Study: Earlier Is Better for Kids' Return to Activity After Concussion

Whom is going to reconcile these two conflicting studies?

First-of-Its-Kind Study Explains Why Rest is Critical After A Concussion  Feb. 2016

Study: Earlier Is Better for Kids' Return to Activity After Concussion

• by Molly Walker
  Contributing Writer
  
• This article is a collaboration between MedPage Today® and:
  

Action Points

• Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
• Children and teens who returned to physical activity within 1 week after a concussion had a reduced risk of persistent post-concussion symptoms (PPCS) compared with those who did not resume early physical activity, based on self-reporting in a small Canadian observational study.
• Note that contrary to guideline recommendations, most symptomatic children resumed exercising at 1 week.

BALTIMORE -- Children and teens diagnosed with a concussion in the emergency department who returned to physical activity in 1 week had a reduced risk of persistent post-concussion syndrome compared with kids who did not resume early physical activity, according to a small observational study from Canada presented here.
In an unadjusted logistic regression analysis, kids who reported resumption of earlier physical activity were less likely to develop persistent post-concussion syndrome (defined as ≥3 concussion symptoms, as per the Post-Concussion Symptom Inventory) versus kids who did not (25% versus 43%, respectively, odds ratio 0.42, P<0.001), reported Roger Zemek, MD, of Children's Hospital of Eastern Ontario in Canada, and colleagues.
Overall, of the 2,413 participants ages 5-18 years, 70% reported resumption of physical activity 1 week following diagnosis of concussion, with one half reporting light activity and 25% returning to full competition. Of those engaging in physical activity, 31% reported being symptom-free. There were 30.4% who reporting meeting the criteria for persistent post-concussion syndrome.
These findings were presented at the Pediatric Academic Societies (PAS) annual meeting.
While these findings may appear controversial, given the media attention surrounding concussion, Zemek told MedPage Today that the amount of rest required following a concussion is unknown. He added that for other neurological conditions, early return to physical activity is part of the treatment protocol.
"In severe traumatic brain injury, such as a stroke, early rehabilitation is cornerstone of management. In stroke, we know that physiological, psychological and functional benefits are clear and have become the standard of care," said Zemek. "Too much rest may lead to deconditioning and an activity restriction cascade in which children become depressed and psychologically more likely to develop persistent symptoms."
Joseph Gigante, MD, of Vanderbilt University, said in an email interview with MedPage Today said that the fact that the study measured both symptoms and return to physical activity via self-report (Web or phone surveys) was a limitation of this research.
"Children want to return to activities as soon as possible so you wonder how truthful the participants in the study were with regard to reporting symptoms," said Gigante, who was not involved with the study. "It is also counterintuitive to think there is a potential benefit of earlier return to physical activity in children who have had a concussion."
Zemek noted these limitations (though he emphasized in the presentation that there is no "gold standard" for measuring physical activity) and said that the next step would be a randomized controlled trial. He said that was necessary, because as this study proved, kids do not adhere to current concussion treatment guidelines.
"We're going to be embarking ourselves on a randomized trial, where kids are randomly assigned to exercise," said Zemek. "We know that 'home jail' doesn't work, but since the mainstay of treatment right now is rest, it's so important to make sure we get that at least right."
In the current study, besides the unadjusted analyses, Zemek and colleagues also performed a propensity score analysis, where 645 kids who returned to physical activity within a week were matched with 645 controls. They also performed an inverse probability treatment weighting of the entire cohort.
Using these three analyses, Zemek and colleagues then performed two sensitivity analyses. The first replaced used symptoms at 1 week as a baseline (instead of their initial ED evaluation) compared to 4 weeks later. All three methodologies found statistically significant differences in persistent post-concussion syndrome among kids who resumed early physical activity vs those who did not:

• Unadjusted OR 0.42 (95% CI 0.35-0.51, P<0.001)
• Matched propensity OR 0.75 (95% CI 0.60-0.94, P=0.013)
• Inverse probability treatment weighting OR 0.69 (95% CI 0.57-0.85, P<0.001)

The second sensitivity analysis was limited to the children who reported ≥3 symptoms at 1 week (n=1,387). The differences remained significant in the unadjusted model (OR 0.68, 95% CI 0.54-0.85, P<0.001), but did not reach significance in the other two models. Zemek said this may have been due to small sample size.