Extending Strict Rest to 5 Days from 1-2 Days May Not Improve Symptoms in Children with Mild Concussion

EBM Focus - Volume 10, Issue 2

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Reference: Pediatrics 2015 Jan 5 early online (level 2 [mid-level] evidence)

Emergency department visits for concussions and traumatic brain injury have increased in the United States over recent years (JAMA 2014 May 14;311(18):1917). There has been a 60% increase in sports-related injuries in children over the last 10 years (MMWR Morb Mortal Wkly Rep 2011 Oct 7;60(39):1337). Reinjury during the recovery process can have significant consequences and rest is therefore recommended to prevent reinjury and allow for full recovery (Pediatrics 2009 Jan;123(1):114, Br J Sports Med 2013 Apr;47(5):250). Information is lacking on the optimal duration of rest, however, especially for children. A recent randomized trial compared strict rest for 5 days vs. usual care in 99 patients aged 11-22 years (mean age 14 years, 34% female) presenting to the pediatric emergency department within 24 hours of mild traumatic brain injury or concussion. Seventy-one percent of injuries were sports-related.

Strict rest was defined as no school, work, or physical activity followed by a stepwise return to normal activities. For patients randomized to usual care, physicians were instructed to recommend activity restriction as they deemed appropriate, which in most cases was rest for 1-2 days followed by a stepwise return to activity after symptoms resolved. All patients were discharged from the emergency department after neurocognitive, balance, and symptoms assessment and were asked to complete an activity diary including a standard Post-Concussive Symptoms Scale (PCSS) for 10 days after injury. PCSS rates 19 symptoms in 4 domains (physical, cognitive, emotional, and sleep) each on 0-6 scale, with higher score indicating greater severity and in this study, resolution of symptoms defined as total PCSS score ≤ 7. The trial analysis included patients completing the 10-day follow-up (89%). There was no significant difference in physical activity between groups during the first 5 days post-injury, however the strict rest group reported fewer total hours of moderate-to-high mental activity on days 2-5 (mean 4.86 hours with strict rest vs. 8.33 hours with usual care, p = 0.03). Though there was no significant difference in the number of patients reporting a resolution of symptoms by day 10 post-injury, the median time to symptom resolution was 7 days with strict rest vs. 4 days with usual care (p = 0.08). The strict rest group also reported a significantly higher total PCSS score period (mean 187.9 vs. 131.9, p < 0.03) as well as a greater number of total post-concussive symptoms (mean 70.4 vs. 50.2) over the 10 day study period compared to the group receiving usual care. There were no significant differences between groups in neurocognitive or balance tests at day 3 and day 10.

This trial suggests that there may be no benefit to an extended period of strict rest for children after mild traumatic brain injury or concussion. In fact, symptom reporting was increased in children who were recommended extended rest. The increased period of rest may have influenced the perception of illness or caused greater emotional distress due to the absence from school and activities. The strict rest group was slightly, but significantly, older than the children in the usual care group, and this age difference may have influenced symptom reporting. The results of this trial may not apply to children with more significant symptoms post-injury, as children admitted to the hospital were excluded from analysis.

For more information, see the Concussion and mild traumatic brain injury topic in DynaMed.