Medscape.com: Physical Activity Better Than Rest After Youth Concussion
www.medscape.com Physical Activity Better Than Rest After Youth Concussion Megan BrooksDecember 23, 2016 Rest may not be best after acute concussion in children and adolescents, according to a study from the Pediatric Emergency Research Canada Concussion Team that has the potential to change concussion management. The study found that resuming some physical activity within 7 days of concussion was associated with lower rates of persistent postconcussive symptoms (PPCS) at 28 days, compared with no physical activity. The finding was consistent across analytic approaches and intensity of exercise. "In my opinion, these findings suggest that the current practice of keeping children out of physical activity for weeks (or months) until children are fully asymptomatic should change," lead investigator Roger Zemek, MD, FRCPC, clinical research chair in pediatric concussion, University of Ottawa, and director, clinical research unit, Children's Hospital of Eastern Ontario, Canada, told Medscape Medical News. The study was published December 20 in JAMA. Rest has long been the cornerstone of concussion management, and pediatric guidelines recommend an initial period of physical rest following a concussion until symptoms resolve. However, "no clear evidence has determined that avoiding physical activity expedites recovery," the investigators note in their article. They studied the association between participation in physical activity within 7 days after injury and incidence of PPCS in a prospective multicenter cohort study. Participants included patients aged 5 to 17 years who sustained an acute concussion and were evaluated at 9 Pediatric Emergency Research Canada network emergency departments. PPCS was defined as the presence of 3 or more new or worsening concussion symptoms 28 days after injury. Among 2413 participants, 733 (30.4%) developed PPCS. At day 7 after injury, 1677 patients (69.5%) reported some type of physical activity, mainly light aerobic exercise (32.9%), but also sport-specific exercise (8.9%), noncontact drills (5.9%), full contact practice (4.4%), and full competition (17.4%). The remaining 736 participants (30.5%) reported no physical activity. In unadjusted analyses, the risk for PPCS was lower in the early activity group than in the no-activity group (24.6% vs 43.5%; absolute risk difference [ARD], 18.9 percentage points). Early physical activity also appeared protective against PPCS in the propensity score matching analysis (28.7% vs 40.1%; ARD, 11.4 percentage points) and inverse probability of treatment weighting analysis (relative risk for PPCS with early activity, 0.74; 95% confidence interval, 0.65 - 0.84). "Good Medicine" "We know that there are physiological, psychological, and functional benefits of early physical rehabilitation in other disease processes, such as stroke, which is an example of a severe traumatic brain injury," Dr Zemek told Medscape Medical News. "Some physiological reasons why physical activity may be better than rest may include improved cerebral blood flow and the release of factors during exercise which promote neuroplasticity and brain healing. Psychologically, getting released from 'home jail' may also be an important factor in that it may reinforce the message that they are going to get better. In general, exercise is a good medicine," he explained. Dr Zemek said future research will need to confirm the ideal timing, type, and intensity of an early exercise protocol after concussion. "For most children it will likely be beneficial to begin with a short walk several days after their injury," he said. "However, regardless of the potential benefit of early physical activity, the current policy of safety and caution in the immediate postinjury period should not change; patients should always be removed from the field of play if a concussion is suspected. Further, return to participation activities that might introduce risk for collision (such as contact sports) or falls (such as skiing, skating) should remain prohibited until the patient has been cleared by a qualified health professional," Dr Zemek told Medscape Medical News. The authors of a linked editorial note that the investigators measured gradations of physical activity (light aerobic exercise, sport-specific exercise or noncontact training drills, and full contact practice or return to competition) and found that more exercise was associated with a lower risk for PPCS. "This finding is somewhat surprising given that a bimodal relationship might be expected (ie, that some amount of exercise would be beneficial but too much would be detrimental) and does raise some concern that there might be residual confounding," write Sara Chrisman, MD, MPH, and Frederick Rivara, MD, MPH, from Seattle Children's Research Institute, Washington. "Overall, this study was carefully designed and the findings support the concept that earlier physical activity after concussion may be associated with beneficial outcomes," the editorialists say. However, they say it's also important to recognize that allowing youth recovering from concussion to engage in physical activity is very different than allowing full return to play; "any such activity must not increase the risk of another impact to the head during the vulnerable period of recovery," Dr Chrisman and Dr Rivara emphasize. "The ethical space around concussion treatment is rapidly changing," they conclude, "and not all clinicians agree about whether a randomized clinical trial of physical activity is appropriate. The next studies will need to navigate this divide and hopefully lead to more evidence-based treatment guidelines for concussion. Until then, clinicians and parents should use common sense about allowing limited physical activity as tolerated and be cautious about resting a previously active athlete for prolonged periods." The study was supported by the Canadian Institutes of Health Research. Dr Zemek, Dr Chrisman, and Dr Rivara have disclosed no relevant financial relationships. JAMA. 2016;316:2491-2492, 2504-2514. Full text, Editorial For more Medscape Neurology news, join us on Facebook and Twitter Medscape Medical News © 2016 WebMD, LLC Send comments and news tips to [email protected] Cite this article: Physical Activity Better Than Rest After Youth Concussion. Medscape. Dec 23, 2016.