A 12-year-old male came to clinic after falling off a sled the day prior. He wasn’t sure how he had landed but says there was no loss of consciousness or specific injuries and he continued sledding but soon became tired. He developed a headache on the way home from the sledding hill which continued to be present. The headache was dull to throbbing and described as annoying to hurting. Tylenol and rest improved his symptoms. He and his mother reported that he seemed “slow” today without a lot of energy. Sounds and lights seemed to annoy him. He denied any nausea/emesis, vertigo, difficulty walking or speaking. He stayed home from school and was resting more but wasn’t specifically sleepy. Trying to do homework or using computers made things worse. The past medical history revealed no specific head injuries and was otherwise non-contributory.
The pertinent physical exam showed a well appearing male with normal vital signs. His physical examination was normal except for some scratches on his forehead.
The diagnosis of concussion was made. His SCAT (sports concussion assessment tool) had 9 symptoms that were in the mild to moderate range. Cognitive and physical rest was recommended with some reasonable activities of daily living. He was to increase activity once the symptoms went away and followup the next week.
The patient’s clinical course the following week showed he was worse with increased severity of symptoms and endorsing some dizziness intermittently. He had tried to do some light activity but his symptoms were exacerbated. The following week he started to feel somewhat better again and the family decided to try letting him go to school but his headache and fatigue returned after about 3 hours. The pediatrician who saw him at the point of 3 weeks after the initial injury decided to send him to her partner who was also trained in sports medicine. She said that that boy had remarkably improved over the ensuing week. “By the time I saw him, most of his symptoms were gone and he had increased his activity. Funny thing was that he told me he kept walking his dog because that was when he felt better. He’s going to go back to school this week and I’ll see him again next week,” she told the pediatrician. The pediatrician and her partner briefly started to discuss his activity, but the partner was called away to see a patient. As she walked away she said, “We can talk more later but do you know about the Buffalo Treadmill Test?”
Head injury and concussion diagnosis and treatment continues to evolve. The current recommendations are evolving from more strict rest and wait to more limited activity and exercise. Interventions have shown data supporting reasonable exercise as not more harmful and potentially beneficial.
The Buffalo Concussion Treadmill Test (BCTT) evaluated 13-18 year old athletes (N=103) using a randomized controlled trial of early subthreshold aerobic exercise for sports-related concussion. The control group performed a stretching program for the same amount of time and were given the same general care instructions. The intervention group performed aerobic exercise on a treadmill or stationary bike wearing a heart rate monitor. Baseline heart rate when symptoms were exacerbated was determined at the initial evaluation. Patients were to perform daily exercise that was 80% of this symptom threshold. Exercise was to be for 20 minutes or to stop if symptoms worsened by 2 points on a visual analog scale. Patients in the intervention group recovered (i.e. were asymptomatic) at a mean of 13 days versus 17 days for controls. Other studies with the same participants showed that males reached symptom exacerbation threshold at a slightly lower heart rate than females but “…the BCTT provides comparable information and both sexes reach symptom exacerbation at similar (changes in heart rate).” They have also found similar outcomes for use of a treadmill versus a stationary bicycle. A stationary bicycle may be helpful for patients with limited mobility.
While heart rate monitoring and supervised aerobic exercise is not practical for the majority of children with concussions, the current recommendation trend seems to be moving toward more focus on having children continue some activity but to slowly increase the intensity and duration of those activities but keeping them below the amount of activity which exacerbates symptoms.
Questions for Further Discussion
1. Describe the Glasgow Coma Scale?
2. What items are on the SCAT or sports concussion assessment tool?
- Disease: Concussion | Head and Brain Injuries
- Age: School Ager
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Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Dev Neuropsychol. 2015;40(5):273-278. doi:10.1080/87565641.2015.1067706
Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514. doi:10.1001/jama.2016.17396
Halstead ME, Walter KD, Moffatt K, Council on Sports Medicine and Fitness. Sport-Related Concussion in Children and Adolescents. Pediatrics. 2018;142(6):e20183074. doi:10.1542/peds.2018-3074.
Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019;173(4):319-325. doi:10.1001/jamapediatrics.2018.4397
Haider MN, Johnson SL, Mannix R, et al. The Buffalo Concussion Bike Test for Concussion Assessment in Adolescents. Sports Health. 2019;11(6):492-497. doi:10.1177/1941738119870189
Chizuk HM, Willer BS, Horn EC, Haider MN, Leddy JJ. Sex differences in the Buffalo Concussion Treadmill Test in adolescents with acute sport-related concussion. Journal of Science and Medicine in Sport. 2021;24(9):876-880. doi:10.1016/j.jsams.2021.04.005
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa