The Safety and Efficacy of Sub-Symptom Threshold Exercise as a Treatment for Post-Concussion Symptoms in Adolescents

Introduction: Concussions are an unfortunately common injury sustained by many young athletes participating in a variety of sports throughout the country. Concussions are notoriously difficult to diagnose and may lead to serious, long-term difficulties if left untreated or treated incorrectly. Severe or repeated concussions can lead to many physical, psychological, neurological, and other symptoms that could potentially lead to death. Current concussion treatment is largely physical and cognitive rest. This research study aims to identify how limited exercise may decrease the duration of symptoms and make it safer for athletes to resume participation in their sport. Methods: A literature search was performed and completed in November of 2019 using the PUBMED and EBSCO search databases. 11 articles were chosen based on inclusion/exclusion criteria as well as the date they were completed. These articles were then analyzed and their data were compared. Results: The studies evaluated demonstrated benefits to the use of exercise in decreasing post concussive symptoms. Several studies also evaluated and demonstrated the safety and tolerability of exercise programs in adolescents with neurologic symptoms post tbi or concussion. These studies used a variety of metrics, evaluation tools, and statistical tests to demonstrate improvements. However, only a few studies were able to collect follow up data at various points post evaluation. Also, a few studies were not able to use an adequate control group to demonstrate the success of the treatment across different populations. Finally, almost all studies were done on too small of sample sizes to allow for broad extrapolation of data. Discussion: The data collected from the studies were able to show strong data in support of subsymptom threshold exercise as a better treatment option for adolescents with post-concussion symptoms than strict rest. Despite this, there are many factors that limit the generalizability of the data to state adequately that the exercise treatment is always both safer and more efficacious. More data must be collected through studies with larger sample sizes that extend over much longer periods of time to evaluate future health outcomes must be completed. One important finding of these data is that the findings were found to be safe, and negative findings were extremely minimal. Future, more robust studies should continue to employ and evaluate subsymptom threshold exercise as a treatment plan for adolescents with post-concussion symptoms. Conclusion: Concussions continue to be a very common issue in adolescent athletes, and a solution on how best to treat them continues to be a mystery. Previous treatment plans have stuck largely to a program of strict cognitive and physical rest until the symptoms improve. As demonstrated in the studies highlighted, properly implemented and monitored exercise has shown data indicating its efficacy as a superior treatment. However, further, more robust studies must be completed to show increased generalizability and long term success before these exercise treatments can be implemented as a mainstream treatment. The demonstrated safety of the exercise and positive findings shown make further research crucial and worthwhile to improve treatment for these millions of adolescent athletes. Kingsley: Exercise and Concussions 3 Introduction A concussion is defined as a complex pathophysiological process affecting the brain (McCrory et al., 2008). This type of brain change is caused by some type of trauma leading to a form of traumatic brain injury referred to as a concussion. At the 3 international conference on concussion in sport (McCrory et al., 2008), the physicians identified concussion symptoms as “a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that in a small percentage of cases, however, post concussive symptoms may be prolonged. ” This definition can then be broken down further to say that these symptoms include somatic symptoms such as a headache or emotional symptoms, physical signs including amnesia or loss of consciousness, behavioral changes such as irritability, cognitive impairment including slower reaction times, and/or sleep disturbances. A concussion may be suspected for diagnosis if one or more of those categories of symptoms are met by the patient. These concussions are certainly a problem for the individuals sustaining the blows and putting themselves at risk, but the burden of these concussions is also a public health problem. The societal impact of concussions can be felt when the epidemiology of these concussions is laid out. 38 million children participate in organized sports in the United States alone. These young athletes are then coupled with the additional 170 million adults that participate in physical activities including similar organized sports (Daneshvar et al., 2011). The number of traumatic brain injuries resulting in concussions and subsequent hospitalizations from sports and recreation activities has also been greatly increased. The CDC reported that from 2001 through 2009, the annual traumatic brain injury related visits to emergency rooms increase from 153,375 per year to 248,418 per year (Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years, n.d.). Also, it was reported that the highest rates of Kingsley: Exercise and Concussions 4 hospitalizations came from males ranging in age from 10 to 19 years old. Many people around sports have heard of the short-term symptoms described above, including but certainly not limited to headache, neck pain, vision problems, sleep issues, cognitive deficits, and emotional changes (Junn, Bell, Shenouda, & Hoffman, 2015). These symptoms have been seen before in athletes in many forms with variations depending on both the athlete herself and the severity of the concussion from the blow to the head. However, it is often discounted that these symptoms are not always easily shaken and, unlike a bruise or cut, can be made significantly worse and leave permanent damage to the athlete beyond simply on the field abilities if left untreated. Concussions left untreated or unmanaged can cause not only the short-term symptoms mentioned, but long-term deficits can cause major issues for the athlete as well. The long-term symptoms include lingering short-term symptoms that make everyday life difficult, but also other neuropsychological outcomes due to alterations in brain physiology due to the injury/injuries sustained by the trauma. These potential outcomes include issues with executive function, attentional dysfunction, memory problems, slowed processing speeds, altered moods, and major depression symptoms (Carman et al., 2015). These lasting symptoms are also much more prevalent in those experiencing concussions than many individuals realize. A longitudinal study completed by Theadom et al. (2016) recruited adults over the age of 16 to completed assessments regarding their cognitive functioning, global functioning, post-concussion symptoms, mood, and quality of life a year after an injury resulting in a concussion. The results showed that after a full year, 47.9% of the participants reported still experiencing four or more of the post-concussion symptoms. Additionally, 10.9% of the participants reported very low cognitive functioning. Concussion treatments have been an area of some mystery as more and more information continues to surface about their outcomes. Previously, a very common Kingsley: Exercise and Concussions 5 recommendation to treat concussion symptoms was a period of strict rest. A study by Thomas et al. (2015) investigated the effectiveness of increasing a specifying that period of rest. In this study, patients randomly assigned to the control group rested one or two days before returning to school and returning to physical activity after the symptoms had resolved. If strict rest was beneficial, the researchers predicted more favorable outcomes with a longer, stricter rest regiment. The intervention group was told to maintain a strict rest period of five days. This included no school, work, or physical activity during those days. The results of this study, however, showed that this strict rest period added no benefit to the intervention group. There were no significant changes in the symptom scale reports (PCSS), the neurocognitive assessment, or the balance assessment (BEESS). In fact, patients in the intervention group experienced higher total symptoms over the course of the study (P<0.03). Many emerging treatments have become relevant recently creating more options for healthcare providers and patients to search for treatments that best suit their specific needs. One such treatment is an earlier use of sub-symptom threshold exercise as part of the recovery process. Data from this treatment approach continue to be positive and should be taken seriously as part of a patient’s treatment plan. The goal of this study is to investigate: in adolescent athletes, ages 11-19, does a limited regiment of sub-symptom, aerobic exercise decrease the duration of symptoms (headache, concentration issues, irritability, sleep disturbances) as compared to strict rest?