Physical Activity and Intermittent Postconcussion Symptoms After a Period of Symptom-Limited Physical and Cognitive Rest

Abstract

Reference: Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304–307. Clinical Question: After concussion and a period of symptom-limited physical and cognitive rest, do athletes who experience intermittent symptoms return to asymptomatic condition more quickly with physical activity than with prolonged physical rest? Data Sources: One investigator performed an individual search for each research question using the following databases: CINAHL, Cochrane Controlled Trials Registers, EMBASE, HealthSTAR, ProQuest, PsychInfo, PubMed, SPORTDiscus, and Web of Science. Search terms for rest were brain concussion, cognitive rest, mild traumatic brain injury, physical exertion, postconcussive syndrome, rehabilitation, sport-related concussion, therapy, treatment, and treatment outcome. Search terms for treatment were the same terms as for rest, as well as brain training, cervical spine, cognitive therapy, dizziness, exercise, headache, neck, pharmacotherapy, postural balance, and vertigo. The authors included peer-reviewed, published articles and abstracts and performed a citation search. Study Selection: Studies were included based on the following criteria as determined before searching: classified as original research, symptoms resulted after sport-related concussion, and investigation of the effects of either rest or treatment on symptoms. Abstracts that were excluded failed to evaluate rest, omitted sport-related concussion as the cause of symptoms, failed to evaluate a treatment's effect on sport-related concussion, or did not present original research. Data Extraction: The following data were extracted from each study that fit the selection criteria: study design; sample size; participants' demographic information (age and sex); type, duration, and intensity of treatment; key findings including effect sizes and means with 95% confidence intervals (calculated when possible using the data provided in the original study, even if not presented in the original study); and relevant comments. Main Results: The search revealed 749 articles evaluating the effects of rest and 1175 articles evaluating the effects of treatment. Of the 749 articles evaluating the effects of rest, only 2 met all the inclusion criteria. Of the 1175 articles evaluating the effects of treatment, only 10 met all the inclusion criteria. Ultimately, the authors were able to identify additional treatment articles that met the inclusion criteria, for a total of 12. The nature of the treatments and the participants differed enough that meta-analysis was not possible.  One of the 2 articles that evaluated rest was a retrospective analysis of athletes that showed those who were prescribed a period of cognitive rest had a longer duration of symptoms. The other study followed athletes postconcussion who were retrospectively assigned to groups based on self-reported activity level after injury. Those who reported moderate levels of cognitive and physical exertion over the first month postinjury appeared to demonstrate improved outcomes compared with those who pursued small or large amounts of activity.  Twelve studies evaluated the effects of treatment on symptoms after sport-related concussion. Various interventions were reviewed, including pharmacotherapy, light aerobic activity, graded exercise treadmill test, hyperbaric oxygen therapy, vestibular physiotherapy, and cervical spine manual therapy. Unfortunately, the authors did not report effect sizes for specific interventions, and due to the varied nature of each study and its respective treatment approach, no pooled data could be analyzed. However, a group of adolescents treated with submaximal aerobic and coordination exercises, visualization, and imagery returned to full normal physical activity at a mean duration of 4.4 weeks (95% confidence interval = 3.1, 5.7 weeks). Furthermore, a randomized controlled trial of patients experiencing persistent neck pain, dizziness, and headaches who underwent manual and physical therapy showed they were more likely to return to sport after 8 weeks of treatment. Despite the inability to pool data, the authors concluded that each treatment appeared to positively influence specific aspects of certain patients' symptoms. Conclusions: Little high-quality evidence has addressed the effects of rest and treatment after sport-related concussion. Current evidence suggests that an initial period of rest appears to be beneficial. Further research is needed to evaluate the long-term outcomes of rest (including the quality and quantity of the rest). Low levels of exercise may benefit the athlete postinjury, but additional study is required to determine the optimal timing for initiation of treatment postinjury. Patients with cervical spine or vestibular dysfunction may benefit from rehabilitation techniques targeted at their individual symptom profile to facilitate recovery. Overall, we need high-quality studies evaluating resting period, pharmacologic interventions, rehabilitative techniques, and exercise and their effects on patients slow to recover from concussion symptoms.