The purpose of this study was to evaluate the safety and preliminary outcomes of the implementation of PT interventions at varying time points after injury for youth diagnosed with concussion. With the low rate of adverse events, all of which were not likely related to PT interventions, these data indicate that multimodal, impairment-based PT is likely safe, regardless of the timing of initiation. In addition, the results indicate that patients receiving PT interventions can experience improvements in their symptoms, irrespective of how early or late initiation of PT occurs. Collectively, the results of this study suggest that multimodal PT interventions administered by licensed physical therapists may be feasible and safe even within the first few weeks after injury to help facilitate prompt recovery and mitigate the onset of secondary effects from delayed treatment.
Previous research illustrates the importance and effectiveness of PT interventions in facilitating recovery for patients presenting with concussion-related impairments.12 , 14 , 16 , 31 However, it is unclear when the administration of PT services should be initiated, as the majority of available studies evaluating PT-related interventions illustrate the recovery patterns for participants who are 3 or more weeks postinjury.12 , 15–17 , 20 , 32 Prolonged physical rest may lead to secondary effects such as physical deconditioning, feelings of depression, and social isolation that can confound symptomology.6 , 24 , 33 Moreover, emerging evidence suggests that strict, prolonged rest following concussion may actually lengthen the recovery process.10 , 31 , 34 , 35
For the current study, the total number of PT sessions and the duration of PT services were also similar across intervention cohorts. These results, coupled with the similarity in improvements in symptoms across cohorts, suggest that introducing PT earlier in the recovery process may be beneficial in minimizing the potential burden of longer recovery trajectories. If patients can safely participate in PT within 3 weeks following injury, as the results of the current study suggest, a logical next step is to investigate whether earlier initiation of PT interventions can help reduce the risk for prolonged recovery and facilitate earlier return to preinjury functional levels. Future studies exploring the rate of recovery and return to preinjury functional participation may provide further insight into the advantages and disadvantages of earlier initiation of PT services.
Several limitations need to be considered before applying the evidence of the current study to the treatment of patients diagnosed with concussion. First, the study's design as a retrospective analysis prevents the formation of a definitive conclusion with regard to safety and tolerability following early implementation of PT. Limited patient information was available when reviewing medical records, including confirmation of full completion of recommended episode of care, level of adherence to provider recommendations, and the precise PT intervention protocols each patient received. Likewise, unless the patient was seen directly in the health system, or a patient self-reported and a clinician documented that an unplanned health provider visit occurred, there is potential that unplanned visits to health care providers for symptom exacerbations were missed. In addition, there was a large variation in physician referral patterns for initiating PT services after concussion, which allowed for the current study to explore timing variables. However, it is possible that there was a selection bias with regard to the timing in which physicians referred patients for PT services after concussion. Physicians may have intentionally or unintentionally screened out patients, using clinical judgment, who may not be ready to safely engage in progressive, monitored physical activity.
It is also important to acknowledge that licensed physical therapists are all trained to work with patients with a variety of health conditions, and specifically brain injuries across the spectrum of severity. However, it is important to consider that the patients in this study were all being treated by physical therapists who were trained and experienced in managing patients with pediatric concussions. Future research is needed to determine how physical therapists' level of training and experience specific to working with patients with concussions may influence the overall success rates and outcomes. Another limitation to the study is that retrospective design constrained the ability to accurately capture and report on any additional services or interventions patients received (eg, medication, occupational therapy, psychological interventions) unless the therapists directly asked and documented it within the patient's medical record. In addition, due to the lack of control group, it cannot be determined whether improvements in symptoms that patients experienced were a result of the PT interventions, other interventions they may have received along the way, or natural recovery processes.
A final limitation of note is that the sample size for this study, although larger than previous studies related to this topic, may have had limited the statistical power to capture differences between the cohorts. A post hoc power analysis using Cohen d of 0.2 and 0.5 estimated effect sizes and a 95% confidence level for capturing differences between the cohorts indicated a statistical power ranging between 0.58 and 0.98 based on the size of the current sample. However, this represents a large range in power, and some statistical experts do not consider a post hoc analysis appropriate for representing observed power in a study.37 Therefore, the results of this study should be considered exploratory and descriptive. Future prospective studies are needed to provide confirmatory and explanatory evidence regarding optimal timing for the initiation of PT services after concussion.
The current study provides evidence for the feasibility of incorporation of multimodal impairment-based PT earlier into the concussion plan of care, specifically within 3 weeks postinjury. The timing of PT services is an important component to consider when determining the most appropriate care for this patient population as there is growing concern regarding the negative effects of prolonged physical and cognitive rest. Future research should aim to validate the results of this exploratory study through prospective clinical trials in order to identify the most optimal and appropriate plan of care for this patient population.
The authors acknowledge the contributions of the physical therapists and staff on the sports and orthopedic team at Cincinnati Children's Hospital for their commitment to diligently document and adhere to the suggested concussion management protocols and trainings. The authors also thank the reviewers and editors for their time and contributions to improving the reporting of the study results.
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