Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial
Leddy JJ, Haider MN, Ellis MJ, Mannix R, Darling SR, Freitas MS, Suffoletto HN, Leiter J, Cordingley DM, Willer B. JAMA Pediatr. 2019; [Epub ahead of print]
Randomized Controlled Trial Evaluating Aerobic Training and Common Sport-Related Concussion Outcomes in Healthy Participants.
Teel EF, Register-Mihalik JK, Appelbaum LG, Battaglini CL, Carneiro KA, Guskiewicz KM, Marshall SW, Mihalik JP. J Athl Train. 2018 Dec;53(12):1156-1165.
Take Home Message: Early sub-symptom threshold aerobic exercise training may help adolescent athletes recover faster after a concussion while not affecting concussion assessments in healthy athletes.
Aerobic exercise is a novel concussion rehabilitation method. This method is a large shift from the typically conservative rest that has been advocated; yet, many athletes with a concussion that are active have better outcomes than their sedentary peers (such as, faster sign and symptom recovery, quicker return to play). To help clinicians implement aerobic exercise after a patient’s concussion we need to know if aerobic exercise affects clinical tests that ascertain readiness to start a return-to-play protocol and causes better outcomes compared to standard of care without aerobic exercise. Therefore, Teel et al. and Leddy et al. randomized athletes to receive either subthreshold aerobic exercise or no aerobic activity. Teel and colleagues wanted to determine if aerobic exercise altered concussion outcomes among healthy adults. Meanwhile, Leddy and colleagues assessed if sub-symptom threshold aerobic exercise vs a stretching program improved outcomes among adolescents in the acute phase of recovery after a sports-related concussion (within 10 days of injury). Teel et al assessed healthy participants (~20 years of age; 50% female) at 2 testing sessions 14 days apart. Participants completed the CNS Vital Signs, Standardized Assessment of Concussion, Balance Error Scoring System, Graded Symptom Checklist, and Vestibular/Ocular Motor Screening at both time points. Between sessions, participants completed 6, 30-minute sessions of either submaximal stationary bike exercise (60-80% VO2max; 20 people) or no intervention (20 people). Meanwhile, Leddy et al instructed athletes (~15 years of age; 47% female) with a concussion to wear a fitness monitor and complete the (52 athletes) or a stretching program (51 athletes) for 20 minutes a day, and report symptoms online every day for 30 days. The authors’ main outcome was days between injury and recovery (defined as being asymptomatic with a confirmed recovery by a physician that was unaware of treatment assignment). Teel et al. found that athletes in the exercise group reported fewer signs and symptoms, better cognitive reports, and improved near point convergence compared to the no intervention group. However, the group differences were small, and the authors suggested that the differences were not clinically meaningful. Leddy et al found that athletes within the excise group recovered in ~13 days compared to the stretching group that recovered in ~17 days.
Generally, Leddy and colleagues reported that aerobic activity after a brief period of rest (~2 days) is relatively safe, affordable, and an easy strategy to implement during a concussion rehabilitation program. Specifically, athletes performing aerobic exercise recovered faster than the stretching group and were compliant with the program. These findings suggest that aerobic exercise could facilitate faster recovery and help prevent delayed recovery that could have longer detrimental effects (social, emotional problems). These findings were supported by evidence offered by Teel et al. that clinical outcome measures are unaffected by aerobic activity and can probably be relied on in trials like the one Leddy and colleagues completed. Currently, medical professionals should identify a protocol that would be best for their population. They should also ensure that early sub-symptom threshold aerobic exercise with symptom reporting is used to prepare a patient for a return-to-play progression and not replace a return-to-play protocol.
Questions for Discussion: Have you started to implement aerobic exercise for athletes that suffered a concussion? If so, what outcomes have you seen? If not, what concerns do you have that have yet to be addressed?
Written by: Jane McDevitt
Reviewed by: Jeffrey Driban