Andrew Howard MD FRCPC (Psychiatry) (biography and disclosures), Tyler Schwaiger MSc (biography and disclosures), Noah Silverberg, PhD (R Psych) (biography and disclosures), Will Panenka MD FRCPC (Neurology and Psychiatry) (biography and disclosures). GF Strong; British Columbia Neuropsychiatry Program; UBC. Disclosures: The authors disclose no financial interest in the academic content of this article.
What care gaps or frequently asked questions I have noticed
Concussion or mild traumatic brain injury (mTBI) results in acute, transient neurometabolic dysfunction (Shaw, 2002) but typically no structural brain injury detectable with clinical neuroimaging (Barkhoudarian et al., 2016; Stillman et al, 2017). Clinical signs of concussion include a brief loss of consciousness and/or a period of post-traumatic amnesia or confusion. The history, physical exam, and imaging should exclude more concerning etiologies, and a thorough accounting of possible confounds such as substance use, anxiety, neck injury, and other factors should be performed (Holm et al., 2005). A complete clinical recovery within a few weeks to months is the most common outcome, but some patients develop persisting disabling symptoms (McCrea et al., 2009a; Cassidy et al., 2014).
Current management practices
The practice of prescribing complete rest after a concussion may have its origin in early observations that psychological stress, physical exertion, loud noise, and bright lights tended to aggravate the acute symptoms of concussion (Symonds, 1928). The “rest until asymptomatic” approach to concussion management may not have become widespread until it was incorporated into the agreement statement of the First International Conference on Concussion in Sport (Aubry et al., 2002). Rest gained traction as a therapeutic strategy to expedite concussion recovery despite conflictual data from randomized controlled trials (Relander et al., 1972, de Kruijk et al., 2002), and became conflated with the concept of restricting athletes from participation in contact sport to prevent repeat injury (Longhi et al., 2005). Cognitive rest, or restriction from mentally demanding activities, became emphasized as an important component of the rest prescription (McLeod & Gioia, 2010; Arbogast et al., 2013). Expert consensus statements and practice guidelines continued to advise rest after concussion until at least 2013 (McCrory et al., 2005; McCrory et al., 2009; McCrory et al., 2013; Harmon et al., 2013). This advice was echoed in patient education materials (Chrisman et al., 2011). The most current physician surveys available suggest that rest is the most commonly prescribed “treatment” for concussion (Zemek et al., 2015; Lebrun et al., 2013; Stoller et al., 2014).
Physicians since post-World War II have exhorted the negative outcomes of bed rest (Asher, 1947), and its potential inefficacy and harm in treating concussions (Meerloo, 1949; Voris, 1950). In the last 5 years, concussion in sport guidelines shifted away from rest as the “cornerstone of concussion management” (McCrory et al., 2005), and eventually replaced their recommendation of “rest until asymptomatic” in favour of recommending a maximum of 24-48 hours of rest, followed by a gradual and progressive return to cognitive and physical activity, so long as symptoms are not exacerbated. However, the Concussion in Sport Group’s most recently published recommendations concede that further studies are needed to determine “the exact amount and duration of rest” (McCrory et al., 2017). Other recent clinical practice guidelines have similarly moved to encourage early gradual return to activity as tolerated.
Data that answers these gaps
Rest might increase symptoms and recovery time following mTBI (Thomas et al., 2015; Buckley et al., 2015; Moor et al., 2015; Grool et al., 2016). Inactivity has been associated with physical deconditioning and exercise intolerance (Smorawinski et al., 2001; Kozlowski et al., 2013), social isolation, discouragement about recovery, and reactive anxiety and depression (Walters and Williamson, 1999; Craton and Leslie, 2014, Vanderploeg et al., 2014). Post-concussive symptoms can be reversed with graded exercise programs (Leddy et al., 2007; Baker et al., 2012). Early mobilization can reduce post-concussive symptoms (Andreassen et al., 1957), and recovery time (Relander et al., 1972). For patients with persistent symptoms after concussion, interventions that promote increased physical activity may be beneficial (Gagnon et al., 2009). Early cognitive (Brooks et al, 2016) or physical exertion (Leddy et al, 2017) does not seem to raise the risk of prolonged recovery. Wiebe and colleagues (2016) used accelerometers to obtain objective measurements of physical activity following concussion, and found that symptoms inversely correlated with level of physical activity. A secondary analysis of the Thomas et al. clinical trial (Silverberg et al., 2016) found that abrupt increases in mental activity (moreso than physical activity) provoked symptoms but this provocation was typically transient and did not impact cognitive function and balance outcomes.
What we recommend (practice tip)
- Diagnosis. Primary care physicians should consider a differential diagnosis of the sequelae of head and neck trauma (especially in the absence of definite loss of consciousness). Neck pain, headaches, and psychiatric symptoms (e.g. anxiety, depression, pain, and sleep disturbance) require prompt behavioural and pharmacological intervention.
- Education. Advise patients about the common self-resolving symptoms they may experience, and that mild symptom exacerbation is common, transient, and will not prolong recovery. Provide strategies for coping with (tolerating) specific symptoms and exacerbations, teach cognitive-behavioural strategies for attenuating anxiety, and address sleep hygiene. Avoidance of symptoms is not the goal in the short-term. Patients with residual symptoms should aim to gradually increase their participation in valued daily activities. Educating patients about this approach may expedite recovery by reducing or preventing reactive anxiety and depression, and by improving adherence to the established return to activity plan.
- Define rest, and establish a timeline. Vigorous physical activity should be avoided if a patient is experiencing intense acute symptoms but not for more than 48 hours. In the Emergency Department or at an acute clinic visit, individualize a reduction in intensity and frequency of daily activities (physical and cognitive) for a specific amount of time with immediate recommendations to slowly increase exposure/functioning (at the patient’s pace), so that an overwhelming symptom burden is not experienced. Complete rest (or symptom avoidance) for an indefinite amount of time, regardless of symptomatology, should be avoided.
- Negotiate a return to activity plan. Youth should have reintegrated into school before returning to sports. Counsel patients to return to activity in a progressive manner, in such a way that limits a significant exacerbation in symptoms (although some emergent symptoms with increases in functioning and activity should be expected). Those patients who have residual symptoms and are activity intolerant (or phobic) may require a detailed collaborative step-wise plan. Athletes should not resume activities with significant risk of re-injury (e.g. full contact practice) until all symptoms have resolved and they have been cleared by a medical professional.
- Monitor response and adherence to plan. Schedule regular follow-up during the key transition points in the return to activity plan. Assertively treat psychiatric symptoms. Counsel patients to stick to the plan and to maintain proper pacing through their recovery. Patients who do not attempt to return to activity should be evaluated for depression, anxiety, and vestibular dysfunction by specialists as soon as possible.
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