Friday, January 30, 2015

Is prolonged rest the best medicine for concussion?

A new study suggests that the common perception that strict rest is best for concussed patients is not only inaccurate, but that prolonged rest may actually be harmful. 
bandaged brain
Over the past 10 years, emergency department visits for sports-related traumatic brain injury have increased by more than 60%.
Concussions account for more than 10% of all sport-related injuries among high school athletes. Over the past 10 years, emergency department visits for sports-related traumatic brain injury have increased by more than 60%. 

The majority of these patients, note the authors of the new study - which is published in the journal Pediatrics - were simply instructed to rest following their diagnosis of concussion. 

This instruction is in keeping with current guidelines, which recommend that patients with concussion should submit themselves to cognitive and physical rest until the acute symptoms are resolved. 

The main motivation for recommending prolonged rest is to avoid re-injury occurring while the patient is recovering. However, the evidence supporting this guideline is considered by many critics to be sparse. 

In a comment linked to the new study, Dr. William P. Meehan III and Dr. Richard Bachur, from The Micheli Center for Sports Injury Prevention in Waltham, MA, explain that the "relative lack of evidence is due, in part, to the difficult nature of quantifying and tracking levels of physical and, particularly, cognitive activity." 

This ambiguity also contributes to variations in the amount of rest recommended by clinicians. For instance, although the consensus view recommends 24-48 hours of rest before gradually returning to activity, many clinicians advocate "cocoon therapy," where patients are restricted to spending several days in a darkened room.

Concussion patients were randomized into 'strict rest' and 'short rest' groups

The researchers behind the new study - from the Children's Hospital of Wisconsin in Milwaukee - randomly assigned 88 concussed patients between the ages of 11 and 22 to follow either 5 days of strict rest or 1-2 days of rest followed by a stepwise return to activity. 

The patients in the "strict rest" group were not allowed to attend work or school or indulge in any physical activity during their rest period. 

The team found that strict rest did not lead to improved recovery in terms of symptoms, balance or the ability to think clearly. In fact, the patients in the strict rest group displayed worse symptoms during the first 10 days after their emergency department visit than their counterparts in the short rest group. 
"We should be cautious when imposing excessive restrictions of activity following concussion and mindful that the discharge instructions we provide patients may influence their perception of illness," study co-author Dr. Danny G. Thomas told Reuters Health

Dr. William Meehan III and Dr. Richard Bachur say that, taking both the new evidence and previous research into consideration, "a recommendation of reasonable rest for the first few days after a concussion followed by a gradual resumption of cognitive activities seems prudent." 

Rather than this care plan being devised in the emergency department, however, the pair emphasize that provision should be made for care to be tailored to the individual. "A few days of rest followed by prompt follow-up with the pediatrician, sports medicine physician or other capable provider should be recommended," they say.

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