In their article, Lennon et al1 investigated the effect of introducing physical therapy intervention at different time intervals following concussion (0-3 weeks; 3-6 weeks; and >6 weeks) on symptom recovery and other variables in a young cohort (12-21 years of age). Their retrospective analysis concludes that the early intervention group was not different with respect to symptom recovery, number of PT visits, and duration of PT episode of care when compared with the mid and late intervention groups. In addition, no safety concerns were identified for the early, mid, or late treatment groups. This study highlights important considerations for physical therapists working with patients following concussion and prompts careful reexamination of "standard practice" as it applies to rest and activity following a concussion.

The first consideration for physical therapists managing patients with concussion is that targeted, multimodal treatment may be safely implemented earlier than previously recommended by consensus statements. Specific treatments discussed in this study include vestibular, oculomotor, cervical, and aerobic exercises. Many clinicians have practiced under the hypothesis that treatment (if appropriate) should be delayed after concussion, as otherwise, exacerbation of the injury would likely occur. Even the most recent Concussion in Sport Group guideline suggests that active rehabilitation should be considered only after a "failure of normal clinical recovery" (>14 days in adults and >4 weeks in children).2 Based on assumptions that early postconcussion symptoms are best managed by minimizing activity and brain energy demands following concussion, active rehabilitation was thought to be contraindicated in the early weeks following a concussion.

While emerging evidence illustrates the benefit of programmed rehabilitation, until recently it had been endorsed only in chronic cases.3-7 As stated earlier, in this current study by Lennon et al,1 patients who underwent early physical therapy treatment did not require more visits and experienced similar levels of symptom recovery, implying that early management is not detrimental. With this report, as well as another recent study from Dobney et al,8 there is an increasing support for the safety of early active rehabilitation implemented by physical therapists.

A second important concept for therapists in clinical management of patients with concussion is that prescription of physical activity in individuals who are symptomatic appears to be as safe in the first weeks after injury as in chronic stages. This also differs from the most recent consensus statement from the Concussion in Sport Group, where it is recommended that in the early weeks following a concussion, patients participate only in light aerobic activity once they are able to tolerate daily activities without symptoms. In both the articles by Lennon et al1 and Dobney et al,8 patients at all time periods postconcussion were moderately symptomatic when intervention programs that included aerobic exercise training were initiated. Of note, in both studies, aerobic conditioning programs were symptom-limited, meaning that the exercise was maintained at levels that did not provoke additional symptoms. While widely applied, it is not known whether symptom-limited exercise is a necessary component of aerobic exercise prescription following a concussion.

The results from several recent studies question the concept of rest as the primary treatment of concussion. Gibson et al9 studied cognitive rest in a cohort of younger athletes, finding that this recommendation did not benefit recovery time. In a retrospective study of adolescents, researchers found that compliance with recommendations for physical and cognitive rest was associated with slower recovery time.10 A randomized controlled clinical trial examined the effect of prescribed rest on clinical outcome and found that patients who were permitted "usual" levels of activity had fewer symptoms and shorter symptom duration than those who rested.11 Finally, in a recent large, prospective, multicenter cohort study of children seen in the emergency room for concussion, patients who were physically active within 7 days of injury were less likely to experience persistent postconcussive symptoms at 28 days than those who were inactive.12

While the article by Lennon et al1 supports the safety of early, clinically supervised physical therapy, several studies demonstrate that uncontrolled early activity may be detrimental. An obvious example of this is at the time of injury, where athletes who were not removed from play experienced significantly longer recovery time than those who were removed from play when a concussion occurred.13,14 Other research examining activity level in athletes and animals in the early days following a concussion showed that unmoderated physical and cognitive activity was associated with worse clinical findings and recovery times.15,16 An important consideration in the current study is that treatment activities were prescribed and supervised by licensed physical therapists and individualized on the basis of presenting impairments.

The findings of this study should not be surprising to physical therapists. Many conditions such as low back pain, whiplash-associated disorder, and stroke have published literature supporting the efficacy of early intervention.17-19 While this study provides evidence that physical therapy and aerobic exercise are safe when implemented in the first 3 weeks after injury, it does not examine whether beginning treatment in the first 3 weeks results in improved outcomes. Likewise, another study by Reneker et al20 (abstracted in this issue of JNPT) provides early evidence that in athletes as soon as 10 days postconcussion, physical therapy that incorporates both neurologic and orthopedic approaches may be associated with faster symptom recovery and medical clearance to return to play. Although this study focused primarily on feasibility, it serves as a basis for larger trials that can further examine specific treatments and timing of intervention to better guide care.

When examining issues of timing and type of intervention, it will be prudent to examine concussion intervention in the context of heterogenous presentations. For example, one study highlighted the high incidence of anxiety in their cohort and introduced interventions such as visualization, relaxation, and aerobic exercise in their treatment program.8 This type of intervention may not benefit patients with oculomotor impairment similarly. In any event, establishing safety in delivering physical therapy intervention at different time points opens the door for further research on these topics to further inform clinicians.

For now, physical therapists have increased support from the available literature to implement treatment at a time point based on best clinical practice, without the arbitrary designation of more than 2 or 4 weeks. The notion that early impairment-based intervention is not harmful, and indeed may be beneficial in managing concussion, is intuitive for physical therapists but a novel concept in concussion management. With studies such as the article by Lennon et al,1 clinicians will have the benefit of empirical evidence to advise care, rather than relying on "expert consensus" guidelines.

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