Early physical activity and clinical outcomes following pediatric sportrelated concussion
Objective: To evaluate clinical outcomes among patients who did and did not report engaging in early physical activity (PA) following sport-related concussion.
Methods: We evaluated pediatric patients seen within 21 days of concussion. The independent variable was early PA engagement (since the injury and prior to initial clinical evaluation). Dependent variables included demographics, injury details, medical history, Health and Behavior Inventory (HBI) score, and balance, vestibular, and oculomotor function tests.
Results: We examined data from 575 pediatric patients: 69 (12%) reported engaging in early PA (mean age=14.3±2.4 years; 30% female). The no PA group (mean age=14.5±2.4 years; 35% female) had significantly longer symptom resolution times than the early PA group (median= 16 [interquartile range (IQR)= 8-24] vs. 10.5 [IQR= 4-17] days; p=0.02). When controlling for pre-existing headache history and time from injury-evaluation time, the early PA group demonstrated lower odds of reporting current headache (adjusted odds ratio=0.14; 95% CI=0.07, 0.26), and reported lower symptom frequency ratings than the no PA group (β= -5.58, 95% CI=-8.94, -2.22).
Conclusions: Patients who did not engage in early PA had longer symptom duration, greater odds of post-injury headache, and greater symptoms at initial clinical evaluation. We cannot determine if patients engaged in early PA due to lower symptom burden and higher functioning at the time of assessment, or if early PA positively affected outcomes. However, as early PA was associated with better post-injury outcomes, clinicians may consider supervised and structured early PA programs as a method to improve clinical outcomes following concussion.
Relevance for patients: Children and adolescents who were engaged in PA after concussion presented to a clinic with less severe symptoms and had symptoms that resolved sooner compared to those who did not engage in early PA after concussion.
[1] Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F. Seattle Sports Concussion Research Collaborative. Sports and Recreation-related Concussions in US Youth. Pediatrics 2016;138:e20154635.
[2] McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus Statement on Concussion in Sport the 5th International Conference on Concussion in Sport Held in Berlin, October 2016. Br J Sports Med 2017;51:838-47.
[3] Harmon KG, Clugston JR, Dec K, Hainline B, Herring S, Kane SF, et al. American Medical Society for Sports Medicine Position Statement on Concussion in Sport. Br J Sports Med 2019;53:213-25.
[4] Rozbacher A, Selci E, Leiter J, Ellis M, Russell K. The Effect of Concussion or Mild Traumatic Brain Injury on School Grades, National Examination Scores, and School Attendance: A Systematic Review. J Neurotrauma 2017;34:2195-203.
[5] Howell DR, Oldham JR, Brilliant AN, Meehan WP 3rd. Trouble Falling Asleep After Concussion is Associated with Higher Symptom Burden among Children and Adolescents. J Child Neurol 2019;34:256-61.
[6] Raikes AC, Schaefer SY. Sleep Quantity and Quality during Acute Concussion: A Pilot Study. Sleep 2016;39:2141-7.
[7] Howell DR, Wilson JC, Kirkwood MW, Grubenhoff JA. Quality of Life and Symptom Burden 1 Month After Concussion in Children and Adolescents. Clin Pediatr (Phila) 2019;58:42-9.
[8] Haran HP, Bressan S, Oakley E, Davis GA, Anderson V, Babl FE. On-field Management and Return-to-play in Sports-related Concussion in Children: Are Children Managed Appropriately? J Sci Med Sport 2016;19:194-9.
[9] Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, et al. Rest and Treatment/ Rehabilitation Following Sport-related Concussion: A Systematic Review. Br J Sports Med 2017;51:930-94.
[10] McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorák J, Echemendia RJ, et al. Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-8.
[11] Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018;172:e182853.
[12] Howell DR, Mannix RC, Quinn B, Taylor JA, Tan CO, Meehan WP. Physical Activity Level and Symptom Duration are not Associated after Concussion. Am J Sports Med 2016;44:1040-6.
[13] Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA 2016;316:2504-14.
[14] Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest after Acute Concussion: A Randomized Controlled Trial. Pediatrics 2015;135:213-23.
[15] Kurowski BG, Hugentobler J, Quatman-Yates C, Taylor J, Gubanich PJ, Altaye M, et al. Aerobic Exercise for Adolescents With Prolonged Symptoms After Mild Traumatic Brain Injury: An Exploratory Randomized Clinical Trial. J Head Trauma Rehabil 2017;32:79-89.
[16] Cordingley D, Girardin R, Reimer K, Ritchie L, Leiter J, Russell K, et al. Graded Aerobic Treadmill Testing in Pediatric Sports-related Concussion: Safety, Clinical Use, and Patient Outcomes. J Neurosurg Pediatr 2016;25:693-702.
[17] Grabowski P, Wilson J, Walker A, Enz D, Wang S. Multimodal Impairment-based Physical Therapy for the Treatment of Patients with Post-concussion Syndrome: A Retrospective Analysis on Safety and Feasibility. Phys Ther Sport 2017;23:22-30.
[18] Dobney DM, Grilli L, Kocilowicz H, Beaulieu C, Straub M, Friedman D, et al. Evaluation of an Active Rehabilitation Program for Concussion Management in Children and Adolescents. Brain Inj 2017;31:1753-9.
[19] Leddy JJ, Hinds AL, Miecznikowski J, Darling S, Matuszak J, Baker JG, et al. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial. Clin J Sport Med 2018;28:13-20.
[20] Lawrence DW, Richards D, Comper P, Hutchison MG. Earlier Time to Aerobic Exercise is Associated with Faster Recovery Following Acute Sport Concussion. PLoS One 2018;13:e0196062.
[21] Leddy JJ, Haider MN, Ellis MJ, Mannix R, Darling SR, Freitas MS, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr 2019;173:319-25.
[22] Howell DR, Taylor JA, Tan CO, Orr R, Meehan WP. The Role of Aerobic Exercise in Reducing Persistent Sportrelated Concussion Symptoms. Med Sci Sports Exerc 2019;51:613-9.
[23] Desai N, Wiebe DJ, Corwin DJ, Lockyer JE, Grady MF, Master CL. Factors Affecting Recovery Trajectories in Pediatric Female Concussion. Clin J Sport Med 2019;29:361-7.
[24] Yeates KO, Kaizar E, Rusin J, Bangert B, Dietrich A, Nuss K, et al. Reliable Change in Postconcussive Symptoms and its Functional Consequences among Children with mild Traumatic Brain Injury. Arch Pediatr Adolesc Med 2012;166:615-22.
[25] Ayr LK, Yeates KO, Taylor HG, Browne M. Dimensions of Postconcussive Symptoms in Children with Mild Traumatic Brain Injuries. J Int Neuropsychol Soc 2009;15:19-30.
[26] Patsimas T, Howell DR, Potter MN, Provance AJ, Kirkwood MW, Wilson JC. Concussion-Symptom Rating Correlation between Pediatric Patients and Their Parents. J Athl Train 2020; [E-pub Ahead of Print].
[27] Meehan WP, Mannix RC, Stracciolini A, Elbin RJ, Collins MW. Symptom Severity Predicts Prolonged Recovery after Sport-related Concussion, but Age and Amnesia do not. J Pediatr 2013;163:721-5.
[28] Howell DR, Potter MN, Kirkwood MW, Wilson PE, Provance AJ, Wilson JC. Clinical Predictors of Symptom Resolution for Children and Adolescents with Sport-related Concussion. J Neurosurg Pediatr 2019;24:54-61.
[29] Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic Review of the Balance Error Scoring System. Sports Health 2011;3:287-95.
[30] King LA, Horak FB, Mancini M, Pierce D, Priest KC, Chesnutt J, et al. Instrumenting the Balance Error Scoring System for use with Patients Reporting Persistent Balance Problems after Mild Traumatic Brain Injury. Arch Phys Med Rehabil 2014;95:353-9.
[31] Echemendia RJ, Meeuwisse W, McCrory P, Davis GA, Putukian M, Leddy J, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5). Br J Sports Med 2017;51:848-50.
[32] Oldham JR, DiFabio MS, Kaminski TW, DeWolf RM, Howell DR, Buckley TA. Efficacy of Tandem Gait to Identify Impaired Postural Control Following Concussion. Med Sci Sports Exerc 2018;50:1162-8.
[33] Mucha A, Collins MW, Elbin RJ, Furman JM, TroutmanEnseki C, DeWolf RM, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. Am J Sports Med 2014;42:2479-86.
[34] Sufrinko AM, Mucha A, Covassin T, Marchetti G, Elbin RJ, Collins MW, et al. Sex Differences in Vestibular/ Ocular and Neurocognitive Outcomes After Sport-Related Concussion. Clin J Sport Med 2017;27:133-8.
[35] Howell DR, O’Brien MJ, Raghuram A, Shah A, Meehan WP. Near Point of Convergence and Gait Deficits in Adolescents Following Sport-Related Concussion. Clin J Sport Med 2018;28:262-7.
[36] Pearce KL, Sufrinko A, Lau BC, Henry L, Collins MW, Kontos AP. Near Point of Convergence After a Sport-Related Concussion: Measurement Reliability and Relationship to Neurocognitive Impairment and Symptoms. Am J Sports Med 2015;43:3055-61.
[37] Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful Selection of Variables in Logistic Regression. Source Code Biol Med 2008;16;3:17.
[38] Amin FM, Aristeidou S, Baraldi C, Czapinska-Ciepiela EK, Ariadni DD, Di Lenola D, et al. The Association between Migraine and Physical Exercise. J Headache Pain 2018;19:83.
[39] Sorond FA, Galica A, Serrador JM, Kiely DK, Iloputaife I, Cupples LA, et al. Cerebrovascular Hemodynamics, Gait, and Falls in an Elderly Population: MOBILIZE Boston Study. Neurology 2010;74:1627-33.
[40] Reneker JC, Hassen A, Phillips RS, Moughiman MC, Donaldson M, Moughiman J. Feasibility of Early Physical Therapy for Dizziness after a Sports-related Concussion: A Randomized Clinical Trial. Scand J Med Sci Sports 2017;27:2009-18.
[41] Park K, Ksiazek T, Olson B. Effectiveness of Vestibular Rehabilitation Therapy for Treatment of Concussed Adolescents with Persistent Symptoms of Dizziness and Imbalance. J Sport Rehabil 2018;27:485-90.
[42] Johnson BD, O’Leary MC, McBryde M, Sackett JR, Schlader ZJ, Leddy JJ. Face cooling Exposes Cardiac Parasympathetic and Sympathetic Dysfunction in Recently Concussed College Athletes. Physiol Rep 2018;6:e13694.
[43] Tan CO, Meehan WP, Iverson GL, Taylor JA. Cerebrovascular Regulation, Exercise, and Mild Traumatic Brain Injury. Neurology 2014;83:1665-72.
[44] Albalawi T, Hamner JW, Lapointe M, Meehan WP, Tan CO. The Relationship between Cerebral Vasoreactivity and Post-Concussive Symptom Severity. J Neurotrauma 2017;34:2700-5.
[45] Wright AD, Smirl JD, Bryk K, Fraser S, Jakovac M, van Donkelaar P. Sport-Related Concussion Alters Indices of Dynamic Cerebral Autoregulation. Front Neurol 2018;9:196.
[46] Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep 2018;17:262-70.