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

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