Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents
Grool AM, Aglipay M, Momoli F, Meehan WP 3rd, Freedman SB, Yeates KO, Gravel J, Gagnon I6, Boutis K, Meeuwisse W, Barrowman N, Ledoux AA, Osmond MH, Zemek R; Pediatric Emergency Research Canada (PERC) Concussion Team. JAMA. 2016 Dec 20;316(23):2504-2514
Take Home Message: Among children and adolescents with acute concussion, participation in physical activity within 7 days of acute injury compared with no physical activity was associated with lower risk of persistent postconcussion symptoms at 28 days post injury.
Following a concussion, many medical professionals recommend cognitive and physical rest until sign and symptoms resolve. Additionally, they typically endorse a graduated return to play program if symptoms are not exacerbated. However, there is limited evidence that following these guidelines result in a positive effect on prognosis. Therefore, the authors of this multicenter cohort study (9 Canadian Pediatric Emergency Departments) examined the association between participation in physical activity within 7 days post injury and the occurrence of persistent postconcussion symptoms (PPCS; 3 new or worsening individual symptoms compared to preconcussion status) following concussions in children and adolescents (2413 participants; 5 to 18 years old) from August 2013 to June 2015. The researchers quantified pre-injury and post injury symptoms using the post concussion symptom inventory (PCSI), and evaluated cognitive status, balance, and physical examination using the Child-Sport Concussion Assessment Tool (Child-SCAT3). Then, researchers followed up with participants about their activity level and PPCS through a web-based survey or telephone interview at 7 and 28 days post enrollment using questions based on the Consensus Statement on Concussion in Sport Return-to-Play. Parents completed the survey for children under 8 while older children completed the survey. Early physical activity subcategories were defined as no activity, light aerobic exercise, moderate exercise (sport specific drills, non contact training), or full exercise (full contact/full return to play). Nearly 70% of the participants reported participating in early physical activity. Most participated in light activity (33%) followed by return to full competition (17%), sport specific exercise (9%), and non-contact drills (6%). Forty-eight percent of the participants that engaged in early activity reported 3 persistent or worsening concussion symptoms at day 7, whereas 80% of the participants that reported no physical activity had at least 3 persistent or worsening concussion symptoms at day 7. Among participants who were symptomatic at day 7, those who engaged in physical activity during the first week (803 participants, 43%) were less likely to have PPCS at 28 days post injury compared with those who reported no physical activity (584 participants, 53%). This finding was less impressive when the authors matched participants on baseline characteristics or tried to analyze the data to represent a broader population.
The authors of this study sought to determine if restricting physical activity was associated with a decreased rate of PPCS , and the authors found that the resumption of physical activity within 7 days post injury may be associated with a lower risk of PPCS compared with no physical activity. This finding was consistent across intensity of exercise but was less impressive when the authors conducted more advance analyses. Regardless, the authors consistently showed that physical activity did not increase the risk for PPCS among athletes who had symptoms at 7 days. The authors noted that physical activity is considered an effective method for improving cognitive function and brain health, and suggested that controlled aerobic exercise may improve recovery by restoring normal cerebral blood flow regulation, and physical deconditioning may contribute to the development of PPCS after a concussion in youth athletes. However, medical professionals should proceed with caution. Physical activity was self-reported and no further objective data on the activity was provided. Therefore, to identify causation we need a well-designed, randomized control trial to confirm the benefits of early physical activity. At this time medical professionals should be aware that strict cognitive and physical rest may not be the best treatment and should continue to investigate concussion rehabilitation strategies supported by research (e.g., vestibular ocular rehabilitation, proprioception exercises).
Question for Discussion: Would you consider adding physical activity to concussion rehabilitation before they start progressing through the RTP program? If so what types of exercises would you start with?
Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban
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Grool AM, Aglipay M, Momoli F, Meehan WP 3rd, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W, Barrowman N, Ledoux AA, Osmond MH, Zemek R, & Pediatric Emergency Research Canada (PERC) Concussion Team. (2016). Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA, 316 (23), 2504-2514 PMID: 27997652