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Original Investigation
December 20, 2016

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

Author Affiliations
  • 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
JAMA. 2016;316(23):2504-2514. doi:10.1001/jama.2016.17396
Key Points

Question  Is participation in physical activity within 7 days following acute concussion associated with lower rates of persistent postconcussive symptoms in children and adolescents compared with conservative rest?

Findings  In this prospective, multicenter cohort study of 3063 children and adolescents aged 5.00 to 17.99 years after propensity matching, the proportion with postconcussive symptoms at 28 days was 28.7% with participation in early physical activity vs 40.1% with conservative rest, a significant difference.

Meaning  Participation in physical activity within 1 week after injury may benefit symptom recovery following acute concussion in children and adolescents.

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.

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