Health  Vol.10 No.4 , April 2018
Effects of Electrical Stimulation in People with Post-Concussion Syndromes: A Pilot Study
Abstract: Post-concussion syndrome (PCS) is a complex disorder with various symptoms. There is limited evidence to support that any intervention enhances recovery after a concussion. This pilot study aimed to examine the efficacy of neck paraspinal muscles electrical stimulation (ES) in conjunction with physical therapy (PT) on reducing the severity of post concussive symptoms. Twenty-four individuals with PCS were randomly assigned to the ES group (PT + ES) or the control group (PT only). Both groups received the intervention twice a week for eight weeks. Clinical measures including the Concussion Signs/Symptoms Checklist, balance error scoring system, King-Devick test, ImPACT, and the Standardized Assessment of Concussion were used to evaluate the symptoms. We investigated the recovery rate by calculating slopes of changes over time for each participant. A changing slope was derived by linearly fitting the symptoms severity over time with the initial severity score as the intercept. Significant overall improvement was observed in both groups after the interventions. There was no significant difference seen in total symptom recovery rate between two groups (-1.49 ± 1.59 versus -1.2 ± 1.56, p = 0.32). The cognitive symptoms recovery rate of the ES group was faster than the control group (-0.5 ± 0.49 and -0.13 ± 0.46 respectively, p = 0.04). Physical therapy targeting the cervical region is beneficial for persons with PCS. Moreover, peripheral electrical stimulation on the paraspinal muscles surrounding the neck region could potentially advance the cognitive function recovery of persons with PCS.
Cite this paper: Wu, Y. , Gravel, J. , Chatiwala, N. , Enis, T. , Stark, C. and Cantu, R. (2018) Effects of Electrical Stimulation in People with Post-Concussion Syndromes: A Pilot Study. Health, 10, 381-395. doi: 10.4236/health.2018.104031.

[1]   ator, C., Bray, G. and Morin, D. (2007) The CBANCH Report—The Burden of Neurological Diseases, Disorders, and Injuries in Canada. Canadian Journal of Neurological Sciences, 34, 268-269.

[2]   Langlois, J.A., Rutland-Brown, W. and Wald, M.M. (2006) The Epidemiology and Impact of Traumatic Brain Injury: A Brief Overview. Journal of Head Trauma Rehabilitation, 21, 375-378.

[3]   McCrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R.J., Engebretsen, L., Johnston, K., Kutcher, J.S., Raftery, M., Sills, A., Benson, B.W., Davis, G.A., Ellenbogen, R.G., Guskiewicz, K.M., Herring, S.A., Iverson, G., Jordan, B.D., Kissick, J., McCrea, M., McIntosh, A.S., Maddocks, D.L., Makdissi, M., Purcell, L., Putukian, M., Turner, M., Schneider, K. and Tator, C.H. (2013) Consensus Statement on Concussion in Sport—The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clinical Journal of Sport Medicine, 23, 89-117.

[4]   Vidal, P.G., Goodman, A.M., Colin, A., Leddy, J.J. and Grady, M.F. (2012) Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent Concussion. Pediatric Annals, 41, 1-7.

[5]   Bazarian, J.J., Wong, T., Harris, M., Leahey, N., Mookerjee, S. and Dombovy, M. (1999) Epidemiology and Predictors of Post-Concussive Syndrome after Minor Head Injury in an Emergency Population. Brain Injury, 13, 173-189.

[6]   Iverson, G.L. (2005) Outcome from Mild Traumatic Brain Injury. Current Opinion in Psychiatry, 18, 301-317.

[7]   Leddy, J.J., Sandhu, H., Sodhi, V., Baker, J.G. and Willer, B. (2012) Rehabilitation of Concussion and Post-Concussion Syndrome. Sports Health, 4, 147-154.

[8]   Schneider, K.J., Iverson, G.L., Emery, C.A., McCrory, P., Herring, S.A. and Meeuwisse, W.H. (2013) The Effects of Rest and Treatment Following Sport-Related Concussion: A Systematic Review of the Literature. British Journal of Sports Medicine, 47, 304-307.

[9]   Majerske, C.W., Mihalik, J.P., Ren, D., Collins, M.W., Reddy, C.C., Lovell, M.R. and Wagner, A.K. (2008) Concussion in Sports: Postconcussive Activity Levels, Symptoms, and Neurocognitive Performance. Journal of Athletic Training, 43, 265-274.

[10]   McCrory, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J., Graf-Baumann, T., Kelly, J., Lovell, M. and Schamasch, P. (2005) Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clinical Journal of Sport Medicine, 15, 48-55.

[11]   Leddy, J.J., Kozlowski, K., Donnelly, J.P., Pendergast, D.R., Epstein, L.H. and Willer, B. (2010) A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion Syndrome. Clinical Journal of Sport Medicine, 20, 21-27.

[12]   Kennedy, E., Quinn, D., Tumilty, S. and Chapple, C.M. (2017) Clinical Characteristics and Outcomes of Treatment of the Cervical Spine in Patients with Persistent Post-Concussion Symptoms: A Retrospective Analysis. Musculoskeletal Science and Practice, 29, 91-98.

[13]   Giza, C.C., Kutcher, J.S., Ashwal, S., Barth, J., Getchius, T.S., Gioia, G.A., Gronseth, G.S., Guskiewicz, K., Mandel, S., Manley, G., McKeag, D.B., Thurman, D.J. and Zafonte, R. (2013) Summary of Evidence-Based Guideline Update: Evaluation and Management of Concussion in Sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology, 80, 2250-2257.

[14]   Herring, S.A., Cantu, R.C., Guskiewicz, K.M., Putukian, M., Kibler, W.B., Bergfeld, J.A., Boyajian-O’Neill, L.A., Franks, R.R., Indelicato, P.A. and American College of Sports, M. (2011) Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement—2011 Update. Medicine & Science in Sports & Exercise, 43, 2412-2422.

[15]   Stern, R.A., Seichepine, D., Tschoe, C., Fritts, N.G., Alosco, M.L., Berkowitz, O., Burke, P., Howland, J., Olshaker, J., Cantu, R.C., Baugh, C.M. and Holsapple, J.W. (2017) Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New Eng-land Emergency Departments. Journal of Neurotrauma, 34, 861-868.

[16]   Ellis, M.J., Leddy, J. and Willer, B. (2016) Multi-Disciplinary Management of Athletes with Post-Concussion Syndrome: An Evolving Pathophysiological Approach. Frontiers in Neurology, 7, 136.

[17]   Leddy, J.J., Baker, J.G. and Willer, B. (2016) Active Rehabilitation of Concussion and Post-Concussion Syndrome. Physical Medicine & Rehabilitation Clinics of North America, 27, 437-454.

[18]   Ellis, M.J., Leddy, J.J. and Willer, B. (2015) Physiological, Vestibulo-Ocular and Cervicogenic Post-Concussion Disorders: An Evidence-Based Classification System with Directions for Treatment. Brain Injury, 29, 238-248.

[19]   Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., Emberson, J., Marschner, I. and Richardson, C. (2002) A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine, 27, 1835-1843.

[20]   Reid, S.A., Callister, R., Snodgrass, S.J., Katekar, M.G. and Rivett, D.A. (2015) Manual Therapy for Cervicogenic Dizziness: Long-Term Outcomes of a Randomised Trial. Manual Therapy, 20, 148-156.

[21]   Johnson, M.I., Claydon, L.S., Herbison, G.P., Jones, G. and Paley, C.A. (2017) Transcutaneous Electrical Nerve Stimulation (TENS) for Fibromyalgia in Adults. The Cochrane Database of Systematic Reviews, 10, CD012172.

[22]   Price, C.I. and Pandyan, A.D. (2001) Electrical Stimulation for Preventing and Treating Post-Stroke Shoulder Pain: A Systematic Cochrane Review. Clinical Rehabilitation, 15, 5-19.

[23]   Doucet, B.M., Lam, A. and Griffin, L. (2012) Neuromuscular Electrical Stimulation for Skeletal Muscle Function. The Yale Journal of Biology and Medicine, 85, 201-215.

[24]   Chuang, L.L., Chen, Y.L., Chen, C.C., Li, Y.C., Wong, A.M., Hsu, A.L. and Chang, Y.J. (2017) Effect of EMG-Triggered Neuromuscular Electrical Stimulation with Bilateral Arm Training on Hemiplegic Shoulder Pain and Arm Function after Stroke: A Randomized Controlled Trial. Journal of NeuroEngineering and Rehabilitation, 14, 122.

[25]   Jonsdottir, S., Bouma, A., Sergeant, J.A. and Scherder, E.J. (2004) Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on Cognition, Behavior, and the Rest-Activity Rhythm in Children with Attention Deficit Hyperactivity Disorder, Combined Type. Neurorehabilitation and Neural Repair, 18, 212-221.

[26]   van Dijk, K.R., Scherder, E.J., Scheltens, P. and Sergeant, J.A. (2002) Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on Non-Pain Related Cognitive and Behavioural Functioning. Reviews in the Neurosciences, 13, 257-270.

[27]   Scherder, E.J., Van Someren, E.J., Bouma, A. and Berg, M. (2000) Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on Cognition and Behaviour in Aging. Behavioural Brain Research, 111, 223-225.

[28]   Hitier, M., Besnard, S. and Smith, P.F. (2014) Vestibular Pathways Involved in Cognition. Frontiers in Integrative Neuroscience, 8, 59.

[29]   Skinner, S.B. and McVey, C. (2012) Pocket Notes for the Physical Therapist Assistant. Jones & Bartlett Learning, Burlington.

[30]   Travell, J. and Simons, D. (1992) Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams & Wikins, Philadelphia.

[31]   Cantu, R.C. (2017) History of Concussion and Chronic Traumatic Encephalopathy. In: Budson, A., Mckee, A., Cantu, R.C. and Stern, R.A., Eds., Chronic Traumatic Encephalopathy, Elsevier, New York, 11.

[32]   Cantu, R.C. (2003) Recurrent Athletic Head Injury: Risks and When to Retire. Clinics in Sports Medicine, 22, 593-603.

[33]   Merritt, V.C., Bradson, M.L., Meyer, J.E. and Arnett, P.A. (2017) Evaluating the Test-Retest Reliability of Symptom Indices Associated with the Impact Post-Concussion Symptom Scale (PCSS). Journal of Clinical and Experimental Neuropsychology, 40, 377-388.

[34]   McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., Cantu, R.C., Cassidy, D., Echemendia, R.J., Castellani, R.J., Davis, G.A., Ellenbogen, R., Emery, C., Engebretsen, L., Feddermann-Demont, N., Giza, C.C., Guskiewicz, K.M., Herring, S., Iverson, G.L., Johnston, K.M., Kissick, J., Kutcher, J., Leddy, J.J., Maddocks, D., Makdissi, M., Manley, G.T., McCrea, M., Meehan, W.P., Nagahiro, S., Patricios, J., Putukian, M., Schneider, K.J., Sills, A., Tator, C.H., Turner, M. and Vos, P.E. (2017) Consensus Statement on Concussion in Sport—The 5th International Conference on Concussion in Sport Held in Berlin, October 2016. British Journal of Sports Medicine, 51, 838-847.

[35]   Pearce, A.J., Hoy, K., Rogers, M.A., Corp, D.T., Davies, C.B., Maller, J.J. and Fitzgerald, P.B. (2015) Acute Motor, Neurocognitive and Neuro-physiological Change Following Concussion Injury in Australian Amateur Football. A Prospective Multimodal Investigation. Journal of Science and Medicine in Sport, 18, 500-506.

[36]   O’Brien, A.M., Casey, J.E. and Salmon, R.M. (2017) Short-Term Test-Retest Reliability of the ImPACT in Healthy Young Athletes. Applied Neuropsychology: Child, 1-9.

[37]   Galetta, K.M., Brandes, L.E., Maki, K., Dziemianowicz, M.S., Laudano, E., Allen, M., Lawler, K., Sennett, B., Wiebe, D., Devick, S., Messner, L.V., Galetta, S.L. and Balcer, L.J. (2011) The King-Devick Test and Sports-Related Concussion: Study of a Rapid Visual Screening Tool in a Collegiate Cohort. Journal of the Neurological Sciences, 309, 34-39.

[38]   Turner, M. (2013) SCAT3. British Journal of Sports Medicine, 47, 259-262.

[39]   Tal, S., Hadanny, A., Berkovitz, N., Sasson, E., Ben-Jacob, E. and Efrati, S. (2015) Hyperbaric Oxygen May Induce Angiogenesis in Patients Suffering from Prolonged Post-Concussion Syndrome Due to Traumatic Brain Injury. Restorative Neurology and Neuroscience, 33, 943-951.

[40]   Maugans, T.A., Farley, C., Altaye, M., Leach, J. and Cecil, K.M. (2012) Pediatric Sports-Related Concussion Produces Cerebral Blood Flow Alterations. Pediatrics, 129, 28-37.

[41]   Morin, M., Langevin, P. and Fait, P. (2016) Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review. Journal of Sports Medicine, 2016, Article ID: 1590161.

[42]   Burns, S.L. (2015) Concussion Treatment Using Massage Techniques: a Case Study. International Journal of Therapeutic Massage & Bodywork, 8, 12-17.

[43]   Horak, F.B., Jones-Rycewicz, C., Black, F.O. and Shumway-Cook, A. (1992) Effects of Vestibular Rehabilitation on Dizziness and Imbalance. Otolaryngology—Head and Neck Surgery, 106, 175-180.

[44]   Krebs, D.E., Gill-Body, K.M., Riley, P.O. and Parker, S.W. (1993) Double-Blind, Placebo-Controlled Trial of Rehabilitation for Bilateral Vestibular Hypofunction: Preliminary Report. Otolaryngology—Head and Neck Surgery, 109, 735-741.

[45]   Shepard, N.T., Telian, S.A., Smith-Wheelock, M. and Raj, A. (1993) Vestibular and Balance Rehabilitation Therapy. Annals of Otology, Rhinology & Laryngology, 102, 198-205.

[46]   Alsalaheen, B.A., Mucha, A., Morris, L.O., Whitney, S.L., Furman, J.M., Camiolo-Reddy, C.E., Collins, M.W., Lovell, M.R. and Sparto, P.J. (2010) Vestibular Rehabilitation for Dizziness and Balance Disorders after Concussion. Journal of Neurologic Physical Therapy, 34, 87-93.

[47]   Gottshall, K. (2011) Vestibular Rehabilitation after Mild Traumatic Brain Injury with Vestibular Pathology. NeuroRehabilitation, 29, 167-171.

[48]   Schneider, K.J., Meeuwisse, W.H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J. and Emery, C.A. (2014) Cervicovestibular Rehabilitation in Sport-Related Concussion: A Randomised Controlled Trial. British Journal of Sports Medicine, 48, 1294-1298.

[49]   Wallace, B. and Lifshitz, J. (2016) Traumatic Brain Injury and Vestibulo-Ocular Function: Current Challenges and Future Prospects. Eye Brain, 8, 153-164.

[50]   Makdissi, M., Davis, G., Jordan, B., Patricios, J., Purcell, L. and Putukian, M. (2013) Revisiting the Modifiers: How Should the Evaluation and Management of Acute Concussions Differ in Specific Groups? British Journal of Sports Medicine, 47, 314-320.

[51]   Baker, J.G., Leddy, J.J., Darling, S.R., Rieger, B.P., Mashtare, T.L., Sharma, T. and Willer, B.S. (2015) Factors Associated with Problems for Adolescents Returning to the Classroom after Sport-Related Concussion. Clinical Pediatrics, 54, 961-968.

[52]   Covassin, T. and Elbin, R.J. (2011) The Female Athlete: The Role of Gender in the Assessment and Management of Sport-Related Concussion. Clinics in Sports Medicine, 30, 125-131.

[53]   McCrea, M., Kelly, J.P., Randolph, C., Kluge, J., Bartolic, E., Finn, G. and Baxter, B. (1998) Standardized Assessment of Concussion (SAC): On-Site Mental Status Evaluation of the Athlete. The Journal of Head Trauma Rehabilitation, 13, 27-35.