Early return to physical activity after concussion may reduce post-concussive symptoms

Physical and mental symptoms can persist after a concussion and strangely, mild concussions are more likely to cause persistent symptoms than severe ones. In a previous post, Rest your brain after a head injury I described a study that involved 335 children and young adults. As the title indicates, cognitive rest was associated with a faster recovery.

Another post on concussion and post-concussion headaches mentioned that experts advocate physical rest as well. However, a new study of over 3,000 Canadian children between the ages of 5 and 18 with concussion suggests that the recovery is faster in those who get physically active within the first week of an acute concussion. Of the children who engaged in physical activity within the first week 29% had persistent post-concussive symptoms four weeks later compared to 40% of those who did not engage in any physical activity. This was true whether the child participated only in light aerobic exercise (33% of kids), sport-specific exercise (9%), noncontact drills (6%), full-contact practice (4%), or full competition (17%). I am very surprised that kids were allowed to return to full-contact practice and full competition before complete recovery.

These finding contradict all of the concussion guidelines, which recommend a period of physical and cognitive rest following a concussion until post-concussive symptoms such as dizziness, fatigue, and headaches have resolved. The guidelines also advise to increase the amount of physical activity only if symptoms do not worsen. These guidelines were developed without the benefit of large controlled studies, but rather by a consensus of experts.

The authors also think that children who rest for a long period of time may be unnecessarily deprived of physical activity’s benefits on the growing body. Too much rest may also lead to symptoms such as depression, anxiety, and social isolation.

“We may need to reconsider the current recommendations for strict conservative rest until patients are symptom-free,” study author Roger Zemek, MD, PhD, associate professor and director of research at the University of Ottawa in Canada, said in an interview with Neurology Today. “Patients should be encouraged to participate in some form of active physical rehabilitation following concussion as long as the activity does not put them at risk of re-injury.”

The study authors did caution that “Participation in activities that might introduce risk for collision or falls should remain prohibited until clearance by a health professional to reduce the risk for a potentially more serious second concussion during a period of increased vulnerability.”

Two prominent sports neurologists said that not much will change at their clinics, because programs like the one in the study are already in place. They generally prescribe an early, graduated, return to physical activity for children and adolescents who present with a sports-related concussion. (Phases include light activity like walking, moderate activity like jogging, and moderate-heavy activity like non-contact practice or drills.) Patients may return to full activity within one week, although they may not progress by more than one phase per day. These neurologists also felt that avoidance of all activity can be harmful – not just on physical health, but also on mental health.

They also agreed that kids must not be allowed to immediately return to full-contact sport or high risk activities before complete recovery because of the increased risk of re-injury.