Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial

Correspondence to Dr Andrée-Anne Ledoux, Emergency Reseach Department, Children's Hospital of Eastern Ontario, Ottawa, ON K1H 8L1, Canada; [email protected]

Introduction

Current concussion consensus guidelines^1–3 recommend 24–48 hours rest, followed by symptom-limited activity. Once symptoms have resolved, patients may gradually resume physical activity (PA). Limited trial evidence exists, especially in younger paediatric athletes and in the general paediatric population, on whether early resumption of PA, even if symptomatic, is safe and prognostically better.

Although rest is important in the initial 24–48 hours post concussion, protracted rest can lead to fatigue, reactive depression and physiological deconditioning.^4–6 Conversely, therapeutic PA has been associated with milder symptoms,^6–11 faster recovery^12–15 and reduced risk of persistent post-concussion symptoms (PPCS).^{13 15} However, most studies investigating PA as treatment have small sample sizes,^{6 8 10 16 17} retrospective designs^{12 18} or initiated PA 1 week post injury¹⁴ or later.^{13 17 19} Many studies included only youth with sport-related concussion,^{14–17 19} who recover faster compared with the general paediatric population,²⁰ or were conducted in controlled environments,^{14 16} which may not be pragmatic or generalisable. A pragmatic randomised clinical trial (RCT) is necessary to determine the efficacy and safety of resuming PA 72 hours post concussion in the general paediatric population.

Our primary objective was to investigate if reintroduction of non-contact PA 72 hours post concussion (even if symptomatic) is safe and reduces symptoms at 2 weeks in children/youth aged 10–<18 years, compared with resting until symptom resolution.²¹ We hypothesised that introducing early non-contact PA in a standardised, incremental fashion 72 hours post injury would result in a lower symptom burden, compared with incremental introduction of PA once asymptomatic, and not cause adverse events (AE). Sex, age, symptoms on ED presentation and the Predicting and Preventing Postconcussive Problems in Paediatrics (5P) score (validated risk score for PPCS at 4 weeks)²² are predictors of PPCS and are associated with recovery duration.^22–24 Subgroup analyses evaluated whether age, sex, initial symptom severity or 5P score moderated the association between the protocol followed and symptom burden at 2 weeks.

Methods

This study was a real-life condition, multicentre randomised clinical trial²⁵ (1:1). Participants were recruited from March 2017 to December 2019 in three...