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

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.

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.

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
by: Jeff Driban


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