A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury

Abstract

Background: There is a paucity of effective management strategies to prevent prolonged symptoms following mild traumatic brain injury (mTBI), and emerging evidence suggesting possible benefits of exercise. The objective of this trial was to determine whether adult patients presenting to the emergency department (ED) with a diagnosis of acute mTBI prescribed light exercise were less likely to develop persistent postconcussion symptoms (PCS).Methods: This was a randomized controlled trial conducted in three Canadian EDs.Consecutive, adult (18-64 years) ED patients with an mTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise, and the control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of three or more symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ).Results: A total of 367 patients were enrolled (control group, n = 184; intervention, n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control, 13.4% vs intervention, 14.6%; ∆1.2%, 95% confidence interval [CI] = −6.2 to 8.5). There were no differences in median change of RPQ scores, median number of return health care provider visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; ∆5, 95% CI = 2 to 15). Conclusion:In this trial of prescribed early light exercise for acute mTBI, there were no differences in recovery or health care utilization outcomes. Results suggest that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent PCS.

Relationship Between Physical Activity Participation and Recovery Outcomes in College-Aged Adults With a Concussion

“…With participants spending the majority of their time in light PA, it may be concluded that light intensity may not be sufficient enough to induce a therapeutic response after concussion. This intensity insufficiency was also noted by Varner et al 27 who found no significant changes in symptoms when implementing a 30minute light PA regiment after mTBI. Conversely, other previous research has utilized a more structured treadmill-based approach in which participants determine their intensity based on symptom exacerbation.…”

Sports-Related Concussions in Adults Presenting to Canadian Emergency Departments

“…[25][26][27] It is reasonable to recommend for 24 to 48 hours of cognitive and physical rest, followed by a gradual return to normal activities as tolerated. 26,28 Some recent studies suggest that low-intensity physical activity during the initial days of a concussion may be safe and even assist in recovery from prolonged symptoms than activity avoidance 25,[29][30][31] ; however, the current understanding of optimal intensity, duration, and frequency is limited.…”

“…17 At the time of the study, most guidelines recommended 24 to 48 hours of cognitive and physical rest 26 ; however, recent research has suggested that early light exercise may not be harmful. 31 Finally, although it is possible that physicians may have provided more treatment advice than their standard care, at the time of the study, they were not aware of the specific research question.…”

More Physical Activity after Concussion Is Associated with Faster Return to Play among Adolescents

“…However, further work is required to understand if a low-level activity prescription (i.e., a step count strategy) results in faster recovery compared to a higher intensity exercise recommendation (i.e., exercise prescription based on HR). One study compared adults who were randomized to a prescription of 30 min of daily light exercise vs. gradual return to exercise after symptom resolution and found no differences in recovery outcomes [ 28 ]. Thus, low level intensity/volume exercise may also not provide the necessary dose to induce a meaningful clinical benefit especially in a population of highly active adolescents.…”