Emergency management of concussion in children: How much rest is too much?

March has arrived and the temperatures in the northeast are rising. With the warm weather come spring and summer sports seasons, and a new batch of concussions in the pediatric and young adult populations. Nearly 4 million sports-related traumatic brain injuries occur each year. The number of children seen in emergency departments for concussion has nearly tripled in the past decade. Over the past 10 years, concussion safety laws have been passed in every state, requiring that children be seen by a medical professional prior to returning to sports. As our awareness of the diagnosis of concussion increases, more and more children will continue to present to emergency departments across the country.

The paradigm for “rest” following a concussion has evolved as our knowledge of the injury has simultaneously grown. Two decades ago, a concussion was simply getting one’s “bell rung,” and the best way to recovery was to get back in the game. As we learned more about the morbidity from mild traumatic brain injury, physicians became extremely cautious in returning children to activity, and began recommending strict rest until patients were symptom-free. Unfortunately, this led to children being out of school and with activity restriction for weeks (sometimes months) at a time, which is not without its own morbidity.

Recent studies published in the past year have shown prolonged rest may actually worsen outcomes. Thomas et al. (2015) demonstrated that children who rested for 1-2 days demonstrated fewer symptoms and had a more expeditious resolution of symptoms than those rested for 5 days. Buckley et al. (2015) found that college athletes who were strictly rested for 48 hours took twice as long to recover compared to those who began a graduated return to activity shortly after the injury. Similarly, aerobic exercise early in the course of recovery has been shown to shorten the duration of symptoms (Leddy et al, 2013). Finally, and perhaps most importantly, removing children from school and exercise is withdrawing them from the most validating activities in their lives, and has been shown to contribute to mood deterioration, avoidance behavior, and anxiety (DiFazio et al, 2015).

In light of this knowledge, one might ask what is the role of the ED provider in prescribing rest and recovery? Given state legislation and increasing concussion awareness, more and more concussions will continue to be diagnosed in emergency departments nationwide. It is imperative that families be armed with appropriate anticipatory guidance from the outset of recovery. While the optimal duration of rest remains unknown, many concussion experts currently recommend a brief (24-48 hour) period of rest, followed by gradual reintroduction to physical and cognitive activity simultaneously, in concert with the patient’s primary care provider. Emergency physicians should feel comfortable initiating this process in the acute setting. The old adage of “rest until you see your primary doctor” no longer applies!

Happy spring, and stay safe!

 

Author:

Daniel Corwin, MD, FAAP

CorwinD@email.chop.edu

 

References

Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics; 2015: 135: 213-223.

Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. J Head Trauma Rehabil. 2015 [Epub ahead of print]

Leddy JJ, Willer B, Cox JL, et al. Exercise Treatment for Postconcussion Syndrome: A Pilot Study of Changes in Functional Magnetic Resonance Imaging Activation, Physiology, and Symptoms. J Head Trauma Rehabil. 2013; 28:241-249.

DiFazio M, Silverberg ND, Kirkwood MW, Bernier R, Iverson GL. Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes? Clin Pediatr (Phila); 2015, [Epub ahead of print]

 

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