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. Author manuscript; available in PMC: 2026 Jul 21.
Published in final edited form as: J Sport Rehabil. 2026 Apr 9;35(7):603–611. doi: 10.1123/jsr.2025-0385

The Integrated Effect of Physical Activity and Sleep Problems on Concussion Symptom Resolution

Zackary P Salfi 1,2, Mathew J Wingerson 1,2, Catherine C Donahue 1,2, Katherine L Smulligan 3, Stacey L Simon 4,5, Julie C Wilson 1,2,4, David R Howell 1,2
PMCID: PMC13383299  NIHMSID: NIHMS2195181  PMID: 41956449

Abstract

Context:

Physical activity (PA) and sleep are modifiers of symptom resolution among children and adolescents with concussion.

Design:

Retrospective chart review.

Methods:

We conducted a chart review on 8–18-year-olds evaluated ≤ 21 days of concussion and followed until symptom resolution. From patient charts, we extracted demographics, initial symptom burden, and relevant medical history. At the initial visit, patients answered 2 yes/no questions about PA participation (yes/no) and experiencing sleep problems (yes/no) since their injury. Based on these responses, patients were grouped as: physically active without sleep problems (+PA/+Sleep), physically active with sleep problems (+PA/−Sleep), not physically active without sleep problems (−PA/+Sleep), and not physically active with sleep problems (−PA/−Sleep). Analysis of variance and chi-squared tests were run to determine significant differences between groups, and a cox proportional hazards model was constructed to identify differences in time to symptom resolution after covariate adjustment.

Results:

Among 335 patients (14.4 [2.3] y old; 62% female; evaluated 8.6 [5.4] d postconcussion), 55% were not physically active and not experiencing sleep problems (n = 184), 29% were not physically active and experiencing sleep problems (n = 96), 14% were physically active and not experiencing sleep problems (n = 46), and 3% were physically active and experiencing sleep problems (n = 9). After adjusting for symptom severity, time since injury, anxiety history, and preinjury sleep problems, the physically active without sleep problems (+PA/+Sleep) group had an earlier symptom resolution time compared with all other groups (−PA/+Sleep group hazard ratio = 0.52, 95% CI, 0.37–0.74; P = .0002; −PA/−Sleep group hazard ratio = 0.56, 95% CI, 0.38–0.83; P = .0038 and +PA/−Sleep group hazard ratio = 0.38, 95% CI, 0.16–0.89; P = .0258).

Conclusions:

Children and adolescents who reported both engaging in PA and not experiencing sleep problems at their initial evaluation for concussion experienced significantly earlier symptom resolution time compared with those who reported one or neither characteristic, suggesting a potential combined effect between sleep and PA on adolescent concussion recovery.

Keywords: pediatric, mild traumatic brain injury, exercise, sleep health, observation

Concussions, a type of mild traumatic brain injury, are an increasing concern among youth athletes.1 There are an estimated 1.1 to 1.9 million concussions related to sports annually in the United States.2 Defined as a transient disruption of neurological function induced by trauma,3,4 concussions can lead to a wide range of symptoms including headaches, fatigue, cognitive difficulties, behavioral changes, and/or disrupted sleep.3 The average time to symptom resolution following initial concussion injury is reported to be about 14 days.5 However, some patients can experience Persistent Symptoms after Concussion (PSaC),6,7 with symptoms continuing beyond 1 month after injury. PSaC patients in particular are negatively affected by delayed return to school and sports and by worse mental health outcomes.8–10

Recent studies have increasingly focused on modifiable factors that may influence symptom recovery,11,12 such as early physical activity (PA) and sleep during the early postinjury period within approximately 7 days of concussion.13 While typically studied independently, both factors may influence recovery, either as pre-existing conditions or as postinjury psychological or physiological responses. For example, preinjury sleep difficulties may persist postconcussion,14 while acute changes in sleep or PA may result from the injury itself or from the patient’s belief about recovery.15,16 Alternatively, trouble falling asleep or reduced PA may indicate concussion severity.17,18 Both sleep disturbances (ie, poor sleep quality, excessive daytime sleepiness, and perceived changes in sleep duration)19 and the lack of engagement in early PA can negatively influence concussion symptom severity and symptom resolution time.11,19–21 Evidence suggests that engaging in progressively more challenging PA at a level that does not exacerbate symptoms after the first 48-hour postconcussion is associated with faster symptom resolution, reduced symptom severity, and lower risk of developing PSaC.22–25 Similarly, studies of self-reported sleep disturbances have identified relationships between poor sleep within the first 2 weeks after concussion, with slower symptom resolution, more severe symptoms, worse mental health, and worse physical or cognitive function, such as balance, and memory recall.19,20,26–28 Accordingly, PA and sleep represent 2 potential targets for optimization during the concussion recovery period.

Independent of a concussion, previous studies of adolescents suggest that reduced sleep duration among healthy adolescents results in similar symptoms experienced following a concussion, complicating the ability to disentangle the effect of sleep on concussion outcomes.29,30 For example, Lo et al29 found that restricting adolescents’ time in bed to 5 hours per night for 6 days resulted in a cumulative decrease in performance on cognitive tests, sustained attention, working memory, positive mood, and executive function compared to a control group with a time in bed of 9 hours per night. Likewise, regular PA has been linked with enhanced cognitive performance, emotional regulation, better mental health, and better psychological well-being among adolescents without concussion.30–33 Furthermore, positive combined effects of regular PA and ideal sleep duration (7–9 h) appear to exist across multiple outcome domains in adolescents without concussion, such as mental health, cognition, and academic success, suggesting that these factors may have compounded benefits.34–39 These parallels raise the possibility that adolescents recovering from concussions may experience similar or even greater benefits when their sleep is undisturbed and are able to engage in PA during concussion recovery.

Because of the lack of evidence on the combined effect of PA and sleep on concussion recovery in adolescents, our purpose was to examine the association of sleep and PA on time to concussion symptom resolution. We hypothesized that children and adolescents who reported PA engagement and no sleep problems at initial evaluation would exhibit earlier symptom resolution than those who reported sleep problems, lack of PA engagement, or both sleep problems and a lack of PA engagement after concussion.

Methods

Study Design and Participants

We conducted a retrospective chart review of medical records of patients ages 8–18 years who presented to a regional children’s hospital between January 2015 and December 2019 for concussion evaluation. We included participants aged 8–18 years to align with Sport Concussion Assessment Tool (SCAT) guideline recommendations, using the Child SCAT for individuals aged 8–12 years, and the standard SCAT for those aged 13–18 years thereby capturing our intended cohort of children and adolescents. Inclusion criteria consisted of patients being symptomatic at initial clinic visit (Health and Behavior Inventory [HBI] score > 0), diagnosis of concussion by a single board-certified sports medicine physician and initial evaluation within 21 days of injury. Concussion diagnosis was defined according to the consensus guidelines for concussion in sport at the time of injury diagnosis.3,40 Exclusion criteria consisted of concussions resulting from more severe mechanisms (eg, motor vehicle collisions), absence of symptoms at the time of evaluation, initial evaluation occurring greater than 21-day postconcussion, or incomplete data on standard visit intake forms. This study was approved by the institutional review board as an exempt protocol prior to study commencement given the retrospective nature of data collection. All data used in the study was obtained from the electronic health records of past patients.

Procedures

Patient data were obtained from standardized intake forms and medical records. Collected data included demographic information (age, sex), relevant medical history (previously diagnosed anxiety, depression, and sleep problems), time from injury to initial evaluation (in days), history of prior concussions (yes/no), initial symptom severity (via HBI score), presence of headache since injury, headache severity (rated 0–10 via visual analog scale, where 0 = no headache and 10 = severe headache), recovery outcomes (self-reported time to symptom resolution as number of days from concussion to symptom resolution), and whether patients continued to experience symptoms beyond 28 days (PSaC).

At the initial evaluation, all patients completed a series of questionnaires documenting their symptoms, PA, and sleep characteristics since their concussion occurred. To assess symptom frequency, patients completed the HBI,41 a validated symptom questionnaire widely used in pediatric and adolescent concussion research and clinical care.24,41,42 Previous studies have proven the HBI to be a reliable and valid measure of symptom frequency in children and adolescents with mild traumatic brain injury.24,41,42 Respondents were asked to rate current symptoms on a 4-point scale (0 = never, 1 = rarely, 2 = sometimes, 3 = often). The responses were then summed to calculate the overall HBI score, which yields total scores in cognitive and somatic domains, ranging from 0 to 60.43 Higher subscale scores indicate a greater symptom burden. The cognitive subscale assessed frequency of cognitive symptoms with questions including “have you had trouble sustaining attention during the last week” or “have you had problems learning.”41–43 The somatic subscale assessed frequency of somatic symptoms with questions including “have you felt dizzy” or “have you had a headache in the past week.”41–43

Patients returned for additional clinical evaluation according to their individual needs based on recommendations of their treating physician. They completed the HBI at each subsequent visit. Presence or lack of symptoms was noted at each clinical visit and if symptom resolution was reported, the date when symptoms were last experienced was documented by the patient. We defined time to concussion symptom resolution (primary outcome variable) as the number of days elapsed from the concussion until the date when patients reported no longer experiencing concussion-related symptoms. If patients were symptomatic at their last visit, time-to-event analysis was right censored in analysis for these patients. Patients who experienced concussion symptoms for >28 days from injury were classified as experiencing PSaC.44,45

At the initial evaluation, patients were asked as part of the standardized clinical intake procedures whether they had engaged in any PA since the injury and whether they were experiencing sleep problems that began after the injury. These brief screening items were developed for routine clinical use to help guide assessment and to identify optimal recovery strategies. Based on the responses to these questions, patients were categorized into one of 4 recovery characteristic groups: physically active and not experiencing sleep problems (+PA/+Sleep), physically active and experiencing sleep problems (+PA/−Sleep), not physically active and not experiencing sleep problems (−PA/+Sleep), and not physically active and experiencing sleep problems (−PA/−Sleep).

Statistical Analyses

We first compared the demographic, clinical, and injury characteristics of the 4 groups univariably using Analysis of Variance and Chi-squared tests. Post hoc tests were used to evaluate differences between individual groups, with P-values adjusted for multiple comparisons using Tukey HSD. We then used Cox Proportional Hazards models to compare concussion symptom resolution time among the 4 groups in a time-to-event analysis. The first Cox Proportional Hazards model was unadjusted and included only the 4 groups as predictors of time to concussion symptom resolution. The second model was adjusted to include covariates that differed univariably between groups (P < .05 in univariate analysis; initial symptom severity, history of sleep problems, history of anxiety, and time since injury). To avoid multicollinearity between predictors in the adjusted model, only one variable representing acute symptom severity was included (ie, the adjusted model would include the sum of the cognitive and somatic HBI scores, but not headache severity given the strong correlation between these variables and risk of variance inflation if both are included as predictors).

Data are presented as mean (SD), or n and percent in group (n [%]). All statistical tests were 2-sided and evaluated at an alpha level of .05. Analysis was conducted in Python. The Python script is available here: https://github.com/wingersonMJ.

Results

We reviewed 1269 patient charts for inclusion and exclusion criteria. The most common reason for removal was presenting for care >21 days postinjury. Other common exclusion criteria were age outside 8–18 years; abnormal findings on neuroimaging; missing sleep or PA data; and missing either symptom resolution time or a follow-up date needed to censor participants. After applying inclusion and exclusion criteria, chart reviews of 335 patients remained for subsequent analysis (62% female, 14.48 [2.3] y old). The average time to clinical evaluation postconcussion was 8.6 (5.3) days. Group distributions based on PA and sleep characteristics at the initial visit were as follows: physically active and not experiencing sleep problems (+PA/+Sleep) N = 46 (14%), physically active and experiencing sleep problems (+PA/−Sleep) N = 9 (3%), not physically active and not experiencing sleep problems (−PA/+Sleep) N = 184 (55%), and not physically active and experiencing sleep problems (−PA/−Sleep) N = 96 (29%). After adjustment for multiple comparisons, we identified statistically significant differences between groups in the time to concussion symptom resolution. The not physically active without sleep problems (−PA/+Sleep) group was evaluated sooner postconcussion than both the physically active without sleep problems (+PA/+Sleep) and the physically active with sleep problems (+PA/−Sleep) groups (2.62 and 4.81 d earlier, respectively; Table 1). There were no statistically significant between-group differences in sex distribution, age, concussion history, or depression history (P > .05). We observed a statistically significant difference in anxiety history across groups (P = .006). The physically active without sleep problems (+PA/+Sleep) group had the lowest proportion of anxiety of all groups (2.2%, n = 1), and the not physically active without sleep problems (−PA/+Sleep) group had a lower proportion (5.4%, n = 10) than the not physically active with sleep problems (−PA/−Sleep) group (15.6%, n = 15). History of sleep problems differed significantly between groups (P < .0001; Table 1). Children and adolescents in the groups which reported sleep problems (−Sleep) had a greater proportion of patients reporting a history of sleep problems, while those in the groups which did not report sleep problems (+Sleep) had lower proportions. The proportion of patients who developed persisting symptoms differed significantly across groups. The physically active without sleep problems (+PA/+Sleep) group consistently showed the most favorable outcomes, with the lowest rates of persisting symptoms, headache presence, headache severity, and total HBI score (Table 1). Independent of group, time between injury to evaluation and self-reported symptom severity (HBI score) at initial evaluation were significantly associated with time to concussion symptom resolution (P < .0001; Table 1). Though the physically active without sleep problems (+PA/+Sleep) group consistently demonstrated the most favorable results, no other specific group consistently demonstrated poorer outcomes throughout.

Table 1.

Demographics and Injury Characteristics for Patients Enrolled in the Study

N Overall +PA/+sleep +PA/−sleep −PA/+sleep −PA/−sleep P
335 46 9 184 96
Demographics and medical history
 Age, mean (SD) 14.5 (2.3) 14.3 (2.3) 14.3 (2.3) 14.6 (2.3) 14.4 (2.1) .88
 Sex (female) 208 (62.1%) 25 (54.4%) 4 (44.4%) 124 (67.4%) 55 (57.3%) .14
 Concussion history 145 (43.3%) 22 (47.8%) 22 (22.2%) 83 (45.1%) 38 (39.6%) .42
 Depression history 14 (4.2%) 2 (4.4%) 0 (0.0%) 6 (3.3%) 6 (6.3%) .61
 Anxiety history 26 (7.8%) 1 (2.2%)a 0 (0.0%) 10 (5.4%)b 15 (15.6%)a,b .006
 History of sleep problems 28 (8.4%) 2 (4.4%)a 2 (22.2%)a,b,d 5 (2.7%)b,c 19 (19.8%)a,c,d <.0001
Injury characteristics
 Days since injury to initial evaluation, mean (SD) 8.64 (5.3) 10.6 (5.2)a 12.8 (5.4)b 8.0 (5.0)a,b 8.6 (5.5) .0018
 Proportion with headache 265 (79.1%) 19 (41.3%)x 8 (88.9%) 148 (80.4%)a 90 (93.8%)a <.0001
 Headache severity (0–10 scale), mean (SD) 2.95 (2.6) 1.2 (2.0)x 3.9 (3.2) 2.7 (2.5)a 4.1 (2.5)a <.0001
 HBI total, mean (SD) 19.6 (12.9) 11.0 (10.8)x 26.1 (11.4) 17.8 (11.9)a 26.2 (12.6)a <.0001
 HBI somatic, mean (SD) 8.9 (5.9) 5.1 (4.9)x 12.9 (5.1) 8.0 (5.3)x 12.0 (5.8) <.0001
 HBI cognitive, mean (SD) 10.7 (8.1) 5.8 (6.6)x 13.2 (7.5) 9.9 (7.8)a 14.2 (8.1)a <.0001
 Persisting symptoms (PSaC %) 67 (20.0%) 2 (4.4%)x 5 (55.6%)a 36 (19.6%)a 24 (25.0%) .0013
 Time to symptom resolution, mean (SD) 21.46 (23.5) 12.85 (10.5) 58.33 (89.4) 21.0 (20.5) 23.0 (15.3) –
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Abbreviations: HBI, Health and Behavior Inventory; PA, physical activity; PSaC, persistent symptoms after concussion.

Note: x = Group is different from all other groups (adjusted P < .05).

a, b, c … = between-group difference is significant (adjusted P < .05).

Unadjusted Cox Proportional Hazards Model

Before covariate adjustment, the physically active without sleep problems (+PA/+Sleep) group had earlier symptom resolution, and a higher hazard of symptom resolution compared to all other groups (−PA/+Sleep group Hazard Ratio [HR]: 0.56, 95% CI, 0.40–0.77, P = .0004; −PA/−Sleep group HR: 0.48, 95% CI, 0.34–0.69, P = .0001; +PA/−Sleep group HR: 0.25, 95% CI, 0.12–0.53, P = .0003; Figure 1). This corresponds to a longer expected time to symptom resolution in all other groups to the + PA/+Sleep group.

Figure 1 —

Figure 1 —

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Kaplan–Meier curves demonstrating time to concussion symptom resolution for each group.

Adjusted Cox Proportional Hazards Model

The adjusted Cox Proportional Hazards model accounted for history of anxiety, history of sleep problems, time between injury and evaluation, and self-reported symptom severity at initial evaluation (Figure 2). After adjusting for these factors, the physically active without sleep problems (+PA/+Sleep) group demonstrated less time from injury to concussion symptom resolution compared to the not physically active without sleep problems (−PA/+Sleep) group (HR: 0.52; 95% CI: 0.37–0.74; P = .0002), the not physically active with sleep problems (−PA/−Sleep) group (HR: 0.56; 95% CI: 0.38–0.83; P = .0038), and the physically active with sleep problems (+PA/−Sleep) group (HR: 0.38; 95% CI: 0.16–0.89; P = .025).

Figure 2 —

Figure 2 —

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Adjusted Cox Proportional Hazards ratios comparing groups and including covariates for adjustment. The +PA/+Sleep group is the reference group; therefore, all hazard ratios represent the hazard of event compared to the +PA/+Sleep group. This group is represented visually as a single dot at the 1.0 vertical line.

Discussion

The purpose of this study was to explore the association between concussion symptom resolution in children and adolescents with postconcussion PA engagement and with presence of sleep problems. Our findings suggest that adolescents who engaged in early PA and did not report sleep problems after concussion had significantly earlier symptom resolution than those who did not engage in PA and/or reported sleep problems. Additionally, we identified several factors that differed among those reporting PA engagement and no sleep problems after concussion compared with the other 3 groups including history of anxiety, history of sleep problems, and initial symptom severity (headache presence, headache severity, and HBI score at initial clinic evaluation). After controlling for initial symptom severity, history of sleep problems, anxiety, and days since injury in our multivariable model, our results suggest that both lack of self-reported sleep problems and early PA engagement may be associated with earlier symptom resolution and should be considered together in future concussion studies evaluating recovery and intervention strategies. This approach helps mitigate the concern that lower initial symptom burden alone explains these findings. Our results also highlight the potential value of assessing sleep health and early, symptom-limited PA during initial clinical evaluations, offering a practical framework that complements current consensus guidelines aimed to help clinicians tailor early recovery recommendations.

Although the physically active without sleep problems (+PA/+Sleep) group had an earlier recovery than the other 3 groups, there are several factors that may have also contributed to recovery time that must be considered. Average HBI score, the proportion of patients with headache, and mean headache severity were all lowest in the physically active without sleep problems group at initial evaluation. Prior research has identified initial symptom burden as a consistent predictor of time to symptom resolution.46–48 Although initial symptom burden and days since injury were significant predictors of recovery, the physically active without sleep problems (+PA/+Sleep) group still demonstrated earlier symptom resolution after multivariable adjustment. The physically active without sleep problems group also had the lowest prevalence of anxiety history. Anxiety may be associated with reporting specific concussion recovery characteristics (lack of sleep problems49 and early PA50) and concussion recovery itself.51–53 Preinjury medical diagnosis of sleep problems were more prevalent in the 2 groups reporting sleep problems postconcussion, suggesting that a history of sleep problems may be a risk factor for acute postinjury sleep problems after a concussion, which could negatively affect recovery.14 These findings highlight that even though early PA and lack of sleep problems may be useful to facilitate earlier recovery, there are several factors that also contribute to engaging in those characteristics. Future research should seek to identify factors that encourage children and adolescents to engage in early PA or sleep-promoting behaviors, as well as those that may predispose them to sleep disturbances or PA intolerance following a concussion.

Importantly, even after adjusting for anxiety history, preinjury sleep problems, initial symptom burden, and days to initial evaluation, the physically active without sleep problems (+PA/+Sleep) group still had significantly earlier symptom resolution compared to all other groups. This demonstrates that while symptom burden, past medical history, and timing of assessment likely contribute to recovery time, the lack of self-reported sleep problems and early PA engagement are modifiable factors and not harmful following concussion,22,54 or in general. In addition, the interval between injury and clinical presentation remains an important consideration, as delayed evaluation has been associated with prolonged recovery in prior work and may influence both symptom burden and subsequent clinical trajectories.5 Notably, the not physically active without sleep problems (−PA/+Sleep) group and the not physically active with sleep problems (−PA/−Sleep) groups had similar time to symptom resolution, suggesting that while lack of sleep problems alone is beneficial, its effect on symptom resolution time may be maximized when paired with early PA. The physically active with sleep problems (+PA/−Sleep) group had the smallest sample size (n = 9) of all the groups, which reflects the true rarity of patients who report PA engagement and sleep problems after concussion, suggesting that children and adolescents who were having sleep problems were less likely to engage in early PA. This evidence warrants further research on the combined effects of optimal sleep and early PA on concussion recovery, potentially with more objective measurements to determine the full impact. Clinicians should consider these findings to encourage engagement in both early subsymptom PA and healthy sleep behaviors during concussion recovery. Guidelines now recommend PA during concussion recovery performed at an intensity that does not exacerbate symptoms beyond a mild threshold (≤2/10 on a visual analog scale) following a brief period of rest and adequate sleep throughout recovery.13

Our findings build on prior evidence showing the individual benefits of sleep and early PA or exercise after concussion,19,20,24–26,55 but uniquely identified a potential combined association. This enhanced benefit may be explained by sleep and PA’s collective influence on 2 important physiological systems disrupted by concussion: the brain’s metabolic response to injury and impaired energetics, and glymphatic system function (the brain’s cerebrospinal fluid-driven waster clearance pathway, most active during sleep).56 Following a concussion, the brain enters an energy crisis characterized by ionic imbalance,57 autonomic nervous system dysregulation,58 impaired cerebral blood flow,59 elevated neuroinflammation,57,60 and mitochondrial dysfunction.57 These disturbances increase ATP demand while simultaneously impairing the brain’s ATP production ability,57 resulting in a substantial energy deficit. Early subsymptom PA, meaning PA that does not create symptoms greater than a 2/10, may help stabilize this energy crisis by improving cerebral blood flow,61 reducing inflammation,62 and stimulating brain-derived neurotrophic factor production,63 which supports mitochondrial function and neuron repair.64,65 Collectively, these effects may promote neuron healing and earlier symptom resolution. Sleep and PA may also improve concussion recovery by supporting the brain’s glymphatic system,56,66–69 which clears neurotoxic waste like tau and amyloid beta proteins,56,66 especially during slow wave sleep.67 Glymphatic function may be disrupted after concussion, likely due to sleep impairments caused by increased cytokine production and release,66 decreasing waste clearance.70 However, regular PA can indirectly improve glymphatic clearance by enhancing sleep depth and duration,55 and directly with increased glymphatic flow through increased cerebrospinal fluid movement.68,69 Given sleep and PA’s bidirectional relationship,55,71,72 together they may optimize waste clearance and support neurological recovery.

Understanding the timing of data collection is important for interpreting our findings. This study used patient records from 2015 to 2019, a period preceding the release of the sixth International Consensus Statement on Concussion in Sport, SCAT6, and other more recent consensus recommendations. During this timeframe, clinical guidance generally emphasized brief rest followed by a gradual return to activity, but there was comparatively less focus on early, subsymptom threshold PA and structured sleep health as components of concussion management.3,13 As a result, the characteristics reported by patients in this cohort may not fully reflect current best practices.

Limitations

There are several limitations to note when interpreting the study results. As a retrospective chart review conducted at a single hospital, our findings may not generalize to other patient populations. Due to the retrospective study design, we are not able to infer causality between PA engagement, lack of sleep problems, and earlier symptom resolution. It remains unclear whether lack of sleep problems and PA engagement facilitated earlier recovery or individuals with lower initial symptoms simply experienced better sleep and were able to tolerate PA.

Our data relied on self-report measures which is useful clinically, but may be prone to inaccuracy in reflecting true behavior. Sleep problems and PA engagement were both assessed using a simple yes/no question. No wearable technology (eg, accelerometry), validated tools (eg, polysomnography), or validated questionnaires (eg, Pittsburgh Sleep Quality Index) were used to assess or quantify sleep or PA characteristics. Objective measurements of sleep and PA may help to improve data accuracy in conjunction with self-reported measures. The nature of our data also limited the granularity of sleep and PA assessment. Important factors for sleep health such as sleep onset latency, duration, timing of sleep, or wakefulness after sleep onset, which have been shown to have clinical value in previous research,26,73,74 were not evaluated. Similarly, intensity, duration, and frequency of PA was not measured, as done in past research.75–77 These elements of PA have been deemed critical when evaluating the role of PA in concussion recovery, establishing dose–response relationships, and determining causality.75–77 We did not assess habitual PA or fitness levels, nor typical sleep patterns prior to concussion, such as sleep duration, or trouble falling asleep. Although a history of sleep problems was collected, this may not fully capture preinjury sleep behaviors. We also did not account for the sport or activity during which the injury occurred, which may influence sleep and activity patterns, or time to symptom resolution.14,78 Though the overall sample size is adequate for our statistical approach, our smallest PA and sleep grouping was +PA/−Sleep (n = 9). The small number of participants in this group is a feature of the data set and could be a focus of future research to better understand how sleep problems and PA engagement interact after concussion.

Participants had a relatively low symptom burden at enrollment (mean HBI score 19.6/60) and were enrolled up to 21 days postconcussion; thus, we are unable to determine the effects of PA and sleep in populations seen more acutely postinjury or with greater symptom burdens. Finally, follow-up visits were conducted as clinically indicated rather than at a standardized interval, resulting in variable assessment points and loss to follow-up. Because patients determined whether or not to return, some patients may have had ongoing symptoms that were not considered or had symptom resolution and did not seek further evaluation.

Conclusions

Our findings suggest that children and adolescents who engaged in early PA and did not report sleep problems had earlier symptom resolution than those who reported one or neither characteristic. Clinicians should continue to recommend early engagement in subsymptom PA, as well as consider the importance of sleep health counseling or intervention when prescribing prorecovery behaviors. Future prospective research with objective measures of both sleep and PA are warranted to better understand this relationship and to identify behavioral interventions that promote engagement in both positive recovery behaviors.

Key Points.

  • Children and adolescents who were physically active and reported no sleep problems recovered from concussion symptoms faster than other groups.

  • The lack of physical activity or the presence of sleep problems, individually or combined, was associated with a slower time to symptom resolution.

  • Findings suggest a combined positive effect of regular physical activity and healthy sleep on concussion recovery in youth.

Acknowledgments

Funding Source:

This study was funded by the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R01HD108133, R21HD117284).

Conflicts of Interest and Disclosure Statement:

Unrelated to this study, Dr. Howell has received research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R03HD094560), the National Institute of Neurological Disorders And Stroke (R01NS100952, R43NS108823), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (1R13AR080451), 59th Medical Wing Department of the Air Force, MINDSOURCE Brain Injury Network, the Tai Foundation, the Colorado Clinical and Translational Sciences Institute (UL1 TR002535-05), and the Denver Broncos Foundation. Dr. Wilson has received salary support from research funding from the 59th Medical Wing Department of the Air Force and the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R01HD108133).

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