A Strict Rest Period May Not Be the Right Treatment for Every Adolescent Concussion Patient
Warren K. Young, MD
Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23. doi: 10.1542/peds.2014-0966
In a randomized controlled study of adolescents diagnosed with concussion, strict rest immediately after a concussion did not improve neurocognitive and balance tests, and conversely resulted in more reported post-concussive symptoms (PCSS) and slower symptom resolution.
The researchers enrolled adolescents between 11 and 22 years old who presented to the emergency room within 24 hours of a head injury and were diagnosed with a concussion. Initial computerized neurocognitive testing and balance assessments were performed and participants were randomized into 2 groups: strict rest (intervention) and usual care (control). In all, 99 adolescents were randomized and 88 completed the study.
The intervention group was placed on strict rest for 5 days at home, defined as no school, work, or physical activity. The control group was instructed to rest for 1 or 2 days and then return to school with a stepwise return to physical activity after symptoms had resolved. All participants were instructed to keep an activity diary and were followed up at 3 days and 10 days with repeat concussion, computerized neurocognitive, and balance testing.
It took 3 days longer for half of the strict rest group to report symptom resolution; they also reported a significantly higher total PCSS over the 10-day period. In addition, PCSS of those assigned to the strict rest group had higher physical symptom scores on days 2 and 3, and overall higher emotional symptoms throughout the follow-up period.
Based on the activity logs, it was noted that the control group had more total hours of high and moderate mental activity during days 2 to 5 compared with the intervention group, while there was no significant difference in the mean daily total energy expenditure. Computerized neurocognitive and balance testing showed no significant difference.
Subgroup analysis found that patients diagnosed with concussion based on PCSS score alone had higher PCSS at day 10 in the strict rest group, and that those with a past history of concussion had higher PCSS at day 10 in the strict rest group. Both were statistically significant differences.
The authors noted that limitations in the study included possible reporting bias based on discharge instructions from the emergency room and possible recall bias in the study participants’ activity diaries. In addition, the follow-up period was only 10 days, and therefore differences in participants who recovered after 10 days were not analyzed.
The rate of diagnosed sports-related concussions has increased significantly over the past decade. This is partly due to the increased understanding of concussions, a change in diagnosis criteria, and a growing awareness of concussion in sports. Along with the change in recognizing concussions, there has also been a shift in the treatment of concussions.
More than a decade ago, and possibly even in some places today, adolescents diagnosed with a concussion would be returned to play on the same day. There were no restrictions on physical and cognitive activity, and symptoms were regarded as a normal part of play without long-term effects.
Then, within the past decade, with heightened concern of concussions, an initial period of “cocooning” occurred, in which the recommended form of treatment to speed recovery was insulating the athlete from all physical and cognitive activity for a period of time. The concern regarding “cocooning” was that unnecessary restrictions would lead to missing social interaction and falling behind academically. The resulting situational depression and increased stress would cause physical and emotional symptoms.
This is the first randomized controlled trial studying the treatment of rest in this population. Physicians managing patients with concussions should be aware that a universal policy of strict rest for 5 days after a concussion might not be beneficial for all patients, and may even be harmful.
As such, the standard of care is that patients with concussions should be managed with an individualized treatment program based on multiple factors including age, gender, history of concussions, and findings on clinical exam.
Further research is still needed in this area of concussion, especially for the pediatric and adolescent population.
Warren K. Young, MD, is an Assistant Professor of Orthopaedic Surgery, Division of Primary Care Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.