By Elena Moro
For February 2017, we have selected: Grool AM, Aglipay M., Momoli F., et al., for the Pediatric Emergency Research Canada Concussion Team. Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA 2017:316;2504-2514.
Practical recommendations in the management of concussion in pediatric patients have stressed the need of physical and cognitive rest starting immediately after the injury. A gradual renewal of any activity is endorsed only after resolution of the postconcussive symptoms. However, there is little evidence supporting this common practice. Moreover, recent studies suggest that prolonged rest might have a negative impact on the recovery, favoring depression, fatigue, and anxiety. There is also growing evidence supporting the benefit of light aerobic physical activity following pediatric concussion.
In this paper the authors measured the impact of physical activity within 7 days after concussion on the occurrence of persistent postconcussive symptoms (PPCS) in children and adolescents. This study was a part of the planned secondary analyses of the Predicting Persistent Postconcussive Problems in Pediatrics (5P) study, a prospective multicenter cohort study involving 9 pediatric emergency departments in Canada (from August 2013 to June 2015). A total of 3,063 subjects aged between 5 and 18 years admitted at emergency departments for acute head injury occurred within the preceding 48 hours were enrolled in the study. Patients with Glasgow Coma Scale ≤13, positive brain imaging, neurosurgical interventions, or multisystem injuries requiring hospitalization were not included. Injury characteristics were assessed using the Acute Concussion Evaluation inventory administrated to patients and parents, whereas the Post Concussion Symptom Inventory (PCSI) was used to quantify pre-injury and current symptoms. Finally, cognitive, physical, and balance assessments were evaluated by the Child-Sport Concussion Assessment Tool-3rd Edition (Child-SCAT3). After the enrollment, patients were followed with web-based survey or telephone calls at 7 and 28 days. Early physical activity was defined as any level of physical activity (light aerobic exercise, moderate exercise, full exercise) at 7 days after the enrollment.
Main outcome was the presence of PPCS (at least 3 new or worsening individual symptoms compare to preconcussion per the PCSI) at 28-day follow-up. The unadjusted association between early physical activity and PPCS was studied with the sample relative risk (RR) and the sample Absolute risk difference (ARD). Propensity scores were also developed for potential confounding by observed baseline characteristics. Participants who did not have any physical activity were matched 1:1 in random order to those who did have early physical activity. Inverse probability of treatment weighting (IPTW) and sensitivity analyses were used at day 7.
A total of 2,413 patients were involved in the primary analyses (age 11.77 ± 3.35 years, 1,205 females – 49.3%). At baseline, 733 patients (30.4%) met criteria for PPCS. Of the 1,677 (69.5%) patients who were engaged in physical activities, mainly light aerobic exercise (32.9%), 803 (47.9%) had at least 3 persistent or worsening postconcussion symptoms at day 7, versus 584 (79.5%) of the 736 subjects with no physical activity. In bivariate analysis at day 28, early participation in any type of physical activity was associated with lower risk of PPCS compared to no activity (24.6% vs. 43.5%; RR, 0.75, 95% CI, 0.70-0.80; ARD, 18.9%, 95% CI, 14.7%-23.0%). In propensity score-matched bivariate analysis (1,108), early participation in physical activity remained associated with lower PPCS risk (28.7% vs. 40.1%; RR, 0.84, 95% CI, 0.77-0.92; ARD, 11.4%, 95% CI, 5.8%-16.9%), as well as in IPTW (RR, 0.74, 95% CI, 0.65-0.84; ARD, 9.7%, 95% CI, 5.7%-13.7%). No significant association was found between age and physical activity.
“Within the limits of an observational study, the authors provide evidence that engagement in physical activities within one week after concussion may be beneficial in children and adolescents”, says Prof. A. Arzimanoglou, Director of the Pediatric Epileptology, Sleep Disorders and Functional Neurology Department, University Hospital of Lyon, France. “Patients who participated in any kind of physical activity had less risk to develop or worsened PPCS at 28 days. These findings are in line with the benefits from physical activities observed in youth for body composition, cardiorespiratory and skeletal health, school performance, and neuropsychological symptoms. According to the authors, this improvement might be related to promotion of neuroplasticity through improved cerebral blood flow.”
“There are several limitations in this study, including the lack of objective assessments, the simple observational design, and the absence of randomization”, says Prof. L. Lagae, Department of Paediatric Neurology, University Hospital, Leuven, Belgium. “Nevertheless, less conservative recommendations can be considered in the management of postconcussion pediatric population, likely with the exclusion of early participation in activities with high risk of collision or falls.”
The other nominees for the February 2017 Paper of the month are:
- Brown CE, Alizadeh D, Starr R, et al. Regression of glioblastoma after chimeric antigen receptor T-cell therapy. N Engl J Med 2016;375:2561-2569. This is a case report of a patients with multifocal glioblastoma who received several intracranial infusions of chimeric antigen receptor- engineered T cells against tumor-associated antigen interleukin-13 receptor alpha 2. Treatment was well tolerated and associated to regression of glioblastoma up to 7.5 months.
- Montalban X, Hauser SL, Kappos L, et al., for the ORATORIO Clinical Investigators. Ocrelizumab versus placebo in primary progressive multiple sclerosis. N Engl J Med 2017;376:209-220. In this multicenter phase 3, double-blind trial, 732 patients with primary progressive multiple sclerosis were randomized to receive intravenous ocrelizumab or placebo every 24 weeks within at least a 120-week period. Patients who received ocrelizumab had a slower progression of the disease compared to placebo (less progression of disability confirmed at 12 weeks in a time-to-event-analysis).