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