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Resumption of physical activity within 7 days of a concussion was associated with lower rates of persistent postconcussive symptoms (PPCS)
  1. Anand Nitin Kanani,
  2. Stuart Hartshorn
  1. Emergency Department, Birmingham Children’s Hospital, Birmingham, UK
  1. Correspondence to Dr. Stuart Hartshorn, Consultant in Paediatric Emergency Medicine, Birmingham Childrenâ’s Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK; Stuart.Hartshorn{at}

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Study design

A planned secondary analysis of a prospective, multicentre cohort study.


Nine emergency departments (ED) within the Pediatric Emergency Research Canada Network.


Aged between 5.00 and 17.99 years and diagnosed with a concussion following a traumatic head injury in the preceding 48 hours.


Return to physical activity within 7 days postinjury (ranging from light exercise to a full return to competitive sports).


No physical activity within 7 days postinjury. Propensity scores were derived to account for potential confounding baseline characteristics. Patients in each intervention group were matched 1:1 in random order based on the propensity scores.

Covariates considered

Age, sex, duration of prior concussion, duration of loss of consciousness, presence of symptoms on the initial concussion evaluation, personal/family history of migraine, learning/developmental disorder, attention deficit hyperactivity disorder, sleep disorder, other psychiatric disorders.


Presence of persistent postconcussive symptoms (PPCS), defined as at least three new or worsening individual symptoms at day 28 compared with the preconcussion status according to a validated Post-Concussion Symptom Inventory (primary outcome).

Follow-up period

28 days.

Patient follow-up

Of 3282 patients for whom consent was obtained, 219 discontinued the study during the ED attendance and 650 did not complete follow-up (missing primary outcome or physical activity data). The remaining 2413 patients were included in the primary analysis.

Main results

PPCS at 28 days occurred in 733 (30.4%) of patients who completed primary analysis. Participants in early physical activity (any and all intensities of exercise) had a lower risk of PPCS than those with no physical activity.

This finding was consistent across analytic approaches, including after application of propensity scores and matching to account for potential confounding by observed baseline characteristics, and following inverse probability of treatment weighting.


Resumption of physical activity within 7 days is associated with a reduced incidence of PPCS at 28 days.

Abstracted from: Grool AM, Apglipay M, Momoli F, et al. Association between early physical activity following acute concussion and persistent post concussive symptoms in children and adolescents. JAMA 2016;316:2504–14.


This study provides additional strength to the assertion that the recommendations on prolonged physical rest following concussion within current paediatric guidelines are overcautious and may hinder concussion recovery. While it remains essential that, following a concussion, activities with a risk of reinjury should be avoided, there is increasing evidence that earlier resumption of physical activity may improve the rate of symptom resolution. Given the overall importance of regular exercise to maintain physical health, any guidelines that avoid unnecessary cessation of physical activity are to be welcomed.

It has been postulated that an improvement in recovery from controlled aerobic exercise may be due to the promotion of neuroplasticity mechanisms and from possible effects on regulatory mechanisms to improve cerebral blood flow.1

Although propensity analysis was conducted to account for the potential confounding patient characteristics identified during the initial ED presentation, the observational nature of the study means that additional unmeasured confounders might have influenced the results. Furthermore, it is only possible to draw a conclusion of an association between earlier resumption of physical activity and reduced incidence of PPCS, rather than a direct causation.

Additional supporting evidence from a large, multicentre, randomised controlled trial is necessary before changing clinical practice, and before revised recommendations on the optimal time to resume physical activity can be made. Future research will also need to explore the potential benefit, or detrimental effect, of cognitive rest, which was not measured within this particular study.



  • Contributors ANK drafted the initial manuscript and drafted revisions. SH developed the concept for the manuscript and contributed to the revision and development of the final manuscript.

  • Provenance and peer review Not commissioned; internally peer reviewed.