It’s possible to do too much for kids with concussions, too

If I had a cohort study of kids with concussions, and I showed you that kids who were told to rest for 1-2 days had fewer symptoms than kids who were told to rest for 5 days, it would be a mistake to immediately assume that 1-2 days is better. After all, it’s just an association. It may be that kids who were injured less severely were assigned 1-2 days of rest, and those who were injured more severely were assigned 5 days of rest. In that case, it’s the injury (and outcomes) driving the recommendation as opposed to the recommendation driving the symptoms.

In order to establish causality, you’d need a randomized controlled trial. Cue Pediatrics, with “Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial“:

OBJECTIVES: To determine if recommending strict rest improved concussion recovery and outcome after discharge from the pediatric emergency department (ED).

METHODS: Patients aged 11 to 22 years presenting to a pediatric ED within 24 hours of concussion were recruited. Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to strict rest for 5 days versus usual care (1–2 days rest, followed by stepwise return to activity). Patients completed a diary used to record physical and mental activity level, calculate energy exertion, and record daily postconcussive symptoms. Neurocognitive and balance assessments were performed at 3 and 10 days postinjury. Sample size calculations were powered to detect clinically meaningful differences in postconcussive symptom, neurocognitive, and balance scores between treatment groups. Linear mixed modeling was used to detect contributions of group assignment to individual recovery trajectory.

Researchers enrolled kids from 11-22 years who came to a pediatric emergency department within 24 hours of a concussion. They were all evaluated, and then randomly assigned to either 5 days of rest versus 1-2 days of rest, followed by a return to normal activity. Patients recorded lots of stuff by diaries in the post-evaluation period. They were all examined 3 and 10 days after the injury.

Of the 99 kids in the study, 88 completed the procedures, pretty much evenly split between the two groups. Both groups had a decrease in energy exertion and physical activity after being seen in the ED. Kids assigned to 1-2 days of rest reported about twice as much school and after-school attendance days 2-5 than the kids in the 5 days rest group. And… wait for it… there were no clinically significant differences in outcomes.

Except for this: Kids in the 5 days of rest group reported more daily postconcussive symptoms than the kids in the 1-2 days of rest group. They also reported that their symptoms took longer to go away. In the beginning, they were more nauseous and had more headaches. Later, they had more irritability and sadness.

The CDC recommends, and International Consensus Guidelines concur, that 1-2 days of rest followed by a stepwise return to activity is appropriate. Many physicians, and some other groups, have been prescribing and calling for longer periods of rest and for more restrictions on activity. Some are even advocating “cocoon therapy“, where patients are put into dark rooms for multiple days. I’m not trying to argue that concussions aren’t significant, or that we shouldn’t be concerned about them. But we should do more only when doing more makes a difference.

In this randomized controlled trial, doing more did not improve outcomes. It did, however, lead to a slower resolution of symptoms, and made the kids feel worse. So why are we doing it again?


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