Adolescent athletes who sustained concussions while playing a sport recovered more quickly when they underwent a supervised; aerobic exercise regimen, a study published in JAMA Pediatrics has found. The study, by University at Buffalo researchers and colleagues; is the first randomized clinical trial of a treatment in the acute phase after a sport-related concussion. The goal was to evaluate prescribed, progressive sub-symptom threshold exercise as a treatment; within the first week of a concussion in adolescents after a few days of rest. Sub-symptom threshold exercise is physical activity that doesn’t exacerbate symptoms.
“This research provides the strongest evidence”
“This research provides the strongest evidence yet that a prescribed; individualized aerobic exercise program; that keeps the heart rate below the point where symptoms worsen is the best way to treat concussion in adolescents,” said John J. Leddy, MD. The researchers plan to investigate if the treatment is also effective in adults with concussion.
No proven treatment
The researchers noted that there is no proven treatment for concussion; especially among adolescents, who typically take the longest to recover. “Until now, nothing else has been proven in any way effective for treating concussion;” said Barry S. Willer. “This is the best evidence so far for a treatment that works.” The findings directly contradict the conventional approach to concussion, which often consists of nearly total rest, eliminating most physical and mental activities, including schoolwork.
“Telling a teenager to go home and basically do nothing is depressing,” said Willer. “It can actually increase their physical and psychological symptoms, and we see that particularly among girls. But with our approach; you’re saying, sure, you can return to school and you should start doing these exercises. Their chins are up, Mom and Dad are happy and so is the student.”The fact that all states have now passed laws requiring schools to make accommodations for students who have sustained concussions is also helpful, said Willer, so that the student can opt out of some activities during the school day, if necessary.
The proper ‘dose’ of exercise
To determine how much exercise each patient could sustain without exacerbating symptoms, the researchers had each one undergo the Buffalo Concussion Treadmill Test, developed by Leddy and Willer, to determine at what level their symptoms worsen. As the patient walks on a treadmill, the incline; gradually increased and the heart rate; recorded at the point where concussion symptoms intensify.”We prescribed exercise at 80% of that threshold,” Leddy explained, “so each patient’s exercise ‘dose’ was individually tailored.”
Patients; randomly assigned to the aerobic exercise group (52) or to a stretching group (51). Researchers sent patients in both groups home with a heart rate monitor so they could make sure they stayed below the threshold while exercising. Both groups performed their assigned exercise for about 20 minutes each day and were required to report compliance and daily symptoms online. Those in the aerobic group either walked on a treadmill, rode a stationary bike, or walked either inside or out. Aside from the prescribed exercise, patients were advised to refrain from contact sports, gym class or team practice.
They were given advice about getting schoolwork done; and told to avoid excessive use of electronic devices, since that can also aggravate symptoms. Researchers re-evaluated each patient’s condition weekly and as symptoms improved; the “dose” of exercise or stretching increased; according to the weekly treadmill test results. Recovery was rigorously defined; requiring agreement among three independent criteria: the patient’s reporting a normal (minimal) level of symptoms; a normal physical examination by a medical doctor; and the return of normal exercise tolerance on the Buffalo Concussion Treadmill Test.
Expanding capacity for exercise treatment
One surprising finding was that only two participants out of 52 (4 percent) in the aerobic exercise group took longer than four weeks to recover compared to seven out of 51 (14 percent) in the stretching group. This did not reach statistical significance, but the scientific literature suggests, by contrast, that between 15 and 25 % of adolescents who do not receive any treatment will be symptomatic past four weeks. “Reducing the number of concussed adolescents; who have delayed recovery has major implications,” Willer said, noting that delayed recovery creates more difficulty with schoolwork; can lead to depression and puts additional demands on the health care system and its costs.
Michael J. Ellis in conclusion said that for years; his clinic is successfully using the Buffalo Concussion Treadmill Test; and a medically supervised sub-symptom-threshold aerobic exercise program to treat professional collegiate and elite adolescent athletes. So, expanding access to this treatment is now critical; he said. “The results of this study suggest that we must build greater capacity within our health care systems; to allow patients access to multidisciplinary concussion programs and clinics; that have the medical expertise to carry out early targeted rehabilitation of acute concussion,” he said.