Association
Between Early Participation in Physical Activity Following Acute Concussion and
Persistent Postconcussive Symptoms in Children and Adolescents
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
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.
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.
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).
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?
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
by: Jeff Driban
Related Posts:
Are We Assessing and Managing Concussions Properly?
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
The initiation of physical activity within 7 days following concussion is interesting given the other literature on the neurometabolic cascade of events that occurs within the 7 to 10-day period following injury, and signifies a window of vulnerability in the brain. If we permit physical activity when an individual endorses persistent or worsening postconcussive symptoms, as this study reported, what would be the clinical indicator that we should decrease physical activity? In other words, clinicians use the recurrence of symptoms during a return-to-play progression as an indicator that an athlete is not at a stage of healing that permits physical activity. If symptoms do not resolve with physical activity, when should activity be decreased and when should it be re-initiated? I understand further prospective studies are needed…just food for thought.
I believe the previous commenters bring up some really good points.
1. It is difficult to compare 5 year old patients to 18 year old patients.
2. How do we define light physical activity
3. At what point do we consider early physical activity.
The authors did succeed in screening a large cohort of pediatric patients. 8,046 were screened and 2,413 completed all of the prospective outcome measures. They also did try include many centers. The recruited from 9 different emergency departments. However, the wide age range is limiting. To overcome this barrier they calculated a propensity score. Propensity score methods replace an entire set of baseline characteristics with a single composite score, and this can be accomplished with numbers of potential confounders in excess of what is possible with conventional regression methods. They included predictors of early activity using multivariate logistic regression to calculate the propensity score: age group, sex, duration of prior concussion (no prior concussion or concussion with symptoms lasting <1 week vs prior concussion with symptoms lasting ≥1 week), personal history of migraines, family history of migraines, learning disability, attention-deficit/hyperactivity disorder, developmental dis- order, anxiety, depression, sleep disorder, other psychiatric disorder, loss of consciousness duration (did not lose consciousness or loss of consciousness <3 minutes vs loss of consciousness ≥3 minutes), time between head injury and triage, seizure, early symptoms on the Acute Concussion Evaluation (appears dazed and confused, confused about events, answers questions slowly, repeats questions, forgetful), balance tandem stance (0-3 errors vs ≥4 errors or physically unable), sports injury, all 20 parent reported indicators of the Postconcussion Symptom Inventory,16 and site.
Therefore, the authors did try and consider every possible confounding variable; however, since this would result in a decrease in the number of patients they recruit they resorted to controlling it statistically.
It is difficult to ascertain what constitutes light versus moderate. An 8 year old may think running an 8 minute mile is moderate but an 18 year old another may think that is very light (or vice versa). The authors did try and control the categories the best they could, but that is certainly a limitation. I think in general they still were able to demonstrate the resumption of activity no matter the level was associated to a lower risk of PPCS compared with no activity.
To the last point many positions statements adhere to the conservative treatment of concussions where you do not start progressing them until the athlete is s/s free. However, I must bring up 2 main points.
1. It is still subjective. The athlete could say they are not having any s/s and progress anyway.
2. There is no evidence to back those statements in the position statements.
A more recent report (Thomas et al., 2015-https://pediatrics.aappublications.org/content/pediatrics/early/2015/01/01/peds.2014-0966.full.pdf) stated that For individuals 11 to 22 years of age, strict rest after a concussion had no added benefit compared to 1-2 days of rest before the stepwise program. Again, suggesting that it may not be healthy for our athletes to have complete physical and cognitive rest.
With all that being said more research needs to be conducted on what point and how much activity should we allow a concussed athlete to participate in. I do not think I would want to allow my concussed athlete to ride a bike at a low speed for 10 minutes if they are reporting 11 s/s at a 5/6 pain scale. But, if they are reporting 3 symptoms around 2/6 I think I would supervise them on the bike for a little and see if the s/s go up or stay the same. Obviously, if they go up I would want him/her to come off immediately.
In the end I think we need to be open to research such as this since it is providing some evidence that supports what we need to be doing for athletes following a concussion.
This article presents some interesting findings related to recovery from concussion in children and adolescents. However, the findings are difficult to interpret and generalize due to several limitations of the study. The use of parents to report the activity levels of their children when under the age of 8 is appropriate, although I wish this method would have been applied for all participants. While children may be able to recall their actions throughout the day, it is difficult to determine if all children and adolescents would interpret the different categories of activity similarly. While some may interpret riding a stationary bike for 20 minutes as light activity, others may interpret light activity as walking around school all day. Another consideration is the wide range of participants in this study (5-18 years of age), which compared 3rd graders to high school seniors. Another concern is the instruments used to assess the student following a concussion. While the use of the post-concussion symptom inventory may be appropriate across the age range observed in this study, the use of the Child SCAT3 may not be appropriate for assessing older participants competing in high school athletics. I also would have liked to see supporting statistics for the findings that were presented in this article.
Overall, the findings of this article should be applied with serious caution. Although symptom resolution is important following a concussion, it does not indicate full and complete recovery. Symptom resolution is a milestone that is used by medical professionals to determine and track medical status, however it is not the only factor involved in full recovery and return to play following concussion. Current research supports utilizing neurocognitive and balance assessments in order to determine subtle or substantial deficits that may be present with or without presentation of symptoms.
I think this article provides some great points, but potentially overlooks one of the most important aspects of early exercise following concussion, and that is the psychosocial aspect of a concussion. For many athletes, their sport is a livelihood to them, and even provides them with their closest friends. A concussion not only prevents them from participation until symptom free, but typically clinicians recommend the athlete staying home until they are symptom free, completely removing them from their sport environment. This can be harmful on their mental health, and may even prolong or worsen symptoms, as the athlete is responding negatively to being removed from one of (if not the) most positive aspect of their life at the time. The inclusion of early exercise may be very beneficial for the fact that this exposes the athlete to their teammates, but also makes them feel as though they are contributing to the team or their personal well-being by preparing for their return to sport. The early exercise may be associated with a positive mindset, and may prevent the athlete from slipping into a state of prolonged symptoms and even depression.
With that said, I believe it is incredibly important to monitor athletes if early exercise is going to be incorporated. If symptoms worsen or persist with exercise, I think the clinician must reassess the athlete and the situation, and determine what the best course of action should be going forward. It is critical to treat each patient and concussion individually, as they may respond very differently to stimuli such as early exercise.
Tyler, great point about the psychosocial aspect of concussions and early physical activity. It would be interesting to see people study this is in more detail.
You are right. We definitely need to carefully monitor an athlete that participates in early exercise.
I think this is a very interesting study. This study has triggered a question regarding the current treatment intervention of concussion, early physical activity or rest which one is better? this study has shown that early physical activity is beneficial for concussion symptoms. However, I will just make one injunction here that what is the amount of activity that is beneficial for the athlete? It has been shown in the previous research (Majerske et al.2008) that high intensity level activity was infact deleterious for resolution of concussion symptoms. So I think this topic needs more elucidation and there is a need of more objective, good quality RCTs to determine the level or amount of activity that is beneficial. Also, I think the symptoms need to be tracked from the day1 after concussion. It is possible that some athletes might be experiencing less symptoms following Day1 or some might be experiencing more already at their baseline (Day1). So I think that needs to be tracked to really determine the scope of intervention in resolution of symptoms. I think that early physical activity can also impact athlete psychologically as well and will be beneficial for the psychological health of the athlete.
Abbis,
I agree as stated in the above comments a more clear definition of activity is necessary. Maybe defining a specific level of perceived excursion. As for the s/s I assume that is tracked every day. How do you progress from stage to stage without the s/s score; however, I think you point out that it is just not stated clearly in the literature if this is truly being done.