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No Benefit Found for Extended Rest in Pediatric Concussion Patients

MILWAUKEE – In hopes of improving concussion recoveries and outcomes, some emergency physicians recommend that pediatric patients presenting with head injuries have strict rest for five days after discharge.

A new study, published recently in Pediatrics, sought to determine if that practice was beneficial compared to the usual care recommendations of one to two days rest followed by gradual return to activity.

The research is important, according to the article, because pediatric head trauma represents a signi?cant injury burden for children, with ED visits for sports-related traumatic brain injury (TBI) increasing 60% over the last 10 years. Most of the patients are discharged from the ED with instructions to rest, although the duration of rest can differ.

“Rest recommendations are motivated by a concern for re-injury during recovery from a concussion,” according to the study by Children’s Hospital of Wisconsin researchers. The authors point out that some retrospective studies and animal models have found early physical and mental activity can impair recovery.

With limited human data on post-injury exertion, expert consensus recommends 24 to 48 hours of rest before beginning a stepwise return, the article notes.

Out of an abundance of caution, however, some clinicians recommend a longer period of rest, with a few even advocating “cocoon therapy,” which restricts patients to several days in a darkened room.

To determine if 5-day rest is superior in avoiding adverse outcomes to usual care, the study team recruited 99 patients aged 11 to 22 years who presented to a pediatric ED within 24 hours of concussion.

Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to strict rest for five days vs. usual care. The patients completed a daily diary, recording physical and mental activity level, energy exertion, and post-concussive symptoms. In addition, neurocognitive and balance assessments were performed at 3 and 10 days post-injury.

Results indicated no benefit to the longer rest period, although researchers noted that the “strict” protocol affected symptom reporting by adolescents.

Post-discharge, both groups reported a 20% decrease in energy exertion and physical activity levels although, as expected, the intervention group reported less school and after-school attendance for days 2 to 5 post-concussion -- 3.8 vs 6.7 hours total.

“There was no clinically signi?cant difference in neurocognitive or balance outcomes,” according to the report. The intervention group reported more daily post-concussive symptoms, however, with a total symptom score over 10 days of 187.9 vs. 131.9 for the control group. They also had slower symptom resolution.

“Recommending strict rest post-injury did not improve outcome and may have contributed to increased symptom reporting,” the authors write. “Usual care (rest for 1–2 days with stepwise return to activity) is currently the best discharge strategy for pediatric mild traumatic brain injury/concussion.”