Over the years, a commonality in concussion research is that greater than 70% of concussion injuries clear up in under 2 weeks. The challenge has been managing those individuals whose concussions last longer.
Zemek et al released a study in 2016 (see previous post) which categorized the risk of persistent post concussion symptoms (PPCS) at greater than 28 days in children aged 5-18 years. In their study, the key traits were:
- Age >12
- Female
- Prior concussion or symptoms longer than 1 week
- Physician DX migraine hx
- Answering questions slowly
- BESS tandem score of >4 errors
- Headaches
- Sensitivity to noise
- Fatigue
For years the conventional treatment for concussions has been complete rest until symptoms were over, including recommendations from the 4th International Concussion in Sport Consensus statement as well as the American Academy of Pediatrics. A growing body of evidence is calling this practice into questions\, and focusing on the benefits of activity.
Grool et al in a December 2016 publication in JAMA evaluated the effects of early participation in physical activity in children aged 5-18. They found that physical activity within 7 days of the acute injury compared with traditional; no activity was associated with a reduced risk of PPCS at 28 days.
Common activities in the study included light aerobic exercise, sports specific exercises and non contact drills.
Of those who began physical activity early, at day 7 31% were symptom free and 48% had 3 persistent post concussion symptoms. By comparison, in those who rested in the 1st week, 80% had at least 3 PPCS. By the end of day 28, those with at least 3 PPCS included 29% in the activity group and 40% in the resting group.
The key was that the activity was performed at a level that did not exacerbate symptoms, and by no means indicate that an athlete can immediately return to full sports activities, especially contact sports.
The researchers theorized that the early activity may have been helpful in several ways:
- Improve cerebral blood flow
- Promote neuroplasticity
- Release brain healing endorphins
- Psychological benefits, especially for active individuals
Although this study provides some ground breaking evidence, it was an observational study versus a randomized control study (RCT), meaning more study is needed to better evaluate the short and long term effects of early activity. What is not known is whether exercise is better, but we do understand that strict rest is not the best way either.
Leddy et al at the University of Buffalo has been evaluating the effects of graded exercise post concussion since 2007. Previous reports showed that individualized graded exercise using a modified treadmill protocol has been beneficial in the recovery of athletes greater than 3 weeks post concussion. They are currently conducting an RCT of individualized exercise for sports concussion in adolescents within the 1st week after injury with the hypothesis that early controlled exercise below the symptom threshold will speed up recovery from a concussion.
Look for results near the end of 2017!
References:
Zemek et al.Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.
Grool et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016; 316(23):2504-2514
Efan Gonsalves PT 