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Does Early Aerobic Exercise Hasten Concussion Recovery in Adolescents?

  • Authors: MDEdge News Author: Jake Remaly; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 11/24/2021
  • Valid for credit through: 11/24/2022
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Target Audience and Goal Statement

This activity is intended for primary care clinicians, neurologists, sports medicine specialists, nurses and other members of the healthcare team who treat and manage patients with concussion.

The goal of this activity is to assess the effects of aerobic exercise after concussion.

Upon completion of this activity, participants will:

  • Assess the results of a previous study of aerobic exercise after concussion in adolescents
  • Evaluate the efficacy and safety of aerobic exercise after concussion in adolescents
  • Outline implications for the healthcare team


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MDEdge News Author

  • Jake Remaly


    Disclosure: Jake Remaly has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson


  • Esther Nyarko, PharmD

    Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

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Does Early Aerobic Exercise Hasten Concussion Recovery in Adolescents?

Authors: MDEdge News Author: Jake Remaly; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 11/24/2021

Valid for credit through: 11/24/2022


Clinical Context

There are an estimated 3.8 million recreation- and sports-related concussions annually in the US, and the standard advice for patients with a history of concussion is complete rest from cognitive and physical activity until the symptoms resolve.[1] However, a previous study by the authors of the current research challenged this principle of management. They randomly assigned 103 adolescents with a recent sports-related concussion to moderate aerobic exercise daily or a control intervention featuring daily stretching. Their results were published in the April 2019 issue of JAMA Pediatrics.[2]

Aerobic exercise was associated a 4-day improvement in recovery time from postconcussion symptoms (median 17 vs 13 days in the control and exercise groups, respectively). Exercise was also associated with a lower rate of delayed recovery past 30 days. However, total symptom scores were similar between groups. Finally, there were no adverse events related to study treatment.

The researchers from this previous study seek to replicate their results in another randomized controlled trial. Doing so could change the recommended management for sports-related concussions among adolescents.

Study Synopsis and Perspective

After a concussion, resuming aerobic exercise relatively early on at an intensity that does not worsen symptoms may help young athletes recover sooner compared with stretching, a randomized controlled trial (RCT) shows.

The study adds to emerging evidence that clinicians should prescribe exercise, rather than strict rest, to facilitate concussion recovery, researchers said.

Tamara McLeod, PhD, ATC, professor and director of athletic training programs at A.T. Still University in Mesa, Arizona, hopes that the findings help clinicians see that "this is an approach that should be taken."

"Too often with concussion, patients are given a laundry list of things they are not allowed to do," including sports, school, and social activities, said Dr McLeod, who was not involved in the study.

The research, published in the Lancet Child & Adolescent Health, largely replicates the findings of a prior trial while addressing limitations of the previous study's design, researchers said.[3,4]

For the trial, John J. Leddy, MD, from the State University of New York at Buffalo, and colleagues recruited 118 male and female adolescent athletes aged 13 to 18 years who had had a sport-related concussion in the past 10 days. Investigators at 3 community and hospital-affiliated sports medicine concussion centers in the United States randomly assigned the athletes to individualized subsymptom-threshold aerobic exercise (61 participants) or stretching exercise (57 participants) at least 20 minutes per day for up to 4 weeks. Aerobic exercise included walking, jogging, or stationary cycling at home.

"It is important that the general clinician community appreciates that prolonged rest and avoidance of physical activity until spontaneous symptom resolution is no longer an acceptable approach to caring for adolescents with concussion," Dr Leddy and coauthors said.

The investigators improved on the "the scientific rigour of their previous RCT by including intention-to-treat and per-protocol analyses, daily symptom reporting, objective exercise adherence measurements, and greater heterogeneity of concussion severity," said Carolyn A. Emery, PhD, and Jonathan Smirl, PhD, both with the University of Calgary, Alberta, Canada, in a related commentary.[5] The new study is the first to show that early targeted heart rate subsymptom-threshold aerobic exercise, relative to stretching, shortened recovery time within 4 weeks after sport-related concussion (hazard ratio, 0.52) when controlling for sex, study site, and average daily exercise time, Dr Emery and Dr Smirl said.

A larger proportion of athletes assigned to stretching did not recover by 4 weeks compared with those assigned to aerobic exercise (32% vs 21%). The median time to full recovery was longer for the stretching group than for the aerobic exercise group (19 vs 14 days).

Among athletes who adhered to their assigned regimens the differences were more pronounced: The median recovery time was 21 days for the stretching group compared with 12 days for the aerobic exercise group. The rate of postconcussion symptoms beyond 28 days was 9% in the aerobic exercise group versus 31% in the stretching group, among adherent participants.

More research is needed to establish the efficacy of postconcussion aerobic exercise in adults and for nonsport injury, the researchers noted. Possible mechanisms underlying aerobic exercise's benefits could include increased parasympathetic autonomic tone, improved cerebral blood flow regulation, or enhanced neuron repair, they suggested.

The right amount and timing of exercise, and doing so at an intensity that does not exacerbate symptoms, may be key. Other research has suggested that too much exercise too soon may delay recovery, Dr Emery said in an interview. "But there is now a lot of evidence to support low and moderate levels of physical activity to expedite recovery," she said.

The study was funded by the American Medical Society for Sports Medicine. The study and commentary authors and Dr McLeod had no disclosures.

Lancet Child Adolesc Health. 2021;5(11):792-799.

Study Highlights

  • The study was conducted at 3 US centers, 1 of which was associated with a university and 2 of which were affiliated with children's hospitals.
  • Study participants were adolescents between the ages of 13 and 18 years who presented within 10 days of a sports-related concussion. Adolescents with moderate to severe symptoms were excluded from study participation, as were those with a past history of more than 3 previous concussions.
  • Participants were randomly assigned to an aerobic exercise or stretching (control) group. Participants in the exercise group initially received a treadmill test and were then instructed to perform aerobic exercise at home at up to 90% of their maximum heart rate for at least 20 minutes daily. Participants in the control group were instructed to perform stretching and breathing exercises for at least 20 minutes per day.
  • The main study outcomes were the rates of clinical recovery within 4 weeks and the development of postconcussive symptoms beyond 28 days after injury. Clinical recovery was defined by normal exercise tolerance on the Buffalo Concussion Treadmill Test and a return to baseline on the Post-Concussion Symptom Inventory.
  • 118 adolescents participated in the study. The mean age of participants was 16 years, and 63% were male. Half the study cohort had a prior history of concussion before the index concussion, and the average time at clinical presentation after injury was 6 days.
  • Adherence to the aerobic exercise and stretching exercises was good overall.
  • The median days to recovery in the exercise and control groups were 14 and 19 days, respectively.
  • No adverse events related to the study interventions were reported. No participant developed symptoms that might portend a bad outcome.

Clinical Implications

  • In a previous study of adolescents with concussion, moderate aerobic exercise was associated with faster recovery and a lower rate of delayed recovery. Total symptom scores were similar between groups, and there were no adverse events related to study treatment.
  • The current study confirms that aerobic exercise after sports-related concussion promotes a higher rate of clinical recovery at 28 days among adolescents.
  • Implications for the healthcare team: The healthcare team should consider recommending moderate aerobic exercise to aid in the recovery from concussions among adolescents.


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