NEJM Paper: Active Management Most Effective Concussion Treatment

The paper is authored by the University at Buffalo researcher whose work over several decades has helped establish that physical activity facilitates faster recovery from sport-related concussion.

“Our work at UB has taken an exercise physiological approach to a neurological injury that has changed clinical treatment from a passive, strict rest approach to a prescribed active rehabilitation approach,” says John J. Leddy, MD, author of the paper and clinical professor of orthopaedics in the Jacobs School of Medicine and Biomedical Sciences at UB and a physician with UBMD Orthopaedics and Sports Medicine.

For more than two decades, Leddy and colleague Barry Willer, PhD, professor emeritus of psychiatry in the Jacobs School, have been developing and studying prescribed aerobic exercise to speed recovery in individuals who’ve had a concussion, which is considered a mild traumatic brain injury (TBI). They and other researchers have consistently demonstrated that individualized physical activity after concussion provides the best evidence-based care for evaluating and managing sport-related concussions.

Their recommendations were included for the first time in the Sixth International Conference on Concussion in Sport, held in Amsterdam in 2022.

The NEJM paper cites statistics that concussion or mild TBI affects approximately 42 million persons worldwide each year, including between 1.6 and 3.8 million sport-related concussions in the United States.

“Red flag” symptoms that require urgent medical attention include loss of consciousness for longer than 30 seconds, uncontrolled vomiting, weakness in the arms or legs, and increasingly severe headache.

The NEJM paper presents the case of a 17-year-old female soccer player whose head hits the ground during a game. She doesn’t lose consciousness, but experiences dizziness, wobbly gait, nausea, photosensitivity and trouble falling asleep.

The paper states that evaluation of a sport-related concussion should be done as soon as possible on the sideline by an athletic trainer or health care provider. It is important to diagnose cervical spine injuries that can occur with concussion and that can mimic the symptoms of concussion. If these injuries go untreated, Leddy says, they can become a risk for persisting symptoms, so early treatment of cervical spine injuries is critical.

Leddy notes that the medical community has fully rejected the prescribed strict rest period known as “cocooning,” which had been the standard of care for decades, and replaced it with a brief period of relative rest followed by “prescribed exercise as medicine” as the standard of care.

His clinical recommendation is that the patient can begin light physical activity (e.g., activities of daily living and going for a walk outside) and graduated aerobic exercise within 24-72 hours of a concussion, which has been shown to be effective in getting patients back to work, school and sport as soon as possible. 

“Exercise intolerance is a frequent sign of concussion and is believed to be from autonomic nervous system dysfunction after concussion,” says Leddy. “Controlled, individualized aerobic exercise rehabilitation initiated within 2-10 days after injury facilitates recovery from sport-related concussion and prevents a good portion of individuals from suffering persisting symptoms lasting more than four weeks after concussion.”

According to the paper, the patient in the case should engage in controlled physical activity and aerobic exercise early on for as long as the patient wants until her concussion symptoms increase by more than two points on a zero to 10-point scale, when compared to their symptom level before beginning the activity. At that point, the patient should rest but can resume once symptoms return to the pre-activity level.

“Once patients can do aerobic exercise at more than 70% of their age-predicted heart rate maximum for about 20 minutes without more than mild exacerbation of symptoms, they can proceed to individual sport-specific training (such as soccer ball drills) outside of the team environment to limit the potential for additional head injury,” Leddy says.

To figure out one’s age-predicted heart rate maximum, subtract age from 220 and halve it; that becomes the initial training target heart rate.

Leddy explains that gradual reintroduction of physiological activity allows the body's altered post-concussion physiology to habituate or adapt to the stresses of exercise after concussion.

Once all concussion signs and symptoms are gone, both at rest and with exertion (aerobic exercise plus sport-specific drills), the patient can advance gradually back to contact sport participation, ideally under supervision of an athletic trainer or coach.

The paper references recent findings that cognitive activity soon after injury, including a return to school with some provider-indicated supportive measures (such as more rest breaks, more time for assignments and postponing of tests until recovery), for the patient is more effective than prolonged absence from school. This is particularly important for adolescents, the group most vulnerable to persisting symptoms after concussion.

Leddy notes that these would be his clinical recommendations for the female soccer player case, in addition to the controlled aerobic exercise. He would recommend good sleep hygiene and a return to walking and activities of daily living along with low stress cognitive activities while prescribing daily walking or stationary cycling at 50% of her age-predicted maximum heart rate.

Patients are discouraged from using short-acting, non-steroidal anti-inflammatory drugs and acetaminophen multiple times per day for weeks or months for headaches because, paradoxically, they can worsen headaches.

Leddy also notes it is important to inform patients and their parents that current evidence does not show that concussions in former amateur athletes (high school, college) is a risk for neurological disease (e.g., dementia) later in life.