Resuming non-contact physical activity three days after a concussion is safe and may reduce symptoms, as well as the risk of delayed recovery, found the first and largest real-world, randomised clinical trial on the topic, conducted with ages 10 to 18.
Led by researchers at the CHEO Research Institute, the multi-site study was published by the British Journal of Sports Medicine. Previous randomised clinical trials have been smaller, conducted in the lab, or using only a sport-related population.
“The findings of this study should give every healthcare professional who manages children with concussions the confidence to prescribe early and controlled return to physical activity, even if they have symptoms,” said Andrée-Anne Ledoux, the studyʼs corresponding author and a scientist at the CHEO Research Institute, a paediatric health-care and research centre in Ottawa, Canada.
“The study confirms that early return to physical activity is safe, can reduce concussion symptoms and reduces the rate of delayed recovery,” added Ledoux, who is also an assistant professor at the University of Ottawa. “Gone are the days of resting in a dark room.”
The clinical trial, called Pediatric Concussion Assessment of Rest and Exertion (PedCARE), divided 456 participants into two groups. One group rested until symptom resolution after their concussion and the second group started to re-introduce physical activity 72 hours after the concussion, according to a set protocol. They regularly answered a standard survey about their symptoms and their activity levels were recorded using an accelerometer.
At two weeks, symptoms were comparable between both groups, meaning early physical activity was not harmful. When examining results of everyone who stayed within the prescribed level of activity, those who re-introduced physical activity early showed improved symptoms and a reduced rate of delayed recovery, compared with those who rested until they were symptom-free.
The study sets out guidelines for gradually introducing physical activity back into the daily routine of a child or youth. For example, at 72 hours after the injury, the youth should start walking for 15 minutes at a moderate level. If symptoms are tolerable the youth should increase their physical activity intensity the next day, for example, light jogging.
If symptoms are not tolerable while doing physical activity or after physical activity, the next day the child or youth should return to the last well-tolerated physical activity intensity and re-attempt progression after 24 hours. They must be cleared by their primary-care provider before returning to contact sports.
Study details
Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial
Andrée-Anne Ledoux, Nick Barrowman, Vid Bijelić, Michael M Borghese, Adrienne Davis, Sarah Reid, Gurinder Sangha, Keith Owen Yeates, Mark S Tremblay, Candice McGahern, Kevin Belanger, Joel D Barnes, Ken J Farion, Carol A DeMatteo, Nick Reed, Roger Zemek.
Abstract
Objective
Investigate whether resuming physical activity (PA) at 72 hours post concussion is safe and reduces symptoms at 2 weeks, compared with resting until asymptomatic.
Methods
Real-life conditions, multicentre, single-blinded randomised clinical trial, conducted in three Canadian paediatric emergency departments (ED). Children/youth aged 10–<18 years with acute concussion were recruited between March 2017 and December 2019, and randomly assigned to a 4-week stepwise return-to-PA protocol at 72 hours post concussion even if symptomatic (experimental group (EG)) or to a return-to-PA once asymptomatic protocol (control group (CG)). The primary outcome was self-reported symptoms at 2 weeks using the Health and Behaviour Inventory. Adherence was measured using accelerometers worn 24 hours/day for 14 days post injury. Adverse events (AE) (worsening of symptoms requiring unscheduled ED or primary care visit) were monitored. Multivariable intention-to-treat (ITT) and per-protocol analyses adjusting for prognostically important covariates were examined. Missing data were imputed for the ITT analysis.
Results
456 randomised participants (EG: N=227; mean (SD) age=13.3 (2.1) years; 44.5% women; CG: N=229; mean (SD) age=13.3 (2.2) years; 43.7% women) were analysed. No AE were identified. ITT analysis showed no strong evidence of a group difference at 2 weeks (adjusted mean difference=−1.3 (95% CI:−3.6 to 1.1)). In adherent participants, initiating PA 72 hours post injury significantly reduced symptoms 2 weeks post injury, compared with rest (adjusted mean difference=−4.3 (95% CI:−8.4 to –0.2)).
Conclusion
Symptoms at 2 weeks did not differ significantly between children/youth randomised to initiate PA 72 hours post injury versus resting until asymptomatic; however, many were non-adherent to the intervention. Among adherent participants, early PA was associated with reduced symptoms at 2 weeks. Resumption of PA is safe and may be associated with milder symptoms at 2 weeks.
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