Strict Rest After Concussion Offers No Additional Benefit

Pauline Anderson

January 07, 2015

Prescribing 5 days of strict rest to a child following a concussion offers no significant benefits in terms of symptoms, neurocognition, or balance, a randomized trial shows.

In fact, youngsters in the study receiving this strict protocol had a heavier burden of symptoms than a control group receiving standard care.

The results suggest that the current strategy following concussion, typically involving 1 to 2 days of rest, then gradual return to activity, is effective for recovery and counteracts the growing trend toward more rest, said author Danny George Thomas, MD, MPH, assistant professor, pediatric emergency medicine, Children's Hospital of Wisconsin, Milwaukee.

"In recent years, the pendulum had been swinging towards recommending more rest," Dr Thomas told Medscape Medical News. "Some physicians have even been recommending strict rest to the point where kids, immediately after a concussion, were cordoned off in a dark room, not allowed to text, and just told to sleep all day and only come out for meals for the first few days — something called cocoon therapy."

The trial results were published online January 5 in Pediatrics.

Activity Diaries

For this report, researchers enrolled 99 patients who were diagnosed with concussion after presenting at the Children's Hospital of Wisconsin Emergency Department and Trauma Center between May 2010 and December 2012 within 24 hours of a head injury.

The most common mechanism of injury was sports-related, specifically involving football. About a third reported a loss of consciousness.

Participants were screened to gather demographic information and injury details. They also received computerized neurocognitive testing, the primary one being the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). This test battery includes 6 neuropsychological modules, the composite scores for which are reported in five fields: verbal memory, visual memory, reaction time, processing speed, and impulse control.

They also completed a paper ancillary neuropsychological test battery and were assessed for balance using the Balance Error Scoring System.

The participants were then randomly assigned to a control (n = 50) or intervention (n = 49) group. About a third of each group was female, and the intervention group was slightly older (mean age, 14.7 vs 13.1 years).

For the control group, treating physicians could recommend activity restrictions as they saw fit, although most instructed patients to rest for 1 or 2 days and then return to school, with a stepwise return to physical activity after symptom resolution. The strict rest group were told to avoid school, work, and physical activity for 5 days, followed by a stepwise return to activity.

Participants had follow-up visits at 3 and 10 days, during which neurocognitive tests and balance assessments were repeated.

Study participants also recorded activities in 15-minute intervals in the Three-Day Activity Diary and then the Seven-Day Activity Diary. These diaries were used to calculate total energy expenditure, activity-related energy expenditure, physical activity level, and mental activity.

The diaries included a daily 19-symptom Post-Concussive Symptom Scale (PCSS), which assesses symptoms in four domains: physical, cognitive, emotional, and sleep. Each symptom was graded from none (0) to severe (6).

Follow-up procedures were completed for 88 (43 usual care and 45 strict rest) participants.

Interestingly, all participants had about a 20% decrease in energy expenditure and physical activity level in the first 5 days after injury. This was true even for those in the control group, who didn't have to remain at rest for so long. Dr. Thomas chalks this up to changing views about concussion.

"Physical rest has become a mantra and the common-sense thing to do after a head injury," he said. "Guidance coming down from the American Academy of Neurology, American Academy of Pediatrics, and sports concussion bodies have told us that after a concussion, kids should rest and not engage in activities that may put them at risk for concussion again."

Symptom Resolution

More than 60% of participants in both study groups had symptom resolution, defined as a PCSS score of 7 or less, during the follow-up period. However, it took 3 days longer for 50% of patients in the strict rest group to report symptom resolution compared with the usual care group.

As well, over the course of the follow-up, the strict rest group had greater total PCSS scores (187.9 vs 131.9; P < .03), a higher total number of postconcussive symptoms (70.4 vs 50.2; P < .03), and higher mean daily PCSS score clustered around day 4.

The results are similar to those previously found in adults.

The study uncovered a trajectory of higher emotional symptoms in participants in the strict rest groups. "Their physical activity didn't change much, but their mental activity did change," mostly because they were away from school, said Dr Thomas. "Maybe we aren't attuned to how important school is as a social function for kids, and being cut off from their peers might slightly increase their symptoms."

Having the distraction of being with peers could somewhat mitigate symptoms, he added. He likened it to a toothache that "bothers you more in the middle of the night" when there's less distraction.

The study showed that kids with immediate signs of concussion, such as loss of consciousness or amnesia, tended to do a bit better with rest, while those with symptoms such as headache tended to do worse with rest, although this wasn't statistically significant, said Dr Thomas.

The new data highlight the fact that whereas loss of consciousness is objective and amnesia is measurable, headaches are more subjective. "If a kid comes in with a high symptom burden but didn't lose consciousness, that might be telling us more about how that person experiences their concussion," said Dr Thomas. "It's a very subjective thing, so we have to tailor our advice towards the individual."

It might be that subjective symptoms are more mitigated by distraction, so kids with these symptoms may actually do better by getting back to their daily routine, as long as it's not putting them at risk for concussion, he speculated.

Dr Thomas and his colleagues plan to test this theory in a larger study. They will compare children who come in with symptoms such as headache, light or sound sensitivity, and dizziness, with those who have early signs of concussion, such as amnesia and loss of consciousness.

If 5 days of rest is no better than 2 days of rest after the concussion, could even less rest be advisable? From a neurologic perspective, this might make some sense; in stroke victims, for example, physical activity is encouraged early on. And a prescribed exercise routine is beneficial for kids with chronic postconcussive symptoms.

"There's a school of thought emerging that maybe we should be doing a little bit of prescribed exercise activity," said Dr Thomas. "I think that's something that needs to be tested in future."

A large randomized controlled trial could be powered to detect the effects of active rehabilitation on subgroups such as athletes and patients with previous concussions or migraines, and different mechanisms of injury, said the authors.

In the current study, there were no significant differences in computer-based neurocognitive tests or balance scores. Although most paper neuropsychological assessments didn't demonstrate a significant difference, the strict rest group performed better at day 3 and worse at day 7 on the Symbol Digit Modalities Test compared with the usual care group.

In addition to the intervention group being a little older, another possible study limitation was the use of diaries, which could be subject to recall bias. Researchers also could not detect differences in participants who recovered after the follow-up period.

Optimal Duration of Rest

The study authors should be applauded for their efforts in trying to quantify and track levels of physical and cognitive activity after a concussion, according to an accompanying editorial.

But although the study adds some data on which to base recommendations for rest after a concussion, the optimal duration of rest remains unknown, said William Meehan III, MD, The Micheli Center for Sports Injury Prevention, Waltham, and Sports Concussion Clinic, Boston Children's Hospital, and Richard Bachur, MD, Division of Emergency Medicine, Boston Children's Hospital, all in Massachusetts.

"Indeed, the optimal period of rest may vary, depending on age, gender, point in the calendar year, initial symptom level, the particular symptoms that predominate, the level of cognitive function or other variables," they write. "As clinicians, we are forced to use the existing evidence, however limited, to develop a plan for our patients."

A recommendation of "reasonable rest" for the first few days after a concussion followed by a gradual resumption of cognitive activities "seems prudent," they said.

Concussion management should involve follow-up with the pediatrician, sports medicine physician or other capable provider following a few days of rest, and each management plan should be tailored to each individual patient, they added.

The study was funded by the Injury Research Center of the Medical College of Wisconsin. Dr Thomas has disclosed no relevant financial relationships. Dr Meehan has received grant funding from the National Football League Players Association and philanthropic support from the National Hockey League Alumni Association. Dr Bachur has no disclosed no relevant financial relationships.

Pediatrics. Published online January 5, 2015. Abstract Editorial

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