Journal of Sport Rehabilitation, 2018, 27, 485-490

https://doi.org/10.1123/jsr.2016-0222
© 2018 Human Kinetics, Inc. CRITICALLY APPRAISED TOPIC

Effectiveness of Vestibular Rehabilitation Therapy for Treatment

of Concussed Adolescents With Persistent Symptoms
of Dizziness and Imbalance
Kyoungyoun Park, Thomas Ksiazek, and Bernadette Olson

Context: Adolescents who suffer sport concussion typically respond to a prescription of cognitive and physical rest in the acute phases
of healing; however, some adolescents do not respond to rest alone. Dizziness, unsteadiness, and imbalance are impairments, which may
linger longer than 30 days, leading to a diagnosis of postconcussion syndrome (PCS). Vestibular assessment and therapy may benefit
adolescents suffering from these persistent symptoms. Clinical Question: Does vestibular rehabilitation therapy (VRT) rather than
continued prescription of rest (cognitive and physical) reduce recovery time and persistent symptoms of dizziness, unsteadiness, and
imbalance in adolescents (12–18 y) who suffer PCS following a sports-related concussion? Summary of Key Findings: All 4 studies
selected included adolescents suffering from PCS, specifically continued dizziness, unsteadiness, and imbalance. VRT was an effective
intervention for this population. Adolescents presenting with this cluster of symptoms may also demonstrate verbal and visual memory
loss linked to changes in the vestibular system postconcussion. Improved screening tools can help better understand vestibular system
changes, identify adolescents who may benefit from VRT sooner, and decrease long-term impairments. Clinical Bottom Line: Moderate
evidence supports that adolescents who suffer from persistent symptoms of dizziness, unsteadiness, and imbalance following sport
concussion should be evaluated more specifically and earlier for vestibular dysfunction and can benefit from participation in individualized
VRT. Early evaluation and treatment may result in a reduction of time lost from sport as well as a return to their premorbid condition. For
these adolescents, VRT may be more beneficial than continued physical and cognitive rest when an adolescent’s symptoms last longer
than 30 days. Strength of Recommendation: Grade B evidence exists to support that VRT is more effective than continued cognitive
and physical rest in reducing persistent symptoms of dizziness, unsteadiness, and imbalance in adolescents who suffer PCS.

Keywords: brain concussion, vestibular therapy, postconcussion syndrome, balance, oculomotor

Clinical Scenario
Sport concussion (SC) in adolescents has become a major priority
among the medical community and media over the past 20 years. As
a community, we are being called to think differently in regard to SC
in youth to ensure greater health and safety in sport participation.1,2
We recognize concussion as a health concern as concussions repre-
sent approximately 8.9% of high school athletic injuries.3,4 More
recently, Pfister et al5 compiled a comprehensive set of incidence and
prevalence data for children (≤18 y) participating in sport. They
reported overall incidence of 0.23/1000 athlete exposure (AE) across
12 sports in this age group, with the highest incidence rates occurring
in contact sports of rugby (4.18/1000 AE), hockey (1.20/1000 AE),
and American Football (0.53/1000 AE).5 An average of 7.08 direct
football head injuries occur in high school football each year.4
Concussion is a complex pathophysiologic process induced by direct
or indirect traumatic forces to the head that disrupts the function of
the brain.6 In adults who experience a concussion, these pathophysi-
ologic changes may resolve as early as 7 to 10 days; however, a
younger brain may take slightly longer to heal (10–14 d or longer).7,8
Cognitive and physical rest is most commonly prescribed in the acute
phases of a concussion to remove aggravating stimulus and allow the
brain’s physiology and functioning to return to normal. Most children
Park is with the Department of Kinesiology, The University of North Carolina at
Greensboro, Greensboro, NC, USA. Ksiazek is with Sports and Therapy Depart-
ment, Great Plains Health, North Platte, NE, USA. Olson is with the Department of
Health and Nutritional Sciences, South Dakota State University, Brookings, SD,
USA. Olson (Bernie.olson@sdstate.edu) is corresponding author.
who are diagnosed early and treated properly will return to activities
of daily living and participation without consequence within a
reasonable time frame (30 d or less). However, some adolescents
do not recover within this time frame and are then diagnosed with
postconcussion syndrome (PCS).9 Dizziness, unsteadiness, and
imbalance are a common cluster of impairments, which may linger
into PCS in both adolescents and adults.10 Continuation of rest may
not be the best course of therapy for adolescents who suffer these
persistent symptoms.11,12 A recent study examining military mem-
bers who suffer from postconcussion peripheral vestibular impair-
ments and completed individualized vestibular rehabilitation therapy
(VRT) demonstrated improved patient outcomes.13 These VRT
programs focused on promoting vestibular adaptation and substitu-
tion to enhance gaze and postural stability, improved vertigo, and
returned patients to productive activities of daily living. Although the
mechanism of injury is different in children who suffer SC compared
with a service member who suffers a blast injury, the continuation of
impairments including dizziness, unsteadiness, and imbalance is
similar. Therefore, clinicians treating concussed adolescents suffer-
ing from persistent symptoms of dizziness, unsteadiness, and imbal-
ance may consider other options such as VRT as opposed to the
continuation of cognitive and physical rest alone.14
Focused Clinical Question
Does VRT rather than the prescription of continued rest (cognitive
and physical) reduce recovery time and persistent symptoms of
dizziness, unsteadiness, and imbalance in adolescents (12–18 y)
who suffer PCS following a sports-related concussion?
485
 486 Park, Ksiazek, and Olson
Summary of Search, “Best Evidence”
Appraised, and Key Findings
• Contemporary medical and health care-related databases were
searched using key words including vestibular rehabilitation
therapy (VRT), sport concussion, and adolescents.
• The search revealed approximately 30 articles, including
numerous literature and clinical reviews, but only 4 studies
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met our inclusion criteria: 1 randomized control trial, 1
retrospective cohort study, 1 retrospective case series, and 1
case series with chart review.
• All 4 studies included adolescents who suffered specifically
from SC as participants.14–17
• Two research studies14,15 included participants who were
referred for evaluation of symptoms and VRT following a
diagnosis of PCS including the cluster of dizziness, unsteadiness,
and imbalance as predominant symptoms. Although patients
varied greatly in the length of time they suffered PCS, the results
of both studies demonstrated marked improvement for patients.
• A retrospective case series study16 examined the relationship
between self-reported symptoms, cognitive performance, and
balance performances in concussed adolescents with PCS who
were referred to vestibular therapy. Relationships were found
between visual/verbal memory domains and balance/gait im-
pairments in adolescents referred for vestibular therapy post-
concussion, suggesting the vestibular system may play a role
in impairments beyond dizziness and imbalance.
• A case series with chart review17 offered a more extensive set
of screening modalities to better understand impairments of the
vestibular system in adolescents to design effective prevention
and treatment programs.
Clinical Bottom Line
Currently, there is moderate evidence to support the referral of
adolescents who suffer from persistent and prolonged symptoms
and physical presentation of dizziness, unsteadiness, and imbal-
ance following SC for vestibular dysfunction assessment and
treatment. All 4 studies supported benefits from participation in
individualized VRT.14–17 For these adolescents, VRT may be more
beneficial than continued physical and cognitive rest when an
adolescent’s symptoms last longer than 30 days, although the
exact timing for referral and treatment is not conclusive.
Strength of Recommendation
There is grade B evidence to support that vestibular rehabilitation
is more effective than continued cognitive and physical rest in
reducing persistent symptoms of dizziness, unsteadiness, and im-
balance for adolescents who suffer PCS. The Centre of Evidence-
Based Medicine recommends a grade B for level 2 and 3 evidence
Table 1 Results of Search
Level of evidence Study design/Methodology of articles retrieved
2 Randomized control trial
3 Retrospective cohort study
4 Retrospective case series
4 Case series with chart review
JSR Vol. 27, No. 5, 2018
with consistent findings. In this critically appraised topic (CAT),
only one randomized controlled trial was found, indicating a lack of
high-level evidence studies on this question.
Search Strategy
Terms Used to Guide Search Strategy
• Patient/Client group: adolescent, child athlete, concussion,
sport-concussion, traumatic brain injury, post-concussion syn-
drome, PCS
• Intervention: cervicovestibular, vestibular, rehabilitation, ther-
apy, VRT
• Comparison: physical and cognitive rest
• Outcome(s): recovery time, dizziness, unsteadiness, unbalance
Sources of Evidence Searched (Databases)
• PEDro
• PubMed
• MEDLINE
• CINAHL
• Google Scholar
Inclusion and Exclusion Criteria
Inclusion Criteria
• Studies including concussions caused by blunt force or SC
• Studies investigating VRT and postconcussion symptoms
• Studies including adolescent (12–18 y) participants
• Limited to past 10 years (≥2006)
• Articles in English
• Level 4 evidence or higher
Exclusion Criteria
• Studies that did not include VRT as a treatment for concussion
• Literature that did not study concussion caused by blunt
trauma or sport-related concussion (ie, blast trauma)
• Studies that did not include adolescents (12–18 y) as participants
• Studies older than 10 years (<2006)
• Level 5 evidence, including clinical reviews
Results of Search
Relevant studies were located and categorized as shown in Table 1.
Level of evidence applied to each study was based on Oxford
Centre for Evidence-Based Medicine 2011 Levels of Evidence.18
Number located Author (year)
1 Schneider et al14 (2014)
1 Alsalaheen et al15 (2010)
1 Alsalaheen et al16 (2016)
1 Zhou and Brodsky17 (2015)
 Table 2 Characteristics of Included Studies
Schneider et al14
Study design Randomized controlled trial
Participants Median time between
concussion and referral was
53 d (range: 8–276 d) for the
treatment group and median
47 d (range: 31–142 d) for the
control group.
Inclusion criteria: Individuals
between 12 and 30 y diagnosed
with sport concussion and
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reporting persistent symptoms
(>10 d) of dizziness, neck pain,
and headaches on the SCAT2
and completing a physician
screening indicating vestibular
or cervical spine involvement.
Exclusion criteria: Fracture,
other neurological conditions,
musculoskeletal injuries (other
than cervical spine), which limit
activity, and medications that
affect neural adaptation.
Participants were randomly
assigned to either a control
group (N = 16; 7 males and
9 females) or an intervention
group (N = 15; 11 males and
4 females); median age for
both groups was 15 y. Two
participants withdrew from the
control group.
Intervention(s) Participants were seen once a
investigated week by a single-study
treatment physiotherapist for
8 wk or until the time of medical
clearance to return to sport.
Treatment received by both
groups includes nonprovocative
ROM exercises, stretching, and
postural education; standard
concussion protocol was also
followed, including rest until
symptom free, then a graded
exertion plan.
All participants kept a daily
diary of activities to ensure
compliance with the home
exercise plan.
Intervention group received an
individually designed plan of
(1) cervical spine physiotherapy
(manual therapy of cervical
and thoracic spines (joint
mobilization techniques),
therapeutic exercise including
cervical neuromotor retraining
exercises (craniovertebral
flexor and extensor retraining),
and sensorimotor retraining
exercises and (2) VRT
(individualized program of
habitation, gaze stabilization,
adaptation exercises, standing
balance exercises, dynamic
balance exercises, and canalith
repositioning maneuvers).
Alsalaheen et al15
Retrospective cohort study
A total of 114 patients (children
≤18 y and adults ≥18 y) who
were referred for vestibular
rehabilitation after being
diagnosed with a concussion
were included.
Median duration between
concussion and referral was
61 d (range: 6–2566 d).
In total, 30 participants received
an initial evaluation and did
not return for a second visit;
reasons included: therapy was
not indicated, lived too far
away, and noncompliance.
In total, 84 participants visited
more than once, and the median
number of visits was 4 (range:
2–13 visits) over a median
duration of 33 d (range:
7–181 d)
In total, 67 children (45 girls
and 22 boys) were included
(median age: 16 y; range:
8–18 y).
In total, 47 adults (25 females
and 22 males) were included
(median age: 41 y; range:
19–73 y).
Of the 84 patients who
continued, 5 were diagnosed
with BPPV.
Once a patient was assessed
with a concussion, they were
referred to a center for
vestibular rehabilitation.
VRT programs were
customized to each patient’s
impairments and functional
limitations related to dizziness,
ocular motor function, and
gait and balance function.
Categories of exercises for
vestibular rehabilitation and
in the home exercise program
included:
• Gaze stabilization
exercise: individual
maintained a fixed gaze
position with turning the
head from side to side in
sitting and standing
position
• Standing balance: standing
with feet apart and feet
together on foam while
eyes open and closed
• Walking with balance
challenge: walking while
head turns, tandem
walking and obstacle
avoidance
• Canalith repositioning
maneuvers (in a few cases)
Exercises were performed
daily.
JSR Vol. 27, No. 5, 2018
Alsalaheen et al16
Retrospective case series
A total of 60 consecutive
patients (40 females and 20
females) were included; mean
age: 15 y (SD = 1.8).
All patients had been referred
to tertiary balance center for
vestibular therapy after
physician’s diagnosis of
concussion.
Participants seen at median of
46 d after concussion; cognitive
testing with average of 1.8 d
(SD = 11 d).
At time of cognitive evaluation
postconcussion, 39 (65%)
participants showed
impairment.
Patients diagnosed with
concussion by physician were
referred to tertiary balance
center for vestibular physical
therapy.
Vestibular therapy was tailored
to each patient’s impairments
and functional limitations
including:
(1) Dizziness
(2) Oculomotor function
(3) Gait function
(4) Balance function
Exercises most frequently
used included:
(1) Gaze stabilization in
standing and sitting
positions
(2) Standing balance
(3) Walking with balance
challenge
Evaluated for relationship
between symptoms, cognitive
measure, and balance at time
of initiation of vestibular
physical therapy.
Zhou and Brodsky17
Case series with chart review
The study includes 42
adolescent patients’ medical
records with balance and/or
vestibular complaints following
sports-related concussions (25
girls and 17 boys; average age:
13.9 (2.8) y; range: 8–18 y).
All patients had undergone
vestibular testing over past 3 y.
All patients had at least 1
concussion as a result of
participating in sport activities.
Six patients had 3–5
concussions.
Patients met criteria for
concussion as outlined by the
2012 International Consensus
on Concussion in Sports.
Average time between initial
concussion and vestibular
testing was 26 (20) wk (range:
1–96 wk).
Patients’ activities included ice
hockey (8), soccer (7), football
(5), ice skating/ski/
snowboarding (5), swimming
(3), lacrosse (2), horse riding
(2), and other (10).
Medical records of 42 patients
were evaluated to summarize
and analyze characteristics of
individuals who underwent
testing of balance and vestibular
function following a diagnosis
of concussion.
Each patient’s hearing was
checked before testing.
Balance and vestibular system
evaluation was completed.
Not every patient completed
all the same tests.
(continued)
487
 Table 2 (continued)
Schneider et al14
Outcomes Primary outcome measure:
measured number of days from treatment
initiation until medical
clearance to return to sports.
Medical clearance was
determined by a sport medicine
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physician who was blinded to
assignment of participants to
the control or intervention
group.
The following secondary
outcome measures were
recorded at baseline and upon
medical clearance or 8 wk:
• 11-point Numeric Pain
Rating Scale scores
• ABC scale
• DHI
• SCAT2
• DVA
• Head Thrust Test
• Modified Motion
Sensitivity Test
• FGA
• CFE
• JPE test
Main Median number of follow-up
findings sessions was 6 for both control
and treatment groups; 10/15
participants in treatment group
and 9/14 participants in control
group reported completing
HEP.
In treatment group, 73.3%
participants were medically
cleared to return to sport within
8 wk of treatment compared
with 7.1% in control group.
More individuals in
intervention group were
medically cleared following the
8-wk treatment regimen than
those in control group (62.2%;
95% confidence interval,
40–92.3; P < .001).
Participants in treatment group
were 10.27 times more likely to
be medically cleared than those
in control group after 8-wk
treatment program.
All medically cleared
individuals reported feeling
no symptoms of headache and
dizziness; 64% reported no
neck pain.
Intervention group participants
reported greater improvement
on SCAT2 (Wilcoxon rank-sum
test, P < .001) and DHI score
(Wilcoxon rank-sum test,
P = .02).
Level of 2 3
evidence
PEDro scale 7/10
488
Alsalaheen et al15
Outcome data were collected at
time of initial evaluation and
discharge.
Self-report measures included:
• Patients reported current
dizziness severity on scale
from 0 to 100; patients
described dizziness using
the following terms:
spinning, lightheadedness,
off-balance, nausea,
sensation of motion, and
others
• ABC scale
• DHI
Observational measures of gait
and balance included:
• DGI
• FGA
• Gait speed
• TUG
• FTSTS
Computerized dynamic
posturography:
• SOT under 6 sensory
conditions
At initial visit, dizziness was
described as off-balance,
lightheadedness, spinning,
nausea, and sensation of
motion.
All patients receiving VRT
demonstrated significant
treatment effects for all self-
report and performance
measures.
Significant interaction between
age group and treatment for:
• Dizziness severity
(F1,62 = 8.6, P = .01);
children’s dizziness
severity was decreased by
mean score of 19 points
(F1,40 = 31.0, P < .001).
• SOT condition 1
(F1,19 = 6.7, P = .02),
significant improvement
in children, not adults
• SOT condition 2
(F1,19 = 5.9, P = .25),
significant improvement
in children, not adults
Three measures demonstrated a
significant main effect of age;
children showed significantly:
• Lower (better) DHI score
compared with adults
• Higher FGA score as
compared with adults
• Lower FTSTS compared
with adults
n/a
JSR Vol. 27, No. 5, 2018
Alsalaheen et al16
Self-report and balance
performance measures
administered during first initial
visit, weekly, and monthly
intervals until discharge.
Utilized self-report measures
including:
• Rate dizziness scale of
0–100
• ABC scale
• DHI
Balance performance measures
included:
• FGA
• DGI
• Gait speed change of
≥0.21 m/s considered
reliable change in
adolescents
• TUG
• FTSTS
• SOT
Cognitive and symptom
measure:
• ImPACT test
In total, 39 (65%) participants
exhibited impairment at least
1 cognitive domain: visual
memory.
In total, 45 (75%) participants
experienced increased
symptoms beyond normal.
Patients showed reduced
balance confidence, increased
complaints of dizziness, and
impaired balance in clinical
tests (χ2 showed no significant
differences between male and
female).
Lower visual memory scores
associated with greater sway
in 3 of 6 SOT conditions:
• Visual memory and
postural sway with eyes
closed (r = .59, P < .001,
and r = .47, P = .01)
• Visual memory and sway
referenced vision with
fixed support (r = .53,
P = .001)
• Reaction time and ABC
(rs = −.35, P = .01) and
FTSTS (r = .38, P = .01)
No significant relationship
between processing speeds to
any measures collected during
VRT.
Vestibular system plays major
role in spatial memory.
4 4
n/a
Zhou and Brodsky17
All patients did a series of
objective vestibular and balance
tests including:
• Computerized dynamic
posturography with SOT
• VNG
• Bithermal caloric test
• Sinusoidal harmonic
rotational chair test
• DVA tests
• cVEMP
• Static SVV
All patients underwent tests to
establish hearing status before
any balance and vestibular
evaluations and then
documented.
All testing was done in
vestibular laboratory by
licensed audiologist.
Majority of patients had normal
hearing after concussions.
More than 90% of patients
participated in
• Computerized dynamic
posturography
• VNG
• Rotary chair
• Static SVV test
• cVEMP
Only 9.5% (4 patients) had
normal vestibular and balance
results after the concussion.
About 55% of patients
underwent DVA test in which
57% of those who participated
had abnormal findings, which
included:
• Decrease in visual acuity
with head movements
About 40% of patients who
participated in computerized
dynamic posturography showed
balance impairment.
n/a
(continued)
 Effectiveness of VRT for Concussed Adolescents 489

Table 2 (continued)
Schneider et al14
Conclusions The combination treatment of
cervical spine physiotherapy
and vestibular rehabilitation
decreases time lost from sport in
individuals with persistent
symptoms of dizziness, neck
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Alsalaheen et al15
Vestibular rehabilitation
intervention improved the
persistent symptoms of
dizziness and gait and balance
dysfunction after having a
concussion in both children and
Alsalaheen et al16
Patients with vestibular
impairments have impaired
spatial memory; links stronger
correlation of visual memory to
balance measures compared
with other scores not using
Zhou and Brodsky17
Vestibular dysfunction is
common in pediatric patients
with sports-related concussions.
Proper and thorough evaluation
is important to identify deficits
in dizziness or imbalance in

pain, and/or headaches after adults. spatial abilities. postconcussive injuries to help
concussion than continuing As a retrospective cohort study, Study has limitations including: create a proper rehabilitation
with rest. certain limitations existed (1) Small sample size and program.
including lack of a control referral process solely
group and the inability to based on clinical
determine how impaired the judgment
patients were immediately after (2) Only represents
concussion and how much individuals after acute
improvement may have phase of concussion
occurred between the time of (3) Time points considered
concussion and referral for for correlation analyses
vestibular assessment and were varied between
therapy. participants.
Although age treatment effect
was included, it should be noted
that several of the tools have not
been validated for children.
Abbreviations: ABC, Activities-specific Balance Confidence; BPPV, benign paroxysmal positional vertigo; CFE, cervical flexor endurance; cVEMP, cervical vestibular
evoked myogenic potential; DGI, Dynamic Gait Index; DHI, Dizziness Handicap Inventory; DVA, dynamic visual acuity; FGA, Functional Gait Assessment; FTSTS, five
times sit to stand; HEP, Home Exercise Program; ImPACT, Immediate Postconcussion Assessment and Cognitive Testing; JPE, joint position error; n/a, not applicable;
ROM, range of motion; SCAT2, Sport Concussion Assessment Tool 2; SOT, Sensory Organization Test; SVV, subjective visual vertical; TUG, Timed Up and Go; VNG,
videonystagmography; VRT, vestibular rehabilitation therapy.

Best Evidence of treatment. Adolescents improved as a result of VRT, particularly

Four research studies were determined as best sources to answer the
clinical question and therefore were used for inclusion in this CAT.
The studies in Table 2 summarize the best studies. These studies
were selected because they investigated VRT as a treatment option
other than rest to improve symptoms of dizziness and imbalance in
adolescents who suffered SC.
Implications for Practice, Education,
and Future Research
Results from both Schneider et al14 and Alsalaheen et al15 demon-
strated a significant reduction of symptoms, such as dizziness,
unsteadiness, and imbalance for adolescents with persistent symp-
toms and who participated in individualized VRT. All 4 studies
included adolescents who suffered concussion due to blunt force
trauma; while Schneider et al14 and Zhou and Brodsky17 also
specifically included adolescents who suffered SC. Schneider
et al14 was the only randomized control trial. In this study,
adolescents who were diagnosed with PCS were then assigned
to either a control group or an intervention group. Adolescents who
received cervical spine physiotherapy and VRT (intervention
group) rather than continued physical and cognitive rest (control
group) demonstrated significant reduction in symptoms of dizzi-
ness, unsteadiness, and imbalance and a reduction in time lost from
sport.14 The retrospective cohort study by Alsalaheen et al15 and the
retrospective case series by Alsalaheen et al16 examined patients
diagnosed with persistent symptoms following concussion and
referred for VRT. Although these studies lacked a control group,
researchers evaluated baseline measures for participants prior to
starting therapy and then again at specified times over the course
JSR Vol. 27, No. 5, 2018
in reports of decreased dizziness and improved gait.15 Vestib-
ular rehabilitation had a positive effect on increasing functional
dynamic visual acuity, standing balance, and gait in patients with
mild traumatic brain injury.19 Although the last 2 articles reviewed
in this CAT by Alsalaheen et al16 and Zhou and Brodsky17 do not
directly compare the difference in vestibular therapy to rest in
patients suffering from PCS, the authors make clear the importance
of vestibular therapy for adolescents who continue to suffer from
dizziness, unsteadiness, and imbalance postconcussion. All studies
demonstrated that if vestibular dysfunction is identified as the
primary cause of symptoms and physical impairments related to
dizziness and imbalance in adolescents suffering from PCS, a
personalized patient-oriented rehabilitation program may reduce
their dysfunction.14–17
Clinicians considering the use of VRT should think through
their approach to assessment and outcome measures to identify
impairments and therefore design individualized treatments. All
4 articles14–17 included a comprehensive set of evaluation strategies
and outcome measures (both qualitative and quantitative mea-
sures). Even though their approaches varied, there was some
overlap in tools. Common tools included and found to be reliable
outcome measures were the Sensory Organization Test, the Activ-
ities-specific Balance Confidence scale, the Dizziness Handicap
Inventory, and the Functional Gait Assessment. Schneider et al14
also included the Sport Concussion Assessment Tool 2 in their
choice of assessment measures as the Sport Concussion Assess-
ment Tool 2 is specific to SC evaluation. As providers develop a
common evaluation pattern, these measures may serve as the core
of common measures implemented into the assessment process to
identify deficits that serve as a basis for designing VRT programs.
Alsalaheen et al16 also utilized the Immediate Postconcussion
Assessment and Cognitive Testing to measure the cognitive and
 490 Park, Ksiazek, and Olson
postconcussion symptom severity of the patients seen for vestibular
therapy.
The impact of these studies suggests that clinicians working
with complicated patients suffering from persistent symptoms
following concussion (including SC) should consider other treat-
ment options besides continued rest.11 What is less clear, however,
is when the appropriate time for referral might be to allow for the
best patient outcomes. Inclusion criteria for the studies describe
participants who reported experiencing dizziness, unsteadiness,
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and imbalance >10 days; however, the median number of days
postconcussion that patients presented for initial evaluation and/or
for referrals ranged from 47 to 63 days. (Some patients referred as
early as 6 d, whereas others as late as 7 y.) Researchers could not
control when participants entered their clinic for the initial visit as
not every patient reports to a clinician for concussion when the
injury occurs. Also, the researchers were not able to report pre-
injury (baseline data) nor postinjury markers at specific time frames
because they did not have contact with the patients prior to the
injury and/or immediately following. They were unable to ascertain
whether the resulting persistent symptoms were due to the injury
severity itself and/or because the injury was not reported in a timely
fashion, it was misdiagnosed, or mistreated early in the healing
process. Adolescents diagnosed early and treated correctly imme-
diately following a concussion may not demonstrate with persistent
impairments after 14 days.
As further research is designed to determine the best timing
and effects of VRT in adolescents who suffer SC, study designers
should consider including preinjury assessments for balance (and
perhaps other measures) as well as more structured time periods for
the collection of outcomes data. In reference specifically to ado-
lescents who suffer SC, tools such as the Balance Error Scoring
System, the Sport Concussion Assessment Tool 3, and oculomotor
tests specific to SC assessment may provide additional outcome
measures at various time points across the spectrum of care.
Treatment effects would also be more strongly substantiated if a
larger sample size was included. This CAT should be reviewed in
2 years to determine whether additional best research evidence has
been published that could aid in answering the focused clinical
question.
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