Thursday, September 1, 2016

The timing of cognitive and physical rest and recovery in concussion

Bruce Taubman, Florence Rosen, Jennifer McHugh, Matthew F. Grady, and Okan U. Elci.  The Timing of Cognitive and Physical Rest and Recovery in Concussion. J Child Neurol 0883073816664835, first published on August 31, 2016 as doi:10.1177/0883073816664835


Immediate cognitive and physical rest in the concussed patient is almost universally recommended in the concussion literature. The authors conducted a prospective observational in a primary care pediatric office to examine the effect of delayed cognitive and physical rest had on recovery time in pediatric concussion. The authors found that patients who started cognitive and physical rest immediately after injury were more likely to recover within 30 days compared to patients who delayed cognitive and physical rest for 1-7 days after their injury (67% vs 35%, P = .016). Within the group of patients who recovered within 30 days those with immediate cognitive and physical rest recovered 4.6 days sooner than those with delayed cognitive and physical rest (10.29 ± 5.83 vs 14.42 ± 6.15 days, P = .005). These data support the recommendation that cognitive and physical rest should be implemented immediately after injury in concussed patients.

From the article

All patients were put on immediate physical and cognitive rest once the diagnosis of concussion was made, regardless of the time between injury and presentation.

Patients were instructed to continue physical and cognitive rest until they were asymptomatic as recommended in the Zurich consensus report.1 They were instructed not to go to school, do school work at home, or play computer games. They were also told to avoid any activity that increased their symptoms. All questions ask by the patients and their parents as to what the patient can and cannot do were answered before leaving the office.

Patients were instructed not to do any physical activity that would cause an increase in their heart rates. Patient’s and/ or their parents were questioned weekly to ensure they were compliant with the instructed cognitive and physical rest. Once asymptomatic, patients returned to school for half a day. If they remained asymptomatic they returned to school full-time. Once in school, patients were continued to be followed to ensure that they were able to read assignments, remember scholastic material, take test without additional time, and perform on exams as well as they did preconcussion. This was verified by parents, teachers and the patient. If symptoms persisted beyond 30 days, home tutoring was arranged through the patients’ school. When the patients were not in school, reading assignments required by the school and other cognitive exercises were used to evaluate recovery…

There were 3 main reasons why some patients delayed cognitive and physical rest after injury. Some were unaware they had sustained a concussion. Others suspected they had a concussion but chose to ignore the symptoms, not wanting to miss school and or sports. Finally, some had been advised by emergency room doctors to rest for only a day or 2 and then return to activities even if still symptomatic.

There were limitations to this study. First, only interviews were used to verify compliance with the authors’ instructions for complete cognitive and physical rest. Patients were not asked to keep diaries. However, the authors followed the patients closely and they had a long-term relationship with them as their pediatricians. The parents were involved and reported to us if their children did not follow the instructions. Second, there may have been some patients that reported continued symptoms for secondary gain. However, the authors would not expect the timing of when cognitive and physical rest was begun to predispose the over-reporting of symptoms in one group versus the other. Third, this study was not randomized. Finally this was not a blinded study. The investigators were aware of which patients had immediate cognitive and physical rest and which did not. Conducting a randomized study to evaluate this question would raise ethical issues….

This study was not designed or intended to examine the most effective length of time for patients to be placed on cognitive and physical rest. There are no randomized studies evaluating the optimal time for stopping cognitive and physical rest or the effect of having a patient return to school while still symptomatic.

The results of this study support the validity of the almost universal recommendation of immediate cognitive and physical rest for patients who have suffered a concussion.  The authors demonstrated that concussed patients with delayed cognitive and physical rest were much more likely to have a prolonged recovery than those who rested immediately (67% vs 35%, P = .016). Within the quick recovery group, recovery took longer for patient with delayed cognitive and physical rest compared to those with immediate cognitive and physical rest (P = .029). These data are especially valuable for primary care physicians as they set up office protocols to manage concussions.


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