5 Questions About Returning to Play After a Sports-Related Concussion
About 1.6 to 3.8 million recreational and competitive American athletes develop a concussion each year. Therefore, it is important for health care professionals, especially neurologists, to keep up-to-date with the current guidelines and research. In fact, the American Academy of Neurology hosts a Sports Concussion Conference each year to ensure everyone is involved in the discussion of preventing, diagnosing, and managing sport-related concussion.
This year, we caught up with John Leddy, MD, from the University at Buffalo, after his session about returning to play after a sports-related concussion.1 John J. Leddy, MD, is the medical director for the Concussion Management Clinic at the University at Buffalo in Buffalo, New York. Here are his answers to our burning questions.
NEUROLOGY CONSULTANT: Can you give us an overview of your session?
John Leddy: The title of my talk is “Return to activity and the role of exercise in sport-related concussion (SRC).” I spoke about the physiology of concussion—the role of the autonomic nervous system in concussion pathophysiology as well as the autonomic nervous system as a target for activity-based treatment. Then I reviewed the evidence supporting moderate levels of spontaneous physical activity during the acute phase after concussion and in patients with prolonged post-concussive symptoms (PPCS). The evidence shows that physical activity is either not harmful or is beneficial for both populations.
I then discussed the evidence for the use of physician-prescribed subsymptom threshold aerobic exercise to treat patients with PPCS and the emerging evidence that shows that exercise can safely shorten recovery from acute SRC and perhaps prevent some patients from experiencing a delayed recovery. I then reviewed the evidence from a cohort study of a dose-response relation to recovery between rest, placebo-stretching, and aerobic exercise, highlighting the difference in response between male and female athletes. Finally, I discussed the use of an early assessment of excess tolerance combined with performance on the King-Devick eye test to predict who may have a delayed recovery from SRC.
NEURO CON: What do the current guidelines say about when individuals should return to activity after a concussion?
JL: The current 2017 Berlin Concussion in Sport Group (CISG) Consensus Statement2 states that after a period of 24 to 48 hours of relative rest, patients can start to gradually resume cognitive and physical activity while staying below their symptom-exacerbation thresholds. This does not mean they can return to intense activity or sports. It means that they can return to light levels of activity and gradually become more active as long as these activities, both cognitive and physical, do not provoke or exacerbate symptoms.
Once athletes are back to their baseline level of symptoms (please note, this is not saying that they have to be completely asymptomatic, since many studies show that nonconcussed persons are not asymptomatic on a daily basis), both at rest and with exertion, and they have a normal neurological physical examination, they can begin a graduated and supervised return-to-play program to return them to sport.
NEURO CON: What is the role of exercise after a concussion?
JL: We are beginning to learn that light levels of physical activity and even prescribed individualized subsymptom threshold aerobic exercise are beneficial for concussion recovery. This appears to be the case from as early as the acute post-injury phase (72 hours after injury) to weeks or months after the concussion. We believe that the exercise must be aerobic in nature, not anaerobic or resistance training, and that it must be performed at a level that does not exacerbate symptoms. We do not know the exact dose that is most beneficial, minimum or maximum, and we do not know the exact intensity that is most beneficial. At the University at Buffalo, we are now using a prescription for 90% of the heart rate achieved at the symptom exacerbation threshold on the Buffalo concussion treadmill test (BCTT) as the exercise intensity (their “target heart rate”).3 We recommend a frequency of 5 to 7 days per week. The intensity can be increased weekly, either by recommending increasing the target heart rate in 5 to 10 beats per minute increments or by retesting on the BCTT to establish a new heart rate threshold.
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About 1.6 to 3.8 million recreational and competitive American athletes develop a concussion each year. Therefore, it is important for health care professionals, especially neurologists, to keep up-to-date with the current guidelines and research. In fact, the American Academy of Neurology hosts a Sports Concussion Conference each year to ensure everyone is involved in the discussion of preventing, diagnosing, and managing sport-related concussion.
This year, we caught up with John Leddy, MD, from the University at Buffalo, after his session about returning to play after a sports-related concussion.1 John J. Leddy, MD, is the medical director for the Concussion Management Clinic at the University at Buffalo in Buffalo, New York. Here are his answers to our burning questions.
NEUROLOGY CONSULTANT: Can you give us an overview of your session?
John Leddy: The title of my talk is “Return to activity and the role of exercise in sport-related concussion (SRC).” I spoke about the physiology of concussion—the role of the autonomic nervous system in concussion pathophysiology as well as the autonomic nervous system as a target for activity-based treatment. Then I reviewed the evidence supporting moderate levels of spontaneous physical activity during the acute phase after concussion and in patients with prolonged post-concussive symptoms (PPCS). The evidence shows that physical activity is either not harmful or is beneficial for both populations.
I then discussed the evidence for the use of physician-prescribed subsymptom threshold aerobic exercise to treat patients with PPCS and the emerging evidence that shows that exercise can safely shorten recovery from acute SRC and perhaps prevent some patients from experiencing a delayed recovery. I then reviewed the evidence from a cohort study of a dose-response relation to recovery between rest, placebo-stretching, and aerobic exercise, highlighting the difference in response between male and female athletes. Finally, I discussed the use of an early assessment of excess tolerance combined with performance on the King-Devick eye test to predict who may have a delayed recovery from SRC.
NEURO CON: What do the current guidelines say about when individuals should return to activity after a concussion?
JL: The current 2017 Berlin Concussion in Sport Group (CISG) Consensus Statement2 states that after a period of 24 to 48 hours of relative rest, patients can start to gradually resume cognitive and physical activity while staying below their symptom-exacerbation thresholds. This does not mean they can return to intense activity or sports. It means that they can return to light levels of activity and gradually become more active as long as these activities, both cognitive and physical, do not provoke or exacerbate symptoms.
Once athletes are back to their baseline level of symptoms (please note, this is not saying that they have to be completely asymptomatic, since many studies show that nonconcussed persons are not asymptomatic on a daily basis), both at rest and with exertion, and they have a normal neurological physical examination, they can begin a graduated and supervised return-to-play program to return them to sport.
NEURO CON: What is the role of exercise after a concussion?
JL: We are beginning to learn that light levels of physical activity and even prescribed individualized subsymptom threshold aerobic exercise are beneficial for concussion recovery. This appears to be the case from as early as the acute post-injury phase (72 hours after injury) to weeks or months after the concussion. We believe that the exercise must be aerobic in nature, not anaerobic or resistance training, and that it must be performed at a level that does not exacerbate symptoms. We do not know the exact dose that is most beneficial, minimum or maximum, and we do not know the exact intensity that is most beneficial. At the University at Buffalo, we are now using a prescription for 90% of the heart rate achieved at the symptom exacerbation threshold on the Buffalo concussion treadmill test (BCTT) as the exercise intensity (their “target heart rate”).3 We recommend a frequency of 5 to 7 days per week. The intensity can be increased weekly, either by recommending increasing the target heart rate in 5 to 10 beats per minute increments or by retesting on the BCTT to establish a new heart rate threshold.
