英語タイトル: Early Subthreshold Aerobic Exercise as Treatment for Sport-Related Concussion
Concussion is defined as a physiological disturbance of brain function and/or traumatic structural injury.1 Concussions are also classified as traumatic brain injury (TBI).2 TBI occurs from forces applied directly or indirectly to the skull that results in rapid acceleration and deceleration of the brain. After a sports-related concussion (SRC), patients show a variety of sleep, physical (e.g., headache, nausea, etc.) and cognitive (e.g., concentration, memory, etc.) disturbances. The 2017 Concussion in Sport Group (CISG) consensus statement2 says that SRC results in a variety of clinical signs and symptoms that commonly follow a subsequent course of resolution.
SRC can contribute to diverse symptoms and problems and can be associated with concurrent injury to the peripheral vestibular system and/or the cervical spine. Current research has not evaluated early interventions for patients with a concussion, as most individuals recover in 10 to 14 days,2 only 10 to 15 % experiencing symptoms that prolong beyond this time frame.3 A treatment classification for each dysfunction (e.g., autonomic dysfunction/exercise intolerance,4 vestibular dysfunction,5-7 cervical spine dysfunction,8 etc.) or a combination of treatment techniques may be required to address impairments following SRC6,9 and with patients experiencing post-concussion syndrome (PCS).10 Clinicians should create individualized treatment plans for each patients with SRC. Rest has been a pillar of concussion treatment because of fear of slowed recovery, aggravation of symptoms, and/or brain damage with exertion early after concussion,11-13 especially for children.14 At present, there is insufficient evidence that prescribing complete rest achieves safer and faster recovery compared to early intervention. Previously published studies support interventions including cervical, psychological, and vestibular rehabilitation for post-concussion syndrome (i.e., syndrome that occurs when concussion symptoms linger for more than 21days).2
A brief (24-48hours) period of cognitive and physical rest is widely accepted and appropriate for most patients.15 After the period of rest, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (i.e., activity level should not worsen or bring on their symptoms). It is understandable for patients to avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined in the literature and requires further study.2 Because the most recent international consensus statement recommends a more active approach to treating patients with SRC, it would be useful to know how soon subthreshold exercise can be executed and how the exercise affects early SRC patients’ symptoms.2
Does a treatment including early, subthreshold, aerobic exercise for athletes with SRC decrease symptoms and days until return to play compared to rest?
Summary of Findings
Pathophysiology – The physiological and metabolic changes of concussion result, among other things, in altered function of control of cerebral blood flow (CBF) and the autonomic nervous system (ANS).16,17 The acute phase of concussion is characterized by the release of excitatory neurotransmitters resulting in unrestricted neuronal depolarization and noninterference exchange of ions including potassium and calcium.18 These ion imbalances are met with up-regulation of adenosine triphosphate (ATP)-dependent sodium-potassium pumps and sequential increases in cellular glucose metabolism demands.19 Following this initial period of hypermetabolism, mitochondrial dysfunction leads to an extensive period of decreased glucose utilization and metabolism, the duration of which is unclear and during which the brain may be at increased vulnerability to repeat trauma,20 and this physiological disturbance may exist even if symptoms disappear.21 Light aerobic exercise in healthy individuals has been showed to improve CBF,22 moods and self-esteem,22 and brain plasticity23-25 by increasing brain-derived neurotrophic factor (BDNF).26-28 In animal models of TBI, aerobic exercise decreases neuronal injury, enhances neuronal recovery, and promotes the production of neuroprotective trophic factors.29
Safety of subthreshold aerobic exercise for PCS
Light aerobic exercise is beneficial for the human brain and general health.30 Light aerobic exercise has been reported to have beneficial effects on cognition,28 moods,22 and sleep.31 Previous studies concluded that a graded aerobic treadmill testing is a safe, tolerable, and clinically valuable tool that can assist in the evaluation and management of children with a diagnosis of PCS secondary to an SRC.32-36 Too much exercise can, however, produce postconcussion-like symptoms in concussed patients and delay recovery.37 Randomized control trials (RCT) done by Kurowski38 and Chan,39 a prospective study done by Dobney,40 a retrospective review done by Grool,41 and a pilot study done by Leddy34 indicate youth experiencing persisting symptoms 4 to 16 weeks post-concussion demonstrated improved post-concussion symptoms scores (sleep-related, cognitive, emotional, and physical) with participation in an active rehabilitation program.
Safety of early subthreshold aerobic exercise for SRC
Emerging evidence indicates moderate levels of physical activity42-45 or prescribed early, subthreshold aerobic exercise46 do not prolong recovery in athletes after SRC. A randomized controlled trial (RCT) study done by Micay47 assessed the feasibility of early physical therapy that included early subthreshold aerobic exercise beginning 10 days post-concussion. The results indicate it is feasible and safe to complete this type of intervention. An RCT done by Leddy48 evaluated the systematic assessment of exercise tolerance in adolescents shortly after SRC within 1 to 10 days of sustaining an SRC and the prognostic utility of such assessment. The result indicates using the Buffalo Concussion Treadmill Test (BCTT)49 within 1 week after SRC did not delay recovery. Buffalo Concussion Bike Test (BCBT)50 can be used instead of BCTT for athletes who feel more comfortable exercising on a stationary bike. Interestingly, a lower heart rate threshold on visit day one was strongly associated with prolonged recovery time (p=0.0032). This result indicates the degree of early exercise intolerance after SRC may be important for prognosis. This has implications for academic and team preparation. This test result may help academic accommodation, as many students require a brief absence from school,51 and help indicate how long the athlete is going to be out of competition.
Effectiveness of early subthreshold aerobic exercise for SRC
A RCT and a preliminary study done by Leddy52,53 assessed the effect of early prescribed aerobic exercise versus relative rest on the rate of recovery in male adolescents acutely after SRC. Recovery time from the initial visit was significantly shorter in the exercise group. This type of exercise prescribed to symptomatic adolescent males within 1 week of SRC may hasten recovery and has the potential to prevent delayed recovery. Another randomized pilot study, however, showed no effect on time to recovery.46 Although the decision to transition the patient from this type of exercise program back into sport-specific activities must be made on an individual basis, it is wise to ensure these patients achieve a heart rate of 160 to 180 beats per minute during this program without developing symptoms.54
Clinical bottom line
An early symptom subthreshold, submaximal, aerobic exercise is safe and may be required for ongoing or persistent symptoms and impairments following SRC. The early, active rehabilitation program should be closely monitored by a physician and/or a health-care provider. This type of exercise is not the only option for SRC treatment, and combined approach to treatment including controlled cognitive stress, pharmacological treatment, and school accommodations may be beneficial. Further research evaluating rest and active treatments should be performed using high-quality designs that account for potential confounding factors and include matched controls and effect modifiers to best inform clinical practice and facilitate recovery after SRC.55 The findings of this Clinical Bottom Line are supported by Level 2-4 evidence.56 The Center for Evidence Based Medicine57 describes grades of recommendation as A, B, C, or D depending on the rigor of published studies and their collective conclusions related to a specific clinical question. For example, a strength of recommendation grade B indicates the recommendation was made based on research with high levels of evidence and consistent conclusions. Including early symptom subthreshold, submaximal, aerobic exercise to patients with acute SRC is safe with a strength of Recommendation(SOR): B. An early symptom subthreshold, submaximal, aerobic exercise with acute SRC may hasten recovery compared to relative rest with a SOR: C.
1. O’Neil ME, Carlson K, Storzbach D, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. Washington (DC)2013.
2. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847.
3. Makdissi M, Cantu RC, Johnston KM, McCrory P, Meeuwisse WH. The difficult concussion patient: what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms? Br J Sports Med. 2013;47(5):308-313.
4. Johnson BD, O’Leary MC, McBryde M, Sackett JR, Schlader ZJ, Leddy JJ. Face cooling exposes cardiac parasympathetic and sympathetic dysfunction in recently concussed college athletes. Physiol Rep. 2018;6(9):e13694.
5. Ellis MJ, Cordingley DM, Vis S, Reimer KM, Leiter J, Russell K. Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion. J Neurosurg Pediatr. 2017;19(1):38-45.
6. Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Inj. 2015;29(2):238-248.
7. Ellis MJ, Cordingley D, Vis S, Reimer K, Leiter J, Russell K. Vestibulo-ocular dysfunction in pediatric sports-related concussion. J Neurosurg Pediatr. 2015;16(3):248-255.
8. Reneker JC, Clay Moughiman M, Cook CE. The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An international Delphi study. J Sci Med Sport. 2015;18(4):366-372.
9. Ellis MJ, Leddy J, Willer B. Multi-Disciplinary Management of Athletes with Post-Concussion Syndrome: An Evolving Pathophysiological Approach. Front Neurol. 2016;7:136.
10. Kapadia M, Scheid A, Fine E, Zoffness R. Review of the Management of Pediatric Post-Concussion Syndrome-a Multi-Disciplinary, Individualized Approach. Curr Rev Musculoskelet Med. 2019;12(1):57-66.
11. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport – the Third International Conference on Concussion in Sport held in Zurich, November 2008. Phys Sportsmed. 2009;37(2):141-159.
12. Broglio SP, Cantu RC, Gioia GA, et al. National Athletic Trainers’ Association position statement: management of sport concussion. J Athl Train. 2014;49(2):245-265.
13. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med. 2013;23(1):1-18.
14. Davis GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med. 2017;51(12):949-957.
15. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934.
16. Leddy JJ, Kozlowski K, Fung M, Pendergast DR, Willer B. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment. NeuroRehabilitation. 2007;22(3):199-205.
17. Barkhoudarian G, Hovda DA, Giza CC. The Molecular Pathophysiology of Concussive Brain Injury – an Update. Phys Med Rehabil Clin N Am. 2016;27(2):373-393.
18. Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train. 2001;36(3):228-235.
19. Erecinska M, Dagani F. Relationships between the neuronal sodium/potassium pump and energy metabolism. Effects of K+, Na+, and adenosine triphosphate in isolated brain synaptosomes. J Gen Physiol. 1990;95(4):591-616.
20. Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery. 2014;75 Suppl 4:S24-33.
21. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935-940.
22. Alderman BL, Arent SM, Landers DM, Rogers TJ. Aerobic exercise intensity and time of stressor administration influence cardiovascular responses to psychological stress. Psychophysiology. 2007;44(5):759-766.
23. Griesbach GS, Tio DL, Nair S, Hovda DA. Recovery of stress response coincides with responsiveness to voluntary exercise after traumatic brain injury. J Neurotrauma. 2014;31(7):674-682.
24. Griesbach GS, Gomez-Pinilla F, Hovda DA. The upregulation of plasticity-related proteins following TBI is disrupted with acute voluntary exercise. Brain Res. 2004;1016(2):154-162.
25. Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience. 2004;125(1):129-139.
26. Erickson KI, Voss MW, Prakash RS, et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A. 2011;108(7):3017-3022.
27. Stroth S, Hille K, Spitzer M, Reinhardt R. Aerobic endurance exercise benefits memory and affect in young adults. Neuropsychol Rehabil. 2009;19(2):223-243.
28. Griffin EW, Mullally S, Foley C, Warmington SA, O’Mara SM, Kelly AM. Aerobic exercise improves hippocampal function and increases BDNF in the serum of young adult males. Physiol Behav. 2011;104(5):934-941.
29. Zafonte RD, Shih SL, Iaccarino MA, Tan CO. Neurologic benefits of sports and exercise. Handb Clin Neurol. 2018;158:463-471.
30. Ahlskog JE, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876-884.
31. Youngstedt SD. Effects of exercise on sleep. Clin Sports Med. 2005;24(2):355-365, xi.
32. Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg Pediatr. 2016;25(6):693-702.
33. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;20(1):21-27.
34. Leddy JJ, Cox JL, Baker JG, et al. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehabil. 2013;28(4):241-249.
35. Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehabil Res Pract. 2012;2012:705309.
36. Chrisman SPD, Whitlock KB, Somers E, et al. Pilot study of the Sub-Symptom Threshold Exercise Program (SSTEP) for persistent concussion symptoms in youth. NeuroRehabilitation. 2017;40(4):493-499.
37. Balasundaram AP, Athens J, Schneiders AG, McCrory P, Sullivan SJ. Do post-concussion-like symptom responses change following exercise or sports participation in a non-concussed cohort? Scand J Med Sci Sports. 2017;27(12):2002-2008.
38. Kurowski BG, Hugentobler J, Quatman-Yates C, et al. Aerobic Exercise for Adolescents With Prolonged Symptoms After Mild Traumatic Brain Injury: An Exploratory Randomized Clinical Trial. J Head Trauma Rehabil. 2017;32(2):79-89.
39. Chan C, Iverson GL, Purtzki J, et al. Safety of Active Rehabilitation for Persistent Symptoms After Pediatric Sport-Related Concussion: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2018;99(2):242-249.
40. Dobney DM, Grilli L, Kocilowicz H, et al. Evaluation of an active rehabilitation program for concussion management in children and adolescents. Brain Inj. 2017;31(13-14):1753-1759.
41. 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.
42. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43(3):265-274.
43. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-223.
44. Lennon A, Hugentobler JA, Sroka MC, et al. An Exploration of the Impact of Initial Timing of Physical Therapy on Safety and Outcomes After Concussion in Adolescents. J Neurol Phys Ther. 2018;42(3):123-131.
45. Lawrence DW, Richards D, Comper P, Hutchison MG. Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS One. 2018;13(4):e0196062.
46. 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.
47. Micay R, Richards D, Hutchison MG. Feasibility of a postacute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a randomised controlled study. BMJ Open Sport Exerc Med. 2018;4(1):e000404.
48. Leddy JJ, Hinds AL, Miecznikowski J, et al. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial. Clin J Sport Med. 2018;28(1):13-20.
49. Leddy JJ, Baker JG, Kozlowski K, Bisson L, Willer B. Reliability of a graded exercise test for assessing recovery from concussion. Clin J Sport Med. 2011;21(2):89-94.
50. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270.
51. Purcell LK, Davis GA, Gioia GA. What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic review. Br J Sports Med. 2019;53(4):250.
52. Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019.
53. Leddy JJ, Haider MN, Hinds AL, Darling S, Willer BS. A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males. Clin J Sport Med. 2018.
54. Ellis MJ, Leddy J, Cordingley D, Willer B. A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes. Front Neurol. 2018;9:1115.
55. McCrory P, Meeuwisse WH, Dvorak J, et al. 5th International Conference on Concussion in Sport (Berlin). Br J Sports Med. 2017;51(11):837.
56. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004;17(1):59-67.
57. Heneghan C. EBM resources on the new CEBM website. Evid Based Med. 2009;14(3):67.
|Concussion【電子書籍】[ Jeanne Marie Laskas ]価格:1,155円|