Concussion Paradigm Change - Rest Is Bad

Short Attention Span Summary

OK, just forget everything you were taught...
Remember just a few weeks ago when I said rest for concussion was good?  Forget that.  In children and adolescents, physical and cognitive rest are often prescribed as treatment for concussion.  However, in this prospective study of kids aged 5-18 years, early physical activity in the first week after concussion decreased the incidence of prolonged post-concussive symptoms at 28 days, NNT = 5.

Spoon Feed: Physical rest after concussion appears to be unhelpful, even harmful, in children and young people after concussion.  This is a major paradigm shift.


Abstract

JAMA. 2016 Dec 20;316(23):2504-2514. doi: 10.1001/jama.2016.17396.

Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents.

Grool AM1, Aglipay M1, Momoli F1, Meehan WP 3rd2, Freedman SB3, Yeates KO4, Gravel J5, Gagnon I6, Boutis K7, Meeuwisse W8, Barrowman N1, Ledoux AA1, Osmond MH9, Zemek R9; Pediatric Emergency Research Canada (PERC) Concussion Team.

Author information:

1Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.

2Sports Concussion Clinic, Boston Children's Hospital, Boston, Massachusetts.

3Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada.

4Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada.

5Department of Pediatrics, Hospital Ste Justine, University of Montreal, Montreal, Quebec, Canada.

6Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.

7Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.

8Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.

9Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.

Abstract

Importance:

Although concussion treatment guidelines advocate rest in the immediate postinjury period until symptoms resolve, no clear evidence has determined that avoiding physical activity expedites recovery.

Objective:

To investigate the association between participation in physical activity within 7 days postinjury and incidence of persistent postconcussive symptoms (PPCS).

Design, Setting, and Participants:

Prospective, multicenter cohort study (August 2013-June 2015) of 3063 children and adolescents aged 5.00-17.99 years with acute concussion from 9 Pediatric Emergency Research Canada network emergency departments (EDs).

Exposures:

Early physical activity participation within 7 days postinjury.

Main Outcomes and Measures:

Physical activity participation and postconcussive symptom severity were rated using standardized questionnaires in the ED and at days 7 and 28 postinjury. PPCS (≥3 new or worsening symptoms on the Post-Concussion Symptom Inventory) was assessed at 28 days postenrollment. Early physical activity and PPCS relationships were examined by unadjusted analysis, 1:1 propensity score matching, and inverse probability of treatment weighting (IPTW). Sensitivity analyses examined patients (≥3 symptoms) at day 7.

Results:

Among 2413 participants who completed the primary outcome and exposure, (mean [SD] age, 11.77 [3.35] years; 1205 [39.3%] females), PPCS at 28 days occurred in 733 (30.4%); 1677 (69.5%) participated in early physical activity including light aerobic exercise (n = 795 [32.9%]), sport-specific exercise (n = 214 [8.9%]), noncontact drills (n = 143 [5.9%]), full-contact practice (n = 106 [4.4%]), or full competition (n = 419 [17.4%]), whereas 736 (30.5%) had no physical activity. On unadjusted analysis, early physical activity participants had lower risk of PPCS than those with no physical activity (24.6% vs 43.5%; Absolute risk difference [ARD], 18.9% [95% CI,14.7%-23.0%]). Early physical activity was associated with lower PPCS risk on propensity score matching (n = 1108 [28.7% for early physical activity vs 40.1% for no physical activity]; ARD, 11.4% [95% CI, 5.8%-16.9%]) and on inverse probability of treatment weighting analysis (n = 2099; relative risk [RR], 0.74 [95% CI, 0.65-0.84]; ARD, 9.7% [95% CI, 5.7%-13.7%]). Among only patients symptomatic at day 7 (n = 803) compared with those who reported no physical activity (n = 584; PPCS, 52.9%), PPCS rates were lower for participants of light aerobic activity (n = 494 [46.4%]; ARD, 6.5% [95% CI, 5.7%-12.5%]), moderate activity (n = 176 [38.6%]; ARD, 14.3% [95% CI, 5.9%-22.2%]), and full-contact activity (n = 133 [36.1%]; ARD, 16.8% [95% CI, 7.5%-25.5%]). No significant group difference was observed on propensity-matched analysis of this subgroup (n = 776 [47.2% vs 51.5%]; ARD, 4.4% [95% CI, -2.6% to 11.3%]).

Conclusions and Relevance:

Among participants aged 5 to 18 years with acute concussion, physical activity within 7 days of acute injury compared with no physical activity was associated with reduced risk of PPCS at 28 days. A well-designed randomized clinical trial is needed to determine the benefits of early physical activity following concussion.

PMID: 27997652 [PubMed - in process]