Prolonged rest after concussion not linked to improved outcomes

1. Recommending 5-day rest (strict rest) to adolescents after concussion was not associated with improved neurocognitive or balance outcomes when compared to 1 to 2 days’ rest, the current usual care plan.

2. Adolescents receiving strict rest recommendations reported more daily postconcussive symptoms and slower resolution of symptoms.

Evidence Rating Level: 1 (Excellent)   

Study Rundown: Current expert guidance for postconcussive care in children is 1 to 2 days’ rest with stepwise return to activity. There are retrospective studies and animal models which suggest that early activity may impair recovery; however, there are no pediatric studies examining the effects of strict rest following concussion. This randomized controlled trial sought to compare the recommendation of strict 5-day rest to usual care of 1 to 2 days of rest in postconcussive adolescents. At the conclusion of this randomized control trial, those in the strict rest following concussion group did not experience significant improvement in neurocognitive outcomes as measured by neuropsychological and neurocognitive test batteries, nor did they have improved objectively-measured balance outcomes. In addition, the strict rest group reported significantly slower resolution of symptoms when compared to the usual care group.

This research was strengthened by its randomized design and its comprehensive follow-up testing. However, it relied on self-reported symptoms and activity levels. Also, the reported physical activity was not significantly different between the 2 groups (although cognitive activity was lower in the strict-rest group), which suggests that the effect of decreased physical activity may not be completely clear. The current study supports the current expert guidance of 1 to 2 days’ rest with stepwise return to activity and, furthermore, indicates that there is no clear benefit to physicians recommending strict rest to adolescents following concussion. However, additional research is needed to continue to elucidate the ideal rest period following concussion.

Click to read the study, published today in Pediatrics

Click to read the accompanying commentary in Pediatrics

Relevant Reading: Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest.

Study Author, Dr. Daniel Thomas, MD, MPH, talks to 2 Minute Medicine: Associate Professor of Emergency Medicine, Medical College of Wisconsin.

“Expert consensus has recommended rest as the mainstay of treatment after concussion. Some clinicians have advocated prolonged strict rest immediately after injury as a treatment strategy.  This is the first randomized controlled trial to assess the benefit of strict rest after concussion.  Contrary to expectations, strict rest for five days immediately after concussion did not help teenagers get better compared to our current advice of 1-2 days of rest followed by a gradual return to activity. We found that teenagers instructed to rest for 5 days actually reported more symptoms over the course of the study. These results demonstrated that our current standard of care was better than prolonged strict rest after injury. We should be cautious when imposing excessive restrictions of activity following concussion and mindful that the discharge instructions we provide patients may influence their perception of illness.”

In-Depth [randomized controlled trial]: This study enrolled 88 children between the ages of 11 and 22 years (mean age 13.7, 33% female) without intellectual disability, mental disorder or intracranial injury who were diagnosed with concussion or mild traumatic brain injury and subsequently discharged from an academic pediatric emergency department in Milwaukee, Wisconsin. Participants were randomized to either strict rest (5 days of no school, work or physical activity followed by a stepwise return to activity) or usual care (the treating physician was free to recommend restrictions as seen fit; usually 1-2 days’ rest and then return to school followed by stepwise return to physical activity once symptoms have completely resolved). Follow-up for both arms included 10 days of activity diaries and standardized symptom surveys along with neurocognitive, neuropsychological and balance assessments at days 3 and 10 post-injury.

The usual care group reported more total hours in high and moderate mental activity in days 2-5 post-injury compared to the strict-rest group (8.33 hours vs 4.86 hours, respectively, P=0.03) but there was no significant difference in estimated mean daily total energy expenditure between the 2 groups. The strict rest group reported more postconcussive symptoms over the 10 day period when compared to the usual care group (70.4 vs 50.2, respectively, P<0.03) and had higher Post-Concussive Symptom Survey scores (187.9 vs 131.9, respectively, P<0.03). There was no significant difference in balance assessment or computerized neurocognitive assessment.

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Image: PD/CDC/ Amanda Mills

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