Exercise as a prescription to address post-concussion syndrome: The CJSM Blog Journal Club

Sports like American football are taking place in the midst of COVID19 — concussions are sure to follow

Our September 2020 edition has just published, and this edition is a particularly compelling one, full of original research.  You have to check it out.

As ever our Jr. Associate Editor Jason Zaremski M.D. has just posted his newest submission to the CJSM journal club.

While COVID19 is wreaking havoc with sports schedules around the globe, there are enough high schools and youth sports programs active that concussions will continue to remain a challenge for clinicians to treat.  And post-concussion syndrome is one particularly challenging aspect to this injury.  Dr. Zaremski walks us through original research looking at an ‘exercise prescription’ to treat post-concussion syndrome.

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Jason Zaremski MD

Gauvin-Lepage J, Friedman D, Grilli L, Sufrategui M, De Matteo C, Iverson, GL, Gagnon I. Effectiveness of an Exercise-Based Active Rehabilitation Intervention for Youth Who Are Slow to Recover After Concussion, Clinical Journal of Sport Medicine: September 2020 – Volume 30 – Issue 5 – p 423-432 doi: 10.1097/JSM.0000000000000634

Introduction:  With the change of seasons, many of our readers return to covering pediatric and adolescent sport. In the Northern Hemisphere, summer vacation is over, and academics and school sports are commencing. Fall is the start of the gridiron football season and there is often a surge of concussed youth who need effective, evidence-based management.

This month the CJSM Journal Club has chosen to highlight original research on the effectiveness of exercise-based rehabilitation in 8-17 year youth who have sustained a concussion. In this age group, return to school is even more important than return to sport, and the lingering difficulties in intellectual ability, vestibular system function, memory, and/or attention can be particularly debilitating.  The authors in this new study report that between 20% and 30% of all concussed youth will endorse post-concussive symptoms (PCS) 1 month after injury. Further research into treatments and modalities aimed at reducing the frequency with which children and adolescents experience PCS is paramount.

Purpose: The authors state two aims:

1) To determine the impact of providing participants (aged 8 to 17 years) who are slow to recover after a concussion with an active rehabilitation intervention (ARI) compared to receiving standard care alone, at 2 and 6 weeks after the initiation of the ARI.

2) To investigate functional recovery 6 weeks after initiation of the ARI.

Setting: Tertiary care pediatric trauma center and associated community health care providers.

Methods/Design:  A multicenter prospective quasi-experimental control group design. The intervention used was already the standard care at the experimental site made it ethically impossible for youth to be randomly allocated to a control intervention. To alleviate potential biases associated with the lack of randomization, youth from another institution in Canada, where this intervention was not delivered but where standard care followed usual rest/symptom-limited activity-based recommendations and return to learn strategies, were recruited as the control group.

Timing and Interventions:

Assessments were performed by phone at 0 and 2 weeks, and in the participant’s home at the 6 week mark. Each participant was randomized to either the Standard/Control group or the Standard/Control + ARI group (aka experimental group).

Standard Care/Control Program:

Rest/light symptom limited activities, general education, academic adaptations, and gradual return to school, as well as watchful waiting with youth, restricting them from participation in vigorous physical activities/sport until complete symptom resolution.

ARI Program:

Please refer to Table 1 (p. 425) for the 5 ARI designs in greater detail.

  • Aerobic activity
  • Coordination/sport-specific activity
  • Mental imagery
  • Education
  • Home Program

Participants:  n = 49, ages 8-17 (experimental group = 36, control = 13) recruited between May 2014 and February 2015 in Montreal, Canada. Inclusion and exclusion criteria for the control group were the same for both groups. Ethical approval from both research ethics boards was obtained before initiation of the study. The experimental group and control groups were matched by age, sex, time since injury, baseline levels of PCS.

Demographics: Table 3 (p. 428) provides all of the sociodemographic variables. However, it should be noted that mean days since injury was 40.9 (control) and 37.2 (experimental), mechanism of injury was 8 out of 13 (control) and 31 out of 39 (experimental) due to sports/recreational play, and when assessing type of sport 1 out 8 (control) and 10 out of 31 (experimental) were due to soccer. Furthermore, the control group had 8 out of 13 and 4 out of 13 (respectively) developmental and psychiatric disorders whereas the experimental group had 0 in both sub-categories.

Inclusion Criteria: Based upon the WHO International Classification of Diseases (ICD-10), an individual is considered to have persistent PCS (PPCS) if presenting 3 or more symptoms at least 4 weeks after injury.

  • Ages 8-17
  • Confirmed diagnosis of concussion per referring physician
  • Speak English or French
  • Presented with slow recovery 4 weeks after injury, defined as presenting with at least one PCS, reported at least once a week (eg, headache, anxiety, and fatigue), interfering with daily activities.

Exclusion Criteria:

  • neck pain was the only PCS
  • sustained another concussion in the 6 months before the current injury
  • coexisting injuries including any previous moderate and severe TBI
  • comorbidities in the past 6 months
  • diagnoses preventing participation intervention or assessment of standing balance/gait

Outcome Measures:

Primary Outcomes:

  • Child- and parent-reported PCS were obtained by the PCS Inventory Scale (PCSI)

**Because all youth included in the final analysis were older than 12 years, only the adolescent version of the PCIS was used

Secondary outcomes included:

  • mood and anxiety
  • quality of life
  • energy level
  • coordination and balance
  • neurocognition
  • parental anxiety
  • satisfaction with intervention

Statistical Measures/Analysis:  As stated by the authors, baseline differences in sociodemographic characteristics between both study groups were examined for continuous variables, to determine the need for adjustments in the main analysis. A 2-way mixed-design analysis of variance was used to investigate the changes in mean total and cluster PCSI scores between the 2 study groups and over 3 time points. A 2-sample Wilcoxon rank-sum Mann–Whitney test was used to investigate the changes in mean functional recovery scores between the 2 study groups baseline and 6 weeks.

Results:

Primary Outcomes: For the child reported PCSI scores, PCSI scores were found to decrease over time for both groups. Post hoc analysis revealed that recovery took place over the whole follow-up period (T1 and T2: P = 0.01) (T2 and T3: P = 0.01).

For the parent-reported PCSI scores, post hoc analysis revealed little recovery over the first 2 weeks, some difference between T2 and T3 (P = 0.001), and a strong difference between T1 and T3 (P = 0.0001).

Child- and parent-reported PCSI scores showed a significant time effect for physical (child: P = 0.004; parent: P = 0.09), fatigue (child: P = 0.02; parent: P = 0.02), and cognitive (child: P = 0.07; parent: P = 0.06) clusters, but not for the emotional cluster—see Table 4 for greater detail.

At T1, 11 participants in the control group (out of 13) and 36 participants in the experimental group (out of 39) were experiencing PPCS. There was an 18% decrease at T2 in the control group (n = 9) compared with 17% in the experimental group (n = 30), and a decrease of 45% at T3 in the control group (n = 6) compared with a decrease of 56% in the experimental group (n = 16).

Secondary Outcomes: Significant higher quality of life, faster speeds in tandem gait, more energy, lower anger scores for the experimental groups at T3. Additionally, there was a trend toward significance in the experimental group for tandem gait of the SCAT-3 and for general fatigue as per youth self-report. There was no significant differences between the two groups for level of physical activity, balance, coordination, cognition, parental anxiety, or overall satisfaction.

Strengths:

  • Well-designed study
  • Contributes to growing literature revealing importance of physical rehabilitation after sustaining a concussion
  • Multiple time measures (0, 2, and 6 weeks) from participant as well as parent(s)
  • Provides information/data from perspective of child and parent(s).

Weaknesses:

  • As the authors state, compliance in the control group regarding inclusion of physical activity in their management protocols was not formally monitored, and so participants may possibly have engaged in some unsanctioned physical activity.
  • Smaller numbers in each group (in particular the control group is three times less than the experimental group)
  • Data may only apply in short term. Studies beyond 6 weeks with similar methods and outcomes would be valuable.
  • The control group had 8 out of 13 and 4 out of 13 (respectively) developmental and psychiatric disorders whereas the experimental group had 0 in both sub-categories. This difference in the prevalence of underlying co-morbidities in the two different groups compared may contribute to a difference in the data analysis.
  • Age range of 8-17 is quite large and would be interesting to compare pre high school (8-12 yo), early high school (13-14 yo), and later high school (15+ yo).
  • The control group program was not specific beyond the general recommendations (as noted above). Thus, were all 13 participants in the control group performing exactly the same program? It would be difficult to say.
  • Lastly, while not a weakness, I am curious as to why an ImPACT test was not administered at 2 weeks and done only at time 0 and at 6 weeks (see table 2)? There may be significant improvements 2 weeks after a child sustains a concussion and has had 2 weeks of treatment.

Conclusion:  The authors data suggest that an ARI improves quality of life, decreases anger, and potentially energy and balance. However, it does not affect PCS.

Clinical Relevance: As the authors note, the data from this study provide continued evidence that physical rehabilitation can be helpful in the treatment of PCS. An ARI may be considered part of the treatment plan after child aged 8-17 years old sustains a concussion as long as under the supervision of trained physicians and physical therapists with training in the management, diagnosis, and treatment of concussions.

About sportingjim
I work at Nationwide Children's Hospital in Columbus, Ohio USA, where I am a specialist in pediatric sports medicine. My academic appointment as an Associate Professor of Pediatrics is through Ohio State University. I am a public health advocate for kids' health and safety. I am also the Deputy Editor for the Clinical Journal of Sport Medicine.

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