Physical Activity Intervention in Youth With Concussion

In this issue of Pediatrics, Chauhan et al¹  present an illuminating systematic review and meta-analysis on the benefit of physical activity interventions on recovery in youth with concussion.

It is critical that we have effective management strategies for promoting recovery and return to typical function after concussion, given its high prevalence. Indeed, 1 in 5 US youth are diagnosed with at least 1 concussion by the time they reach adolescence.²  The recognition that significant harm can be caused by sending a concussed athlete back into active play³  led to a “rest is best” treatment model. However, the pendulum may have swung too far toward bedrest because there are myriad consequences of lying in a dark and quiet room for prolonged periods waiting for concussion symptoms to abate. Over time, the loss of routine, social isolation, multisensory deprivation, and physical deconditioning can develop. This can lead to further disruptions in sleep, greater sensory sensitivities with sensory-avoidant behavior, worsening of symptoms triggered by even minor physical activity, and anxiety and depression from being disconnected from school and friend groups and may intensify feelings of loss and despair for how different life is since the concussion. Although the concussion acts as the inciting event, these symptoms likely feed into each other and support symptom persistence.⁴ 

Now the pendulum is swinging back because mounting evidence supports a more moderate approach of thoughtful and incremental increases in physical, cognitive, and social activity in a manner that avoids repeated concussion during the recovery period. The findings of Chauhan et al¹  support this moderate approach by demonstrating that youth with concussion who participate in a physical activity intervention experience greater symptom resolution. There were not significant improvements in all metrics, including quality of life and time to recovery, in the physical activity intervention compared with standard-of-care groups. This may be due in large part to fewer studies reporting these outcomes. However, overall, the meta-analysis supports physical activity intervention for concussion treatment and there was no indication that a physical activity intervention led to worse outcomes. Approaches that included multiple methods of increasing activity (aerobic exercises, coordination exercises, and relaxation/visualization techniques to manage symptom exacerbation) yielded the greatest improvement. They did not identify any studies that solely assessed the role of return to social activities in concussion recovery, indicating a great need for study in this area.

One critical question is how early physical and social activity should be encouraged. Chauhan et al¹  identified physical activity interventions across a wide range of time that had passed since the concussion. Some were initiated within 1 week, whereas others were started years after the injury. The Centers for Disease Control and Prevention guidelines, which recommend that, after 2 to 3 days of rest, light activity with reintroduction of regular nonsport-related activities followed by sport-related activities in a gradual manner that does not significantly worsen symptoms,⁵  have been supported in previous systematic reviews on this topic.⁶  Avoiding electronic screens during the first 48 hours may also be beneficial for recovery.⁷ 

A challenge faced by researchers studying concussion recovery is that symptoms can include multiple and overlapping areas of neural function, including sensory processing, cognitive processing, pain, balance, and sleep, among others. The severity and types of symptoms experienced with concussion is highly variable and can affect recovery. Those who experience relatively mild symptoms are more likely to recover quickly^8,9  and will also likely face fewer barriers in tolerating physical activity increases. Collaborative care models that integrate physical therapy, cognitive behavioral therapy, and thoughtful medication management when needed to manage symptoms like headache, may be the most effective approach for youth with a protracted concussion recovery.^10,11  The findings of Chauhan et al¹  support the use of physical activity as a key component of these interventions.

We have known for decades that placing players back into a game moments after sustaining a concussion can be harmful.³  However, the other extreme, complete avoidance of physical activity, may also impede recovery. Chauhan et al¹  highlight the benefit of physical activity intervention, which supports a measured approach guided by incremental increases in physical, cognitive, and social activity that avoids reinjury, as the optimal path to concussion recovery.