Multimodal vs Symptom-Specific Treatments for Concussion

(SMART Trial)

Overseen by Carolyn Emery, PhD

Age: < 65

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Academic

Recruiting

Sponsor: University of Calgary

Disqualifiers: Developmental delay, Neurological conditions, Active cancer, others

No Placebo Group

Trial Summary

What is the purpose of this trial?

Given the rising rates of concussion in youth ages 10-19 and the significant proportion of young people who remain symptomatic for months following concussion, research evaluating the efficacy of multifaceted treatment options following concussion is imperative. Studies examining the efficacy of treatment strategies following concussion in children and adults are surprisingly limited, and most focus on one treatment approach, have small sample sizes, are not randomized controlled trials, and focus on individuals with prolonged recovery (months). There is a need for a multifaceted treatment trial to examine the early implementation of treatment approaches that may reduce prolonged recovery while considering the heterogeneous presentation of symptoms and patient preferences in the sub-acute stage following concussion. Randomized controlled trials that consider a multifaceted transdisciplinary approach to treatment in the early period following concussion are needed to raise the bar regarding evidence-informed management following concussion

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.

What data supports the effectiveness of the treatment for concussion?

Research suggests that a multimodal approach, including physical therapy and neck treatment, can help manage symptoms like headache, dizziness, and neck pain in people with persistent post-concussion symptoms. Studies indicate that these treatments can improve or sustain symptom relief over time, although some symptoms may recur. ^{1 2 3 4 5}

Is the multimodal or symptom-specific treatment for concussion safe for humans?

Research indicates that treatments involving physical therapy and multidisciplinary care for concussion, including neck treatment and symptom-specific approaches, are generally safe. Participants in studies reported improvements in symptoms like headache, dizziness, and neck pain, although some experienced recurrent symptoms over time. ^{1 2 3 6 7}

How is the Multimodal vs Symptom-Specific Treatments for Concussion unique compared to other treatments?

This treatment is unique because it combines multiple approaches, such as physical therapy, vestibular rehabilitation, and symptom-specific treatments for dizziness, neck pain, headaches, and sleep disturbances, to address the diverse symptoms of post-concussion syndrome. This comprehensive, multidisciplinary approach aims to improve recovery by targeting the specific needs of each patient, unlike standard treatments that may focus on only one aspect of the condition. ^{1 2 3 5 8}

Research Team

Carolyn Emery, PhD

Principal Investigator

University of Calgary

Eligibility Criteria

The SMART Concussion Trial is for young people aged 13-19 who've had a concussion with symptoms like headaches, dizziness, or neck pain lasting over a week but less than three weeks. They must be able to communicate in English and have access to a smartphone or computer. Those with severe brain injuries, certain medical conditions, or an inability to participate in physical activities due to reasons other than the concussion cannot join.

Inclusion Criteria

I've had moderate to severe dizziness, neck pain, headaches, or sleep issues for 1-3 weeks.

If you have memory loss from an injury for less than a day, you cannot participate.

If your Glasgow Coma Scale score is between 13 and 15.

Exclusion Criteria

I currently have active cancer.

Inability to provide informed consent

I do not have uncontrolled rheumatologic, inflammatory, or neurologic disorders, fibromyalgia/chronic fatigue syndrome, coagulopathy, or immunosuppression.

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

2 weeks

1 visit (in-person)

Treatment

Participants receive symptom-specific or multimodal treatment for up to 6 weeks, including headache treatment, dizziness/neck pain treatment, or a combination of physiotherapy and cognitive-behavioral interventions.

6 weeks

6 sessions (in-person or virtual)

Follow-up

Participants are monitored for safety and effectiveness after treatment, with assessments of symptom changes and quality of life.

6 weeks

2 visits (virtual)

Long-term Follow-up

Participants are monitored for return to unrestricted physical activity and long-term outcomes.

3 months

Treatment Details

Interventions

• Generic Concussion Treatment (Behavioral Intervention)
• Symptom-specific Dizziness &/or Neck Pain Treatment (Other)
• Symptom-specific Headache Treatment (Procedure)
• Symptom-specific Sleep Disturbance Treatment (Behavioral Intervention)

Trial Overview This trial tests multiple treatments for concussions in youth. It's looking at how effective different symptom-specific approaches are when started early after injury. The study uses randomized controlled methods meaning participants are randomly assigned to treatment groups without choosing which one they receive.

Participant Groups

Group I: Multimodal Treatment Experimental Treatment 1 Intervention

The multimodal treatment consists of 6 treatment sessions that will combine basic physiotherapy exercises to address dizziness and balance problems, training in deep breathing, progressive muscle relaxation, visualization to address headache, sleep hygiene education to address insomnia, and cognitive-behavioral intervention and gratitude exercises to promote coping and resilience. The treatment is designed to be implemented by a variety of clinical health care professionals.

Group II: Headache Treatment Experimental Treatment 2 Interventions

Participants in the headache arm will be randomized to receive a peripheral, greater occipital nerve block with 0.5% Bupivacaine or the multimodal treatment protocol. Participants will complete a daily headache diary over the 6-week treatment period, following a link on their mobile device. Patients receiving a nerve block will have weekly over-the-phone or virtual check-ins by the study team to evaluate for any side effects, pain, as needed medications, and study compliance. These patients will be given supplemental HA education as needed. Participants receiving the block will be offered a second block at 6 weeks if they meet the following criteria: a. no side effects with the first block, b. participant received relief from the first block and prefers a second, and c. headache is still occurring at least once per week. Participants randomized to the multimodal treatment portion, will have up to 6 weeks of scheduled multimodal treatment sessions.

Group III: Dizziness and/or Neck Pain Treatment Experimental Treatment 2 Interventions

Participants will be randomized to receive cervicovestibular physiotherapy (CV PT) or the multimodal treatment program. The CV PT group will participate in a combination of cervical spine and vestibular rehabilitation as per a standardized treatment algorithm based on individual assessment findings for six weeks. This form of therapy combines treatment techniques for both the cervical spine and vestibular system that are commonly used in physiotherapy practice. Cervical spine treatments may include neuromotor retraining, sensorimotor retraining, manual therapy, soft tissue techniques, and range of motion exercises. Vestibular rehabilitation may include gaze stabilization, habituation, standing balance, and dynamic balance.

Generic Concussion Treatment is already approved in Canada for the following indications:

Approved in Canada as Generic Concussion Treatment for:

• Symptomatic relief for post-concussion syndrome
• Rehabilitation for concussion-related injuries

Who Is Running the Clinical Trial?

University of Calgary

Lead Sponsor

Trials

827

Recruited

902,000+

Dr. Shweta Patel

University of Calgary

Chief Medical Officer since 2020

MD from the University of Baroda Medical College, India

Dr. Edward McCauley

University of Calgary

President and Vice-Chancellor since 2018

PhD in Ecology and Evolutionary Biology from the University of California, Santa Barbara

Canadian Institutes of Health Research (CIHR)

Collaborator

Trials

1,417

Recruited

26,550,000+

Dr. Paul C. Hébert

Canadian Institutes of Health Research (CIHR)

Chief Executive Officer

MD, University of Ottawa

Dr. Paul C. Hébert

Canadian Institutes of Health Research (CIHR)

Chief Medical Officer

MD, University of Ottawa

Findings from Research

In a study of 11 individuals with persistent concussion symptoms, neck treatment as part of multidisciplinary care led to sustained improvements in post-concussion symptoms over 6 and 12 months.

While most participants found neck treatment beneficial for their recovery, 7 out of 11 reported recurring headaches, neck pain, or dizziness, indicating that while neck treatment is helpful, some symptoms may persist long-term.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Can the neck contribute to persistent symptoms post concussion? Long-term follow up from a prospective descriptive case series. Kennedy, E., Chapple, C., Quinn, D., et al.[2022]

A multidisciplinary approach is essential for effectively managing concussions in children and adolescents, highlighting the importance of Physical Therapists in the recovery process.

Targeted treatments such as vestibular rehabilitation, cervicogenic rehabilitation, and exertional training can help alleviate common concussion symptoms like headache, dizziness, and balance dysfunction.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Role of Physical Therapy in Concussion Rehabilitation. Brown, L., Camarinos, J.[2020]

A comprehensive physical therapy approach, including manual therapy, vestibular rehabilitation, and neuromotor retraining, effectively improved symptoms and function in a 21-year-old male with chronic post-concussion syndrome (PCS) after nearly a year without treatment.

After eight sessions over five weeks, the patient's postural stability and cervical range of motion improved significantly, and his symptom severity score dropped from 20 to 2, indicating substantial recovery except for persistent headaches.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Utility of Neuromotor Retraining to Augment Manual Therapy and Vestibular Rehabilitation in a Patient with Post-Concussion Syndrome: A Case Report. Teare-Ketter, A., LaForme Fiss, A., Ebert, J.[2023]

A new treatment-based profiling model has been proposed to assist physical therapists in managing patients after a concussion, focusing on symptom type, intensity, and movement response.

The model emphasizes three key treatment areas: symptom management, movement system optimization, and performance optimization, which can help therapists make informed decisions tailored to individual patient needs.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A Treatment-Based Profiling Model for Physical Therapy Management of Patients Following a Concussive Event. Alsalaheen, B., Landel, R., Hunter-Giordano, A., et al.[2020]

Posttraumatic headaches after traumatic brain injury can be effectively managed with treatments similar to those for migraines, and adding physical therapy may enhance recovery.

For dizziness and balance issues caused by vestibular dysfunction, vestibular physical therapy is the primary treatment approach, highlighting the importance of targeted rehabilitation in recovery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Rehabilitation Assessment and Management of Neurosensory Deficits After Traumatic Brain Injury in the Polytrauma Veteran. Bhatnagar, S., Anderson, M., Chu, M., et al.[2018]

References

1. England pubmed.ncbi.nlm.nih.gov

Can the neck contribute to persistent symptoms post concussion? Long-term follow up from a prospective descriptive case series. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

The Role of Physical Therapy in Concussion Rehabilitation. [2020]

3. Netherlands pubmed.ncbi.nlm.nih.gov

Postconcussion syndrome. [2019]

4. United States pubmed.ncbi.nlm.nih.gov

Osteopathic Manipulative Treatment Relieves Post-concussion Symptoms in a Case of Polytrauma. [2020]

5. United States pubmed.ncbi.nlm.nih.gov

The Utility of Neuromotor Retraining to Augment Manual Therapy and Vestibular Rehabilitation in a Patient with Post-Concussion Syndrome: A Case Report. [2023]

6. United States pubmed.ncbi.nlm.nih.gov

Concussion in Combination With Whiplash-Associated Disorder May Be Missed in Primary Care: Key Recommendations for Assessment and Management. [2020]

7. United States pubmed.ncbi.nlm.nih.gov

A Treatment-Based Profiling Model for Physical Therapy Management of Patients Following a Concussive Event. [2020]

8. United States pubmed.ncbi.nlm.nih.gov

Rehabilitation Assessment and Management of Neurosensory Deficits After Traumatic Brain Injury in the Polytrauma Veteran. [2018]