) outcomes (range 36–78 indicating severity that headaches impact daily quality of life) from initial intake, 65 (25.0 % relief from initial headache [HA] level), to before the sixth session, 58.5, and after the eleventh session, 44 (90.0 % relief from initial headache level). In review of the patient’s self-report sleep journal, he was able to normalize his sleep schedule by the end of his participation.

Through their series of case studies (n=6), Hugentobler and colleagues [32] further investigated if a multimodal approach to PT, including graded physical activity, sports-specific exercises, cervical manipulation, vestibular rehabilitation, and postural stabilization, would help pediatrics athletes manage and improve their prolonged postconcussive symptoms [32]. Four of the six cases in this study dealt with a head injury that occurred in an athletic setting, and the other two were motor vehicle accident–related. The cervical manipulation aspect of this study was minimal in comparison to the other modalities utilized and was not a primary outcome measure in order to see if this component of the treatment plan changed symptomatology. This study was able to suggest that a multimodal individualized treatment plan may help to facilitate symptom reduction, improve self-management abilities, and safely enhance function, but not to determine which specific interventions provided the greatest benefit to patients.

Limitations

Articles were searched utilizing several databases but were not universally inclusive. This may have led to authors missing other articles not listed in our review article, which would impact our results.