Evidence Against Restricting Physical Activity After Concussion

December 20, 2016

Evidence Against Restricting Physical Activity After Concussion

  1. John D. Cowden, MD, MPH

Engaging in physical activity within 7 days after concussion was associated with a lower rate of persistent postconcussive symptoms.

  1. John D. Cowden, MD, MPH

Although physical and cognitive rest are universally recommended elements of concussion treatment (NEJM JW Emerg Med Sep 2014 and Ontario Neurotrauma Foundation 2014 Jun), prolonged inactivity after concussion has been linked to negative health effects. Light aerobic activity that avoids risk for reinjury has been shown to treat refractory concussion symptoms in preliminary studies, suggesting that low-level physical activity after concussion might be beneficial, rather than harmful.

Researchers assessed the association between physical activity and postconcussive symptoms in a prospective cohort study of 2413 children aged 5–18 years presenting with acute concussion to nine Canadian emergency departments (EDs). Children and their parents were surveyed in the ED and at 7 and 28 days. Early physical activity was defined as any activity within 7 days after enrollment. The primary outcome was presence of persistent postconcussive symptoms (at least three new or worsening symptoms) at 28 days. Propensity matching was used to account for more than 20 covariates.

Overall, 69.5% of patients reported early physical activity and 30.4% had persistent symptoms. Early physical activity was associated with significantly lower rates of persistent symptoms than no physical activity in both unadjusted analyses (24.6% vs. 43.5%) and propensity score–adjusted analyses (28.7% vs. 40.1%). Among 1387 patients symptomatic on day 7, rates of persistent symptoms at 28 days were lower in those who engaged in early physical activity at any level — light aerobic, moderate, and full — compared with no activity.


Evolution of concussion management continues as there is more compelling evidence that we may be wrong to recommend that all children with concussions observe strict physical rest until symptom-free. Results from this and other recent studies justify a randomized, controlled trial to help define which children need rest and which can be active. Such trials might lead to more individualized concussion management than is available in current guidelines.

Editor Disclosures at Time of Publication

  • Disclosures for John D. Cowden, MD, MPH at time of publication Leadership positions in professional societies Co-Chair, Culture, Ethnicity, and Health Care Special Interest Group, Academic Pediatric Association


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