A Randomized Controlled Trial Comparing Prescribed Light Exercise to Standard Management for Emergency Department Patients With Acute Mild Traumatic Brain Injury.

Introduction:The emergency department (ED) is the first point of health care contact for most head injured patients. The majority (estimated 85%) of patients suffering head injury will not have intra-cranial damage requiring neurosurgical consultation, but may have symptoms of mil traumatic brain injury (MTBI). Patients with MTBI may have physical, emotional, behavioral, or cognitive symptoms such as headache, sleep disturbance, disorders of balance, fatigue, irritability, memory and concentration problems, and the majority have self-limited symptoms that abate within 7 to 10 days. Although early and spontaneous resolution occurs in most patients, a small proportion of adults with MTBI will have a protracted course. It is estimated between 15-30% of patients with MTBI develop post-concussion syndrome (PCS), which is a persistence of head injury symptoms after MTBI.3 PCS usually lasts 2-4 months, and the symptoms typically peak 4-6 weeks following the injury4. However, in a smaller percentage of patients, the symptoms of PCS last for a year or longer. Approximately 20% of adults with PCS will not have returned to full-time work 1 year after the initial injury, and some are disabled permanently by PCS.

Current guidelines recommend a period of 'cognitive rest' and stepwise return to usual activities following MTBI. Cognitive rest is defined as the avoidance of mental activities that may trigger symptoms, such as watching television, using the computer, exercising, or talking on the phone. Patients following 'return to usual activity' instructions are encouraged to only resume normal activities once symptoms have resolved, and if symptoms return upon recommencement of activities, to return to rest. However, a recent systematic review of early educational interventions in the ED for MTBI concluded there are no clear and consistent interventions or standard management practices that exist for this population. Additionally, previous research evaluating a period of strict bed rest, which includes both physical and cognitive rest, has also not been shown to decrease severity or duration of MTBI symptoms. Based on the best available evidence, current guidelines for the management of MTBI suggest complete bed rest should be avoided after the first 48 hours post-injury.

Regular exercise has been shown to have positive effects on well-being, including mental health, improved self esteem, sleep and memory. Recent studies including patients with PCS have reported exercise treatment programs improved exercise tolerance and decreased symptoms, even for those patients where exercise previously exacerbated PCS symptoms. Additionally, Wise et al., randomized patients with severe TBI to either a structured exercise program for 10 weeks or usual care and found patients in the exercise group were less depressed and reported better health status compared to those not included in the exercise program.

Rationale: Given the paucity of effective management strategies that prevent PCS following MTBI and emerging evidence of the benefits of exercise in MTBI patients, there is an urgent need for more research on the effectiveness of an early exercise intervention in the acute MTBI patient population as prevention of PCS.

Research Question: Among adult (18-64 years) patients presenting to the ED with a discharge diagnosis of acute MTBI (defined by the Zurich consensus statement), does prescribing light exercise (ie: 30 min daily walking) reduce the proportion of patients with PCS at 30 days, compared to standard discharge instructions?