concussion -- a less aggressive approach

i have sent out several different concussion guidelines over the past few years -- most recently ones by the american academy of neurology in 2013 (see http://www.neurology.org/content/early/2013/03/15/WNL.0b013e31828d57dd ), and the Ontario Neurotrauma Foundation in 2014 (see http://onf.org/system/attachments/266/original/GUIDELINES_for_Diagnosing_and_Managing_Pediatric_Concussion_Recommendations_for_HCPs__v1.1.pdf​ )

these guidelines are pretty complete, but as i have noted in prior blogs, they tend to be conservative (mostly because there are not much great data available regarding many of the recommendations, so they err to being appropriately pretty aggressively conservative, with many of their specific recommendations based on animal studies in conjunction with the known increased susceptibility of adolescents to concussion sequelae). in this setting, a Wisconsin study compared patients aged 11-22 with concussions to see if strict rest afterwards really mattered (see concussion bed rest pediat 2014 in dropbox, or doi: 10.1542/peds.2014-0966). this study compared 88 patients who went to the ER, 45 were then randomized to 5 days of strict rest at home (no school, work, or physical activity) vs 43 who were to rest for 1-2 days then return to school, with stepwise return to physical activity after symptoms resolved. all presented to ER within 24 hours of injury and were diagnosed with mild traumatic brain injury/​concussion. The researchers used the 19 symptom post-concussive symptoms scale (PCSS) to assess physical, cognitive, emotional and sleep criteria; the immediate post-concussion assessment and cognitive testing (ImPACT computerized test for neurocognitive assessment) to assess verbal memory, visual memory, reaction time, processing speed, and impulse control; and the balance error scoring system (BESS) to objectively assess balance.

baseline: median age 13.7, 34% female, 71% had concussion from sports injury (mostly football, basketball, soccer), rest from car accident, fall, assault. 1/3 had loss of consciousness.
results:
    --approx 20% decrease in energy expenditure and physical activity in both groups in first 5 days post-concussion
    --the less-strict group on days 2-5 had 8.33 vs 4.86 hours of high and moderate mental activity (including more school and after-school mental activities). though no difference in physical activity between the groups (ie poor adherence to recommendations in both groups).
    --although >60% of patients in each group had symptom resolution during the follow-up period, it took 3 days longer for 50% of those in the strict rest group to report symptom resolution
    --the strict-rest group had higher symptom score on the PCSS over a 10-day followup and more postconcussive symptoms.

so, this study is consistent with a couple of older studies in adults showing that strict bedrest led to delayed return to work, and no significant outcome difference at 2 week, 3 months, and 6 months. and it is mostly consistent with other pediatric studies, a few showing that moderate physical and mental activity post-concussion was better than either low or high levels of such activity. Having been through this with one of my kids, I am not surprised with the low adherence to physical activity restriction, and I think that adding the cognitive restriction in the strict-rest group would likely drive most active adolescents crazy (and perhaps explain their slower recovery!!).  as with most medical situations, there is undoubtedly wide variability in the degrees of brain trauma with concussions as well as wide variability in response to rest – and guidelines should not be treated as prescriptions to be administered mechanically: it makes much more sense to have a flexible approach in the ER, with a strong suggestion to refrain from physical and cognitive activity for a couple of days, but then to be seen by their primary care provider to work out the details of how to continue. And this study provides support for a less-aggressive initial approach with a titrated, patient-specific longer term plan

Comments

Post a Comment

if you would like to receive the near-daily emails regularly, please email me at gmodest@uphams.org

Popular posts from this blog

cystatin c: better predictor of bad outcomes than creatinine

  another article found significant discordance between creatinine and cystatin C in assessing renal function,  finding that the latter correlated most strongly with both renal and non-renal adverse clinical outcomes (see   ckd cystatin c better than creat AJKD2023  in  dropbox or doi: 10.1053/ j.ajkd.2023.04.002)   Details: -- 158,601 adults who were in the Stockholm Creatinine Measurements (SCREAM) project and had testing of creatinine and cystatin C on the same day during a healthcare encounter, from 2010-2018     -- >400,000 outpatient tests were done for both creatinine and cystatin C levels -- mean age 62, 48% female -- mean eGFR by creatinine (   eGFR cr ) 80; mean eGFR by cystatin C ( eGFR cys  ) 73 -- mean stage of renal insufficiency: 39%  eGFR cr   90+; 38%  eGFR cr  60-89; 12%  eGFR cr  45-59; 7.1%  eGFR cr  30-44; 3.2%  eGFR cr  15-29, 0.7%  eGFR cr ...
Read more

diabetes DPP-4 inhibitors and the risk of heart failure

the FDA just came out with a safety alert about 2 DPP-4 inhibitors and the increased risk of heart failure (released 04/05/2016)(see  http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm494252.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery ​ ). details: --saxagliptin and alogliptin were singled out because of 2 clinical trials in diabetic patients with heart disease. in each trial more patients taking these meds were hospitalized for heart failure vs those on placebo     --in the saxagliptin trial: 3.5% were hospitalized for heart failure (vs 2.8% on placebo). risk factors included prior heart failure or kidney disease     --in the alogliptin trial: 3.9% were hospitalized for heart failure (vs 3.3% on placebo) --recommendation by the FDA:     -- we should consider stopping these drugs if the patient develops heart failure ...
Read more

UPDATE: ASCVD risk factor critique

I decided to do an extensive update of my prior ASCVD (atherosclerotic cardiovascular disease) risk analysis and critique of risk calculators, with much more information about the “non-traditional” risk factors. I felt that there should be more data/clarification, since I think we are really undertreating/not preventing the most common cause of death by relying on the current ASCVD risk calculators   -- Cardiovascular risk models:      -- many of us rely on the various cardiovascular risk models to determine the appropriate approach to patients, and these are often integrated into the electronic medical records      -- these risk models have several very important limitations:          -- they are typically based on community data, eg from the Framingham study etc. But, in clinical practice, we are dealing with the individual and not the community:          ...
Read more