Sports Medicine Research: In the Lab & In the Field: No Strict Rest for the Weary or Concussed (Sports Med Res)
Monday, February 2, 2015

No Strict Rest for the Weary or Concussed

Benefits of strict rest after acute concussion: A randomized controlled trial

Thomas GD, Apps JN, Hoffman RG, McCrea M, Hammeke T. Pediatrics. 2015;135(2):1-11.

Take Home Message: For individuals 11 to 22 years of age, strict rest after a concussion had no added benefit compared to 1-2 days of rest before the stepwise program.

Following a concussion injury most patients are instructed to rest for longer than 1 to 2 days prior to a stepwise recovery program. Most research on brain recovery are retrospective human studies or animal studies that conclude that early physical and mental activity can impede recovery. To date, the optimal period of rest after a concussion remains unknown. Therefore, the authors developed a randomized control trial to investigate the effectiveness of a 5-day rest program compared with the usual 24-48 hour rest program among individuals with an acute concussion who were 11 to 22 years of age. The authors assessed outcomes after discharge from the emergency room between May 2010 and December 2012. Following the initial screening, demographic collection, and concussion assessment (Post concussion symptom scale, ImPACT, & Firm BESS) 99 participants were randomized into one of two groups: 1) strict rest group (5 days of strict rest; 43/49 patients completed the study), or 2) standard of care group (1-2 days rest; 45/50 patients completed the study). After the rest period, both groups returned to school and a stepwise return to activity. The only difference was that the standard of care group was only allowed to start the stepwise return to activity when their symptoms resolved. Participants received follow-up examinations 3 and 10 days after their initial emergency room visit. These exams consisted of neurocognitive testing and balance. Participants completed a diary to record physical and mental activity level, calculate energy exertion, and record daily post-concussive signs and symptoms. Both groups exhibited a 20% decrease in energy expenditure and physical activity level in the first 5 days post-injury. The standard of care group reported more total hours in high and moderate mental activity on days 2 to 5 compared with the strict rest group, and the strict rest group lost more school days than the standard care group (6.7 days versus 3.8 days, respectively). In both groups over 60% of the signs and symptoms resolved during the follow up period; however, it took 3 days longer for 50% of the patients in the strict rest group to report symptom resolution compared with the standard care group. Additionally, the strict rest group reported more post-concussion symptoms over the course of the 10-day follow-up. The authors found that the strict rest group had more physical symptoms on days 2 and 3 and a trajectory of higher emotional symptoms throughout the follow-up. There was no difference in neurocognitive or balance scores between groups.

This was the first randomized control trial of rest strategies for patients with acute concussions. The authors found that recommending 5 days of strict rest did not improve symptoms, neurocognitive, or balance outcomes. The strict rest group experienced more symptoms and a slower recovery than the standard of care group. Strict rest could have adverse consequences that could have effected mood, sleep patterns, and increased stress related to not attending school. Since there was no difference in the patients reported physical exertion between groups this suggests poor compliance of physical rest within the strict rest group. However, this study may indicate that an individualized rest period before the stepwise return may be better for the patient. Future research is needed to determine the optimal emergency room discharge recommendation for patients following a concussion. In the meantime, medical personnel should note that endorsing strict rest following a concussion is not yet proven beneficial, and recommending modest limitation in mental and physical rest is an effective strategy for recovery.

Questions for Discussion: How many days rest do you recommend your athletes? On average, how many days of school do your athletes lose due to a concussion?

Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban

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Thomas, D., Apps, J., Hoffmann, R., McCrea, M., & Hammeke, T. (2015). Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial PEDIATRICS DOI: 10.1542/peds.2014-0966

2 comments:

Stacy Schurr, ATC said...

I thought this was an interesting article and was on the same page as far as your recommendations. I'm not sure there will ever truly be an "optimal" rest period because concussions and their effects are so individualized, especially in a sample of 11-22 year olds. So I wasn't too surprised that the longer complete rest period did not help with symptoms. I've only been certified for a short time, but in my experience, holding an athlete from any activity for a longer period of time only lengthened the total recovery period. The athletes may have more time during their complete rest to think about their symptoms, with anxiety building to return to their sport. I have seen disrupted sleep patterns and increased stress a couple athletes who took longer to return. I think it just has to be more of a day to day, check with the athlete to determine when to increase activity rather than recommend a specific amount of rest.

Jane McDevitt said...

Stacy,

I agree, I am not sure there will ever be an "optimal" rest time since a concussion is such a multifaceted injury. I think you made some very interesting points about anxiety with a concussion injury. I can imagine that some athletes would start to be fearful about their brain health if they are not recovering in the "normal" time frame, which could affect their sleep and emotional stability. Maybe more research needs to be done on the best coping strategies that we as athletic trainers can provide to our athletes as they are recovering from a concussion.

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