Increased cognitive activity post-concussion associated with prolonged symptoms

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1. Complete recovery from all concussion-related symptoms was achieved over a significantly longer time course by patients who participated in the highest amount of cognitively demanding activities.

2. Recovery duration was not associated with age, gender, loss of consciousness after injury, amnesia, or previous concussions.

Evidence Rating Level: 2 (Good)    

Study Rundown: For several years, concussion management guidelines have advised for cognitive rest, but minimal research has been conducted to support this recommendation. Previous studies have established the importance of reduced physical and mental activity but no prospective study centered on cognitive rest has been completed. Authors of the current study focused their efforts on evaluating the connection between cognitive activity and the duration of concussion symptoms. Results indicated that both extensive time engaging in cognitively demanding activities and higher initial scores on the PCSS (Post-Concussion Symptom Scale, a measurement of current symptoms) were independently associated with prolonged time to symptom-free health. Among the included patients, the sports most represented included ice hockey, American football, and basketball. Although this study is limited by its homogeneous population and small sample size its results support the current recommendations for attempted cognitive rest in the medical community. More research is needed to further elucidate the mechanism and timing of cognitive rest, but clinicians should be aware of these findings and urge patients to seek ample cognitive rest for timely concussion recovery.

Click to read the study, published today in Pediatrics

Relevant Reading: Consensus statement on concussion in sport-the 4th international conference on concussion in sport held in Zurich

Study Author, Dr. William P. Meehan, MD talks to 2 Minute Medicine: Director, Micheli Center for Sports Injury Prevention.

“The study has 2 findings that I believe are the most worthy of attention.  First, although cognitive rest has been recommended as a therapy for concussion for several years now, there has been little data showing its effect. We believe this is the first study showing the independent, beneficial effect of limiting cognitive activity on recovery from concussion. Second, only those engaging in the highest levels of cognitive activity had a substantial increase in their symptom duration.  Those engaging in the first 3 quartiles of cognitive activity level recovered in a similar time frame.  This would suggest, that while vigorous cognitive exertion is detrimental to recovery, more moderate levels of cognitive exertion do not seem to prolong recovery substantially. Thus, we recommend a period of near full cognitive rest acutely after injury, approximately 3-5 days, followed by a gradual return to sub-symptom levels of cognitive activity.”

In-Depth [prospective cohort study]: A total of 335 individuals (mean age = 15 + 2.6 years, 62% male) who presented to the Sports Concussion Clinic of Boston Children’s Hospital within 3 weeks of sustaining a sports-related concussion from October 2009 through July 2011 were included for analysis in this study. At each office visit, patients completed a PCSS form as a record of current concussion-related symptoms as well as a cognitive activity evaluation which assess for engagement in activities such as reading, homework, texting, etc. Patients were followed until they were symptom free. A Kaplan-Meier* estimator was used to determine the association between cognitive activity days and symptom duration, and a Cox proportional hazard model was used to evaluate the effect multiple variables on symptom length. Participants engaging in the highest amount of cognitive activity required the most time to recover from all of their symptoms. PCSS initial score (hazard ratio [HR] = 0.980, CI .9738-.9856) and cognitive activity days (HR = .994, 95% CI: 0.992 – 0.996) were independently associated with symptom timing while gender, age, loss of consciousness or amnesia after injury, and number of previous concussions were not. Hockey, American football, and basketball accounted for 21.8%, 20.6%, and 14.9%, respectively, of all concussions sustained in this study.

By Brandon Childs and Leah H. Carr

*A Kaplan-Meier plot is a graphical representation of the estimation of time related to a desired outcome. Authors used this plot to examine the time course of persistent concussion related symptoms in participants.

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