O3279: Benefits of Early Activity or Behavioral Intervention after Acute Concussion

Background: Current standard of care for pediatric patients with acute concussion recommends rest followed by a symptom-guided return to activity. Research suggests that physical activity and behavioral management in the subacute and chronic time periods may facilitate recovery. There is limited evidence to inform specific physical and behavioral interventions in the acute ( < 72 hours) time period following concussion.

Methods: We conducted a multicenter prospective 2x2 factorial randomized controlled trial to determine the benefit of early physical activity and behavioral management or both on patients 11-24 years old who presented to the emergency department or concussion clinic within 72 hours of injury. Participants were randomized into 4 groups based on recommended level of physical activity (or rest) and use of a mobile health (mHealth) application for behavioral management (or no app). Activity group was prescribed low-intensity physical activity (e.g. targeting steps/day). Behavioral management prescribed using a free mHealth app that awards points for completing tasks that promote mental, physical, social, and emotional resilience. Patients were assessed at enrollment and then at 3-5 days, 14 days, 1 month, and 2 months post-enrollment. Assessments measured concussion symptoms, quality of life, balance, vestibular-ocular function, and cognitive function. Somatic symptoms and other risk factors were evaluated at enrollment. Compliance with treatment and symptoms were assessed daily using actigraphy, app use, and daily self-report. The primary study outcomes were post-concussion symptom severity and quality of life at 14 days. Analyses were intention to treat with a focus on main effects of the 2 factors.

Results: We randomized 239 patients; with 210 completing all study procedures. Groups were similar in demographics, mechanism of injury, signs/symptoms on presentation, and acute evaluation and treatment. (See Table 1). The physical activity group averaged 7008 steps/day compared to 5697 steps/day in the rest group in the first week post-enrollment (p < 0.001). At 14 days, there were no differences between activity groups in post-concussion symptom severity and quality of life. The Rest group had better balance at 14 days (4.7 vs 6.1 mBESS errors at 14 days; p=0.02). However, the activity intervention group reported higher daily post-concussion symptom severity over the first 5 days and took 5 days longer to recover compared to the rest group (10 days vs 5 days to achieve symptoms score < 7; p=0.03; see Figure 1). No differences were observed for patients assigned to the mHealth intervention.

Conclusion: Prescribed early physical activity and behavioral management did not improve outcomes in pediatric patients in the first 2 weeks following acute concussion. Prescribed activity was associated with slower acute post-concussion symptom improvement. While activity-based treatment has shown benefit in recovery from sports concussion, in this heterogenous population, acute activity may transiently increase symptom scores without improving overall rate of recovery.