Purpose: To describe physical examination (PE) findings of individuals with protracted concussion recovery and evaluate an integrated primitive reflex (PR) disinhibition, vision, and vestibular rehabilitation intervention. Method: Retrospective study of 82 patients with protracted concussion (60.98% female) who received ≥ 2 phases of treatment. Following a baseline PE, patients completed the Post-Concussion Symptom Survey (PCSS), Activities-Based Balance Confidence Questionnaire (ABC), Dizziness Handicap Index (DHI), and Acquired Traumatic Brain Injury (aTBI) Vision Questionnaire. A subset of patients (Group 1), completed a final PE and second questionnaire administration. Descriptive statistics characterized the sample. T-tests and Wilcoxon rank sum tests compared characteristics of Group 1 vs Group 2. Wilcoxon sign rank tests assessed changes in patient-reported outcomes. Results: Patients in Groups 1 (median age=23.5) and 2 (median age=17.5) were similar regarding demographic and PE findings. Statistically and clinically significant improvements were seen for Group 1: PCSS (-21 points, MCID 6.8), DHI (-27 points, MDC 17.8, MCID 19), ABC (+ 8.5 points, MDC 9)and aTBI Vision Questionnaire (-16.5 points). Conclusion: Patients with protracted concussion recovery can benefit from a multitude of interventions ranging from orthopedic to vision and vestibular interventions in order to address objective deficits and subjective complaints such as headache, dizziness, or blurry vision following a concussion. Patients who completed the full intervention demonstrated clinically significant improvements in function, including return to school/work and recreational activities. These data suggest there is a potential positive benefit to a structured, integrative concussion rehabilitation approach for individuals with protracted concussion recovery.

Author Bio(s)

Lauren Ziaks, PT, DPT, ATC is a concussion specialist at Park City Hospital with Intermountain Healthcare in Park City, UT. She specializes in vision and vestibular therapy and has helped to develop protocols for primitive reflex integration and concussion.

Chelsea Brown, PT, DPT is a physical therapist who specializes in concussion management for Boston Sports Medicine in Watertown, MA.

Maura Iversen, PT, DPT, SD, MPH is Dean and Professor in the College of Health Professions at Sacred Heart University in Fairfield, CT. She is a Behavioral Scientist and Clinical Epidemiologist in the Department of Medicine for Harvard Medical School in Cambridge, MA.


Drs. Ziaks and Brown were both employed at Wasatch Physical Therapy and Sports Medicine in Park City, UT at the time of data collection and appreciate their continued. Dr. Iversen was employed at Northeastern University in Boston, MA at the time of submission. The authors would like to thank their supervising neuro-optometrists and physician for their ongoing support in the creation of these protocols.




Submission Location


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