A Novel Approach to Integrative Concussion Rehabilitation: A Pragmatic Study

Research Article

Phys Med Rehabil Int. 2024; 11(1): 1222.

A Novel Approach to Integrative Concussion Rehabilitation: A Pragmatic Study

Lauren Ziaks¹*; Jenna Tucker²; Thomas Koc²; Meaghan Dowdell²; Giana Giorello²

¹Intermountain Rehabilitation Services, Park City Hospital, Intermountain Health, USA

²Department of Physical Therapy, Kean University, USA

*Corresponding author: Lauren Ziaks Intermountain Rehabilitation Services, Park City Hospital, Intermountain Health, 900 Round Valley Drive, Park City, Utah 84049, USA Tel: 435-658-7350; Fax: 435-658-7360 Email: [email protected]

Received: December 08, 2023 Accepted: January 18, 2024 Published: January 25, 2024


Purpose: The purpose of this study is to evaluate the effectiveness of the novel Ziaks Integrative Neurological Concussion (ZINC) Protocol in evaluating and treating persistent post-concussion symptoms.

Methods: Individuals with concussion were systematically evaluated for neurological impairments and subsequently received six modules of integrative and progressive therapies. Treatment addressed motor function impairment, oculomotor and binocular vision deficits, and central vestibular deficits while incorporating postural stability, dual task and cognitive loading skills and providing instruction in cardiovascular exercise to promote autonomic stability.

Results: Of 30 patients, 15 completed all 6 protocol modules for inclusion in data analysis. Mean treatment duration was 6.6 (SD±.99) visits over 69.53 days (SD±21.92). The Post-Concussion Symptom Scale and Dizziness Handicap Inventory outcomes from pre- to post-treatment achieved clinical and statistical significance. Statistical significance was achieved for the Brain Injury Vision Symptom Survey, Brock String near point of convergence, King Devick and the novel binocular vision screening tool.

Conclusions: A structured, integrative, and progressive rehabilitation program addressing the vestibulo-oculomotor and motor function domains of concussion may be effective in the management of persistent post-concussion symptoms.

Impact Statement: This study details one potential comprehensive and sequential method to integrate the neurological domains of concussion rehabilitation while screening for impairments in the physical domains. There is a gap in knowledge regarding the most effective timing, sequencing, and implementation of intervention methods across the 4 concussion domains. This study provides the groundwork for future research to establish treatment protocols aimed to efficiently reduce symptoms associated with persistent post-concussion symptoms.

Keywords: Rehabilitation; Brain injury; Vestibular; Oculomotor; Motor function

Abbreviations: PPCS: Persistent Post-Concussion Symptoms; CPG: Clinical Practice Guidelines; PT: Physical Therapy; BPPV: Benign Paroxysmal Positional Vertigo; BBI: Brain-Body Integration; ZINC: Ziaks Integrative Neurological Concussion; PCSS: Post Concussion Symptom Scale; DHI: Dizziness Handicap Inventory; BIVSS: Brain Injury Vision Symptom Survey; MCID: Minimal Clinically Important Difference; mCTSIB: Modified Clinical Test of Sensory Interaction and Balance; KD: King Devick; HEP: Home Exercise Program; VOMS: Vestibulo-Oculomotor Screen; NPC: Near Point of Convergence; SD: Standard Deviation


Concussions are complex injuries with a wide-range of symptoms that can involve the musculoskeletal, nervous, cardiovascular and/or psychological systems [1,2]. Most adults demonstrate full recovery within 1-2 weeks, however, 5-58% can experience symptoms for weeks or months after injury, now referred to as Persistent Post-Concussion Symptoms (PPCS) [2,3].

Historical treatment protocols focused on rest during the acute period, but recent studies demonstrate that an active rehabilitation approach is more beneficial for recovery [4-7]. The 2020 Clinical Practice Guidelines (CPG) for Physical Therapy (PT) evaluation and treatment of concussion provides evidence supporting serial evaluations for dysfunction across 4 functional domains: cervical musculoskeletal, vestibulo-oculomotor, autonomic/exertional intolerance, and motor function [2].

However, it identifies knowledge gaps for preferred evaluation strategies, recommended intervention approaches and sequencing multimodal treatment interventions, which can be complicated by the interrelationship of the vestibular, visual, and musculoskeletal systems [8].

A multifaceted evaluation used to create an individualized treatment plan can promote quicker clinical improvement, specifically in those with PPCS; however few studies have assessed effectiveness of combined interventions [9,10]. Level one evidence supports the efficacy of subthreshold aerobic exercise in reducing PPCS, with less robust research available to guide clinicians in sequencing individualized multimodal treatment plans for the remaining domains [9,11,12].

Due to the heterogeneity of concussion symptoms presenting in multiple concussion domains, adapting an individualized treatment protocol that combines the benefits of subthreshold graded aerobic exercises while addressing the other domains is warranted. Cervical musculoskeletal and vestibulo-ocular PT care models have been proposed to address this gap. Multiple studies have concluded that addressing cervical spine limitations and Benign Paroxysmal Positional Vertigo (BPPV) symptoms, integrated with visual and vestibular rehabilitation, can improve clinical and patient-reported outcomes across all systems [13,14]. In addition, Ziaks et al 2021 proposed that phased primitive reflex integration therapy targeting complex movements and Brain-Body Integration (BBI) as a precursor to vision and vestibular therapy can have improved motor function post-concussion [15]. This study expanded on the integrated vision and vestibular protocol introduced by Ziaks et al in 2019, to include a BBI protocol derived from primitive reflex integration research, theorized to target the moro reflex, asymmetrical tonic neck reflex, symmetrical tonic neck reflex, tonic labyrinthine reflex, and spinal galant reflex (Figure 1) [15,16].