RELATIONSHIP BETWEEN PHYSICAL ACTIVITY PARTICIPATION AND RECOVERY OUTCOMES IN COLLEGE-AGED ADULTS WITH A CONCUSSION

ABSTRACT Context: Previously, the most common treatment for a concussion was prolonged physical and cognitive rest. Recent research suggests that earlier physical activity (PA) may be better at promoting recovery. Research has not evaluated the relationship between free-living PA (e.g., walking) and symptom reporting or recovery duration. Objective: To assess the relationship between free-living physical activity (PA) participation and two recovery outcomes in college-aged adults with a concussion. Design: Prospective Cohort Setting: Division 1 & 3 Universities Participants: Thirty-two college-aged adults (68.8% female, age: 19.8±1.4) with a concussion. Main Outcome Measures: Participants completed a post-concussion symptom evaluation at visits 1 (<72 hours from concussion) and 2 (8 days later). Between visits, participants' PA was monitored using an Actigraph GT9X Link PA monitor and expressed as total PA (counts per minute) and percent time of PA spent in moderate-to-vigorous intensity (%MVPA). Recovery time was the number of days from injury occurrence to medical clearance. Separate hierarchical multiple regressions evaluated the relationship between total PA and each recovery variable (visit 2 symptom severity, recovery time). Additionally, separate exploratory hierarchical multiple regressions evaluated the relationship between %MVPA and each recovery variable. Statistical significance was set a priori at p ≤ .05. Results: Participants averaged 2446±441 counts per minute and spent 12.1±4.2% of their PA performing MVPA. Participants yielded median symptom severities of 28[24] and 2[8] for visit 1 and 2, respectively. Average recovery time was 14.7±7.5 days. Total PA did not significantly contribute to the model for visit 2 symptom severity (p=.122) or recovery time (p=.301). Similarly, %MVPA had little contribution to the model for visit 2 symptom severity (p=.358) or recovery time (p=.276). Conclusion: Results suggest that free-living PA may not be enough to reduce symptoms or shorten recovery. Thus, clinicians may need to provide patients with more structured PA protocols mimicking previous research.

The Effects of Aerobic Exercise on Postconcussion Symptoms in Patients With Persistent Symptoms: A Critically Appraised Topic

Context: Patients who do not fully recover from a concussion in 7–14 days may require an impairment-based rehabilitation program. Recent evidence indicates improved outcomes with active rehabilitation compared to passive physical and cognitive rest. Clinical Question: In patients with persistent symptoms (greater than 4 weeks) following concussion, how does aerobic exercise affect postconcussion symptoms? Clinical Bottom Line: There is moderate and sufficient SORT Level B evidence to support the inclusion of subsymptom threshold (SST) exercise in the multimodal treatment plan for patients suffering from persistent symptoms after concussion. All five included studies reported moderate to very large effects ranging from d = 0.72 to d = 10.64 in reducing symptoms after the implementation of SST aerobic exercise. Additionally, two studies also identified moderate and very large effects (d = 0.77, d = 2.56) favoring aerobic exercise over stretching interventions. These results indicate that this treatment has potential clinical utility and is a viable option to reduce symptoms in patients with postconcussion syndrome and persistent symptoms following concussion.

Return to Play Following Concussion

Return-to-play protocols have existed for many years, and have evolved over time. Current guidelines mandate that an athlete cannot return to play on the same day as a suspected concussion. Although physical and cognitive rest are recommended in the immediate aftermath of concussion, athletes should begin to engage in some type of activity in 24–48 hours after a concussion. A more formal stepwise increase in activity should occur once the athlete has returned to his or her baseline symptoms. Ultimately, return-to-play is a balance between ensuring player safety and avoiding concussion symptoms that persist because of inactivity.

Rest Evaluation for Active Concussion Treatment (ReAct) Protocol: a prospective cohort study of levels of physical and cognitive rest after youth sports-related concussion

IntroductionAlthough current guidelines for the early clinical management of sports-related concussion (SRC) call for a gradual return-to-activity, the optimal level of rest needed to promote recovery remains unknown. This paper describes the protocol of the Rest Evaluation for Active Concussion Treatment (ReAct) study which objectively measures physical and cognitive rest following SRC and its relation to recovery among youth athletes.Methods and analysisYouth athletes aged 11–17 years are recruited preinjury and enrolled within 72 hours following a physician-diagnosed concussion. Injury information and acute clinical presentation are assessed at the time of injury. Youth participants are prospectively followed to objectively monitor daily physical and cognitive rest using two electronic devices: ActiGraph (to measure physical rest and sleep) and Narrative Clip (to measure cognitive rest), along with self-reported postconcussive symptoms using daily surveys. Other concussion outcomes, including functional outcomes, are assessed by surveying youth and their parents at three time points: (1) within 72 hours of injury, (2) at day 7 postenrolment and (3) at symptom resolution (or a maximum of 45 days postconcussion).Ethics and disseminationThis study has received ethical approval from the Institutional Review Board (IRB) at the participating institution (IRB at Nationwide Children’s Hospital, IRB16-00613). The results of the study will be presented at national and international scientific conferences and published in peer-reviewed journals.

Return to School

Consider a graded stepwise approach to return to school, analogous to the strategy for return to play. This requires coordination with teachers, administrators, school nursing/medical providers, parents, and often classmates. The steps include mental rest, light cognitive activity (e.g., reading familiar material), moderate cognitive activity (e.g., new material in the student’s strongest subject), back to school with accommodations and extra rest, back to school without accommodations, catch up on missed work, then resume extracurricular activities. For complex concussions, reduce barriers to optimal cognitive performance, such as sleep disorders, headache, depression, and anxiety. There is no point in trying to return to school when any of these are substantially impairing. Reduced cognitive activity is associated with faster resolution of concussion-related symptoms, but complete cognitive rest is not necessary. Patients do not have to be completely symptom-free to return to school and to light exercise. Consider using a quantitative measure such as the Behavior Rating Inventory of Executive Function (BRIEF).

An experimental study of the effect on activity intentions of postconcussion recovery advice

This study tested the effect of issuing return-to-activity advice on activity intentions at Day 2 and Day 10 days post simulated mild traumatic brain injury. One hundred and twenty-eight volunteers were randomly allocated to one of two groups who received ( n = 65) or did not receive standardized post-injury advice ( n = 63). To prime the simulation, the participants read a mild traumatic brain injury vignette about a person who is concussed while playing sport. Then the participants role-played the injured person and reported activity intentions for three activity types (cognitive, physical and restful) twice, once for each time frame (i.e. Day 2 and Day 10). The advice was to rest for the first 24–48 h and then gradually resume normal activities. There was no significant group by activity-type interaction ( p > .05) at Day 2. When both time frames were considered, there was no significant group × time frame interaction for any activity type or any item, except for an increase in non-manual (clerical) work and weight training at Day 10 compared to Day 2 in the group with the advice. In general, the intentions for all activity types were consistent with the recovery advice (i.e., rest then increasing activity), even when the advice was not given. However, at Day 10, cognitive and physical activity levels were still expected to be lower than usual (pre-injury), and many participants were uncertain about the concept of cognitive rest. These factors, along with individual patient circumstances, should be taken into account in rehabilitation planning.

The Effect of Cognitive Rest as Part of Postconcussion Management for Adolescent Athletes: A Critically Appraised Topic

Clinical Scenario:It is hypothesized that cognitive activity following a concussion may potentially hinder patient recovery. While the recommendation of cognitive rest is often maintained and rationalized, a causal relationship between cognitive activity and symptom duration has yet to be established.Clinical Question:Does the implementation of cognitive rest as part of the postconcussion management plan reduce the number of days until the concussed adolescent patient is symptom free compared to a postconcussion management plan that does not incorporate cognitive rest?Summary of Key Findings:A thorough literature search returned 7 possible studies; 5 studies met the inclusion criteria and were included. Three studies indicated that increased cognitive activity is associated with longer recovery from a concussion, and, therefore, supported the use of cognitive rest. One study indicated that the recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution. One study indicated that strict rest, defined as 5 days of no school, work, or physical activity; might prolong symptom duration.Clinical Bottom Line:There is moderate evidence to support the prescription of moderate cognitive rest for concussed patients. Clinicians who intend on implementing cognitive rest in their concussion protocols should be aware of inconsistencies and be open-minded to alternative treatment progressions while taking into consideration each individual patient and maintaining adequate patient-centered care principles.Strength of Recommendation:Grade B evidence exists that prescription of moderate cognitive rest for concussed patients may be beneficial as a supplement to physical rest as treatment for symptom reduction in adolescents.

Neurobiological and connectivity changes after sports-related concussion

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide. Sports-related TBI is a subset that encompasses cerebral concussion and chronic traumatic encephalopathy (CTE), the latter of which is a long-term neurodegenerative sequela of repeated mild TBI that affects behaviour, cognition, motor control, and memory. On a cellular level, TBI can result in diffuse axonal injury (DAI). This injury causes axonal transport dysfunction, leading to accumulation of tau and amyloid beta deposits in the brain. Damage occurs in neuronal tracts of both local and distant brain regions. DAI disrupts brain network function, which correlates with decreased cognitive function, by impairing the default mode network’s (DMN) normal ability to deactivate during cognitive tasks. The salience network (SN) can be affected by DAI as well, which ultimately also impairs deactivation of the DMN. These changes coincide with the clinical manifestations of concussions and CTE. Both concussions and CTE are currently clinical diagnoses, as no diagnostic lab tests exist to delineate these conditions. As with many brain disorders of traumatic origin, there is no specific medical treatment for these conditions, though concussion is managed through physical and cognitive rest. The most important consideration for all TBIs, however, is prevention.