Rest has long been the cornerstone of the management and treatment of concussion, especially in children and adolescents. This advice includes both physical and cognitive rest. Physicians have been advising both rest at home and avoidance of classwork for many years. A recent study out of Ottawa, Canada, published in the Journal of the American Medical Association, casts more doubt on the current recommendations for concussion management. There is limited evidence in the medical literature that the current recommendations result in a positive effect on prognosis, especially in adolescents. Although strenuous exercise in the post-concussion period may be harmful and may increase re-injury risk, evidence is mounting that prolonged rest after a concussion may increase the likelihood of the patient developing persistent postconcussive syndrome (PPCS), which is characterized by fatigue, anxiety, depression, and physical deconditioning.
Evidence about the importance of physical activity for maintaining physical and cognitive health is unequivocal. Physical activity is considered an effective method for improving cognitive and brain health, especially in children. There is overwhelming evidence that physical activity in youth promotes better body composition, skeletal health, and cardiorespiratory fitness. It also improves depression, anxiety, self-concept, cognitive performance, and academic achievement. It was with these concepts in mind that the Ottawa study was designed. The study enrolled more than 3,000 participants aged five to 18 who presented to the ED with acute head injury. They excluded those who were found to have an abnormal brain scan, acute intoxication, neurological abnormalities, or a lack of head trauma. Then they compared the rates of development of PPCS among those who were kept at rest against those who resumed light aerobic exercise (walking, swimming, and stationary-bicycle riding) within three to seven days after the head injury.
The study found that the proportion of participants with postconcussive symptoms at 28 days after the injury was 28 percent in those who had resumed light exercise vs. 40 percent in those who had remained at rest, a significant difference. This matches a number of other studies that have shown similar results. The theory is that light aerobic exercise increases cerebral blood flow and increases the output of certain neurochemicals, both of which lead to faster brain healing. Early physical activity can lessen the negative effects that prolonged inactivity has on body and brain conditioning. Regardless of potential benefit, however caution in the immediate postconcussion period is prudent. Participation in activities where there is a risk of collision (contact sports) or falls (skiing, bicycle riding, skating) should remain prohibited until clearance from a health professional is obtained.
While more research is needed, it would seem that in many concussion cases the recommendation to resume light exercise early on will replace the recommendation of complete rest. Of course the recommendations would be from a health professional and on a case-by-case basis, but it is hoped that the number of those suffering from prolonged post-concussive syndrome, or PPCS, will be decreasing over time.
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