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Figure.  Bidirectional Association of Daily Step Counts and Postconcussion Symptom Scores (PCSs) Among Concussed Youth Aged 11 to 17 Years
Bidirectional Association of Daily Step Counts and Postconcussion Symptom Scores (PCSs) Among Concussed Youth Aged 11 to 17 Years

Diagrams show cross-lagged panel model (A) and random intercept cross-lagged panel model (B) of bidirectional association of daily step counts and PCSs the first week postinjury among 83 concussed youth aged 11 to 17 years. Numbers denote regression coefficients (with P values in parentheses).

Table.  Zero-Order Correlation Coefficients Between Daily Step Counts and PCS Scores During the First Week Postinjury Among 83 Youth With Concussion Aged 11-17 Years
Zero-Order Correlation Coefficients Between Daily Step Counts and PCS Scores During the First Week Postinjury Among 83 Youth With Concussion Aged 11-17 Years
1.
Leddy  JJ, Haider  MN, Ellis  MJ,  et al.  Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial.   JAMA Pediatr. 2019;173(4):319-325. doi:10.1001/jamapediatrics.2018.4397PubMedGoogle ScholarCrossref
2.
Yang  J, Yeates  K, Sullivan  L,  et al.  Rest Evaluation for Active Concussion Treatment (ReAct) Protocol: a prospective cohort study of levels of physical and cognitive rest after youth sports-related concussion.   BMJ Open. 2019;9(4):e028386. doi:10.1136/bmjopen-2018-028386PubMedGoogle Scholar
3.
Joyce  AS, Labella  CR, Carl  RL, Lai  JS, Zelko  FA.  The Postconcussion Symptom Scale: utility of a three-factor structure.   Med Sci Sports Exerc. 2015;47(6):1119-1123. doi:10.1249/MSS.0000000000000534PubMedGoogle ScholarCrossref
4.
Hamaker  EL, Kuiper  RM, Grasman  RP.  A critique of the cross-lagged panel model.   Psychol Methods. 2015;20(1):102-116. doi:10.1037/a0038889PubMedGoogle ScholarCrossref
5.
Lumba-Brown  A, Yeates  KO, Sarmiento  K,  et al.  Diagnosis and management of mild traumatic brain injury in children: a systematic review.   JAMA Pediatr. 2018;172(11):e182847. doi:10.1001/jamapediatrics.2018.2847PubMedGoogle Scholar
6.
Ledoux  AA, Barrowman  NJ, Boutis  K,  et al; Pediatric Emergency Research Canada PedCARE team.  Multicentre, randomised clinical trial of paediatric concussion assessment of rest and exertion (PedCARE): a study to determine when to resume physical activities following concussion in children.   Br J Sports Med. 2019;53(3):195. doi:10.1136/bjsports-2017-097981PubMedGoogle ScholarCrossref
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    Research Letter
    Pediatrics
    November 17, 2020

    Bidirectional Association Between Daily Physical Activity and Postconcussion Symptoms Among Youth

    Author Affiliations
    • 1Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
    • 2Department of Pediatrics, The Ohio State University, College of Medicine, Columbus
    • 3Department of Internal Medicine, The Ohio State University, College of Medicine, Columbus
    • 4Discipline of Children's Studies, National University of Ireland, Galway, Galway, Ireland
    • 5Biobehavioral Health Center, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
    • 6Department of Psychology, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
    • 7Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
    JAMA Netw Open. 2020;3(11):e2027486. doi:10.1001/jamanetworkopen.2020.27486
    Introduction

    Emerging evidence suggests that youth with concussion who resume physical activity during the acute and subacute phases of injury could have fewer postconcussion symptoms (PCS) and more rapid recovery.1 Although earlier physical activity may be associated with fewer PCS, fewer PCS may also be associated with increased activity. Additional research is needed to further our understanding of the directionality of this association. This study investigated the longitudinal and bidirectional association between daily physical activity and PCS during the first week postconcussion among youth aged 11 to 17 years.

    Methods

    This cohort study was approved by the Nationwide Children’s Hospital’s institutional review board. Participants provided written informed consent. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline

    We prospectively enrolled youth aged 11 to 17 years with a physician-confirmed concussion within 72 hours of injury from the emergency department and concussion clinics at Nationwide Children’s Hospital between [date] and [date].2 We measured daily physical activity as reflected in daily step count using an ActiGraph and daily PCS using the Postconcussion Symptom Scale from day 1 to day 7 postinjury.3 We grouped daily step count and PCS into 3 waves: days 1 to 3 (wave 1), days 4 to 5 (wave 2), and days 6 to 7 (wave 3) postinjury. Using both a traditional cross-lagged panel model (CLPM) and a random-intercept cross-lagged panel model (RI-CLPM), we examined the bidirectional associations between daily step counts and PCS in this 3-wave, longitudinal design.4 RI-CLPM disentangles the within-person process from stable between-person differences, whereas CLPM does not differentiate the covariance between these 2 levels.4 Models were estimated using the package lavaan in R statistical software version 3.6.2 (R Project for Statistical Computing), with 2-sided testing and a significance level of α = .05. Statistical analysis was performed from June to July 2020.

    Results

    This study’s participants included 83 youth with concussion (54 boys [65%]; mean [SD] age, 14.2 [1.9] years; 59 White participants [72%]; 70 sports-related concussions [84%]). The mean (SD) daily step counts were 9167 (3635) at wave 1, 10 143 (4018) at wave 2, and 10 786 (4038) steps at wave 3, whereas the mean (SD) daily PCS scores were 27.7 (19.6), 21.0 (18.4), and 15.9 (16.4), respectively. Zero-order correlation coefficients between daily step count and PCS were statistically significant (Table). In the CLPM, daily step counts and PCS scores showed significant positive autoregressive associations across all waves (Figure A), reflecting stability across time in both activity and symptoms. In contrast, in the RI-CLPM, which accounted for between-person differences, the only significant autoregressive association was the path for PCS scores from wave 1 to wave 2 (β = 0.652; SE = 0.196; P = .002) (Figure B). In the CLPM, only 1 cross-lagged path was significant, with higher PCS scores at wave 1 being associated with lower daily step counts at wave 2 (β = −0.181; SE = 0.101; P = .047). No cross-lagged paths were significant in the RI-CLPM. However, daily step counts and PCS showed a significant stable negative correlation between participants (β = −0.454; SE = 0.110; P = .03).

    Discussion

    This study assessed the bidirectional association between physical activity and PCS using cross-lagged panel analyses. Although youth who engaged in more physical activity during the first week postinjury reported fewer PCS than those who engaged in less physical activity, only 1 cross-lagged association between physical activity and PCS was significant. Specifically, greater PCS during wave 1 (days 1 to 3) postinjury was associated with lower daily physical activity during wave 2 (days 4 to 5) postinjury, suggesting that youth with greater PCS may limit their physical activity, perhaps per physician recommendations.2,5 However, this association was not apparent in the RI-CLPM, which accounts for between-person associations.

    The study was limited by a small sample size and lack of adjustment for individual differences including preinjury physical activity. Future randomized clinical trials with larger sample sizes and longer follow-up are critically needed to better understand the associations of physical activity with PCS and other concussion outcomes among youth.1,6 Such studies could inform health care practitioners’ recommendations for physical activity postconcussion and hasten concussion recovery among youth.

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    Article Information

    Accepted for Publication: October 1, 2020.

    Published: November 17, 2020. doi:10.1001/jamanetworkopen.2020.27486

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Yang J et al. JAMA Network Open.

    Corresponding Author: Jingzhen Yang, PhD, MPH, Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr—RBIII, Columbus, OH 43205 (ginger.yang@nationwidechildrens.org).

    Author Contributions: Dr Yang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Yang, Taylor, Yeates.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Yang, Sullivan.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Yang, Xu.

    Obtained funding: Yang.

    Administrative, technical, or material support: Sullivan, Taylor.

    Supervision: Yang.

    Conflict of Interest Disclosures: Dr Yeates reported receiving grants from the National Institutes of Health, the Canadian Institutes of Health Research, and the Brain Canada Foundation; and book royalties from Guilford Press and Cambridge University Press outside the submitted work. No other disclosures were reported.

    Funding/Support: This research work was supported by funding from the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award R21HD086451.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank the ReAct Clinical Study Group, physicians, certified athletic trainers, and clinical research coordinators at Nationwide Children’s Hospital and The Ohio State University who assisted in participant recruitment and data collection for this project. We also acknowledge the invaluable contributions of the families who were involved in this project.

    References
    1.
    Leddy  JJ, Haider  MN, Ellis  MJ,  et al.  Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial.   JAMA Pediatr. 2019;173(4):319-325. doi:10.1001/jamapediatrics.2018.4397PubMedGoogle ScholarCrossref
    2.
    Yang  J, Yeates  K, Sullivan  L,  et al.  Rest Evaluation for Active Concussion Treatment (ReAct) Protocol: a prospective cohort study of levels of physical and cognitive rest after youth sports-related concussion.   BMJ Open. 2019;9(4):e028386. doi:10.1136/bmjopen-2018-028386PubMedGoogle Scholar
    3.
    Joyce  AS, Labella  CR, Carl  RL, Lai  JS, Zelko  FA.  The Postconcussion Symptom Scale: utility of a three-factor structure.   Med Sci Sports Exerc. 2015;47(6):1119-1123. doi:10.1249/MSS.0000000000000534PubMedGoogle ScholarCrossref
    4.
    Hamaker  EL, Kuiper  RM, Grasman  RP.  A critique of the cross-lagged panel model.   Psychol Methods. 2015;20(1):102-116. doi:10.1037/a0038889PubMedGoogle ScholarCrossref
    5.
    Lumba-Brown  A, Yeates  KO, Sarmiento  K,  et al.  Diagnosis and management of mild traumatic brain injury in children: a systematic review.   JAMA Pediatr. 2018;172(11):e182847. doi:10.1001/jamapediatrics.2018.2847PubMedGoogle Scholar
    6.
    Ledoux  AA, Barrowman  NJ, Boutis  K,  et al; Pediatric Emergency Research Canada PedCARE team.  Multicentre, randomised clinical trial of paediatric concussion assessment of rest and exertion (PedCARE): a study to determine when to resume physical activities following concussion in children.   Br J Sports Med. 2019;53(3):195. doi:10.1136/bjsports-2017-097981PubMedGoogle ScholarCrossref
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