After
a concussion, most pediatricians recommend that teens and children rest until
all their symptoms disappear. A new study questions this advice.
Compared
with those who rested, children who began physical activity within seven days
of an injury reduced their risk of persistent postconcussive symptoms,
according to research published Tuesday in the Journal of the American Medical
Association.
“We
know that there are hundreds of thousands of pediatric emergency visits across
North America for acute concussions,” said Dr. Roger Zemek, lead author and
director of the research unit at Children’s Hospital of Eastern Ontario.
“Approximately one-third of those children will continue to experience ongoing
or worsening symptoms for one month following their original injury.”
Zemek
added that the actual rates are difficult to calculate, given that many
children do not report injuries or do not get treated.
Postconcussive
syndrome
Concussion is a form of mild traumatic brain injury. If the effects last for weeks or even months, doctors refer to this as “postconcussive syndrome.” Each child is different, so each may experience a unique set of symptoms, explained Zemek.
Concussion is a form of mild traumatic brain injury. If the effects last for weeks or even months, doctors refer to this as “postconcussive syndrome.” Each child is different, so each may experience a unique set of symptoms, explained Zemek.
“Typically,
children can have ongoing symptoms that are physical in nature. Examples of
that would be ongoing headaches, dizziness, maybe even some nausea or vision
changes,” Zemek said. Other children may have symptoms that are more cognitive
in nature, so they might have problems concentrating or feel like they’re “in a
fog. They can have symptoms that are more emotional or behavioral in nature,
feeling sad or feeling low energy.” Sometimes, patients can’t sleep.
Although
postconcussion symptoms usually go away within three months, some can last a
year or more.
Typically,
pediatricians recommend that patients get rest until their symptoms disappear.
“Unfortunately, most of those recommendations were not based on evidence; they
were based on expert opinion only,” Zemek said.
Other
experts agree that more work is needed in the area of concussions, generally.
“The
big question following a concussion is: How long should kids and adults stay
away from physical activity?” said Dr. Richard Temes, director of the Center
for Neurocritical Care at North Shore University Hospital in Manhasset, New
York. He did not participate in the research. “This paper is kind of the first
step to addressing the timing of physical activity.”
Noting
that early physical rehabilitation is encouraged after a stroke — severe brain
trauma — Zemek and his colleagues set to work to find out whether it might also
help prevent lingering concussion symptoms.
Is
exercise the greatest medicine?
To investigate the possible effects of physical activity, Zemek and his colleagues assessed more than 2,400 children and teens diagnosed with concussion. After rating each child’s physical activity participation and postconcussive symptom severity using standardized questionnaires at day seven, the researchers assessed persistent postconcussive symptoms at day 28.
To investigate the possible effects of physical activity, Zemek and his colleagues assessed more than 2,400 children and teens diagnosed with concussion. After rating each child’s physical activity participation and postconcussive symptom severity using standardized questionnaires at day seven, the researchers assessed persistent postconcussive symptoms at day 28.
Of
all the participants, about 70% became active again within seven days. Activity
primarily consisted of light aerobic or sport-specific exercise, noncontact
drills and even, in a small percentage of cases, full-contact practice.
Of
the patients who began physical activity early, 31% were symptom-free and 48%
had at least three persistent or worsening postconcussive symptoms at day
seven. By comparison, 80% of those who rested for the first week after a
concussion had at least three postconcussive symptoms at day seven. At 28 days,
the proportion with postconcussive symptoms was nearly 40% among those who
rested versus about 29% among those who resumed early activity — a significant
difference.
“I
think there are many different ways in which exercise may be beneficial,” Zemek
said, explaining that activity can improve cerebral blood flow, promote
neuroplasticity and release endorphins, which may heal the brain.
Getting
out of the “home jail” can be a psychologically important factor for kids as
well, he said, reinforcing the message that they are going to get better.
However, he still urges caution: Patients should not go skiing, participate in
collision sports or risk another head injury while symptomatic.
Temes
wholeheartedly agrees. “This is not a stamp of approval to get back in the
football game,” he said, adding that the study tells families only that “some
level of physical activity may be helpful in improving symptoms of concussion.”
This
was not a randomized control trial but a simple observational study based on
self-reports from families, noted Dr. Lynn Babcock, associate professor in the
division of emergency medicine at Cincinnati Children’s Hospital Medical
Center. Some attempt was made to guess at the quantity, intensity and timing of
exercise after an injury, but objective data are still needed, she said.
“Still,
we’re pretty excited to see more evidence saying we need to better study this
question,” said Babcock, who was not involved in the research.
Zemek
and his colleagues have begun a randomized clinical trial to learn more about
preventing postconcussive syndrome. “One-third of all kids is too many,” he
said. “Exercise itself can be a great medicine.”
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