Recommending strict rest for adolescents following concussions leads to slower symptom recovery and no better outcome. A recent article in Pediatrics from the Medical College of Wisconsin looked carefully at treatment for children who sustained concussions and were discharged from the ED in order to determine whether a recent trend of strict rest with no activities led to improved outcomes over the usual 1 to 2 day rest and stepwise return to activity. The strict rest approach was based on animal and retrospective human data that suggested that physical and mental activity within days following concussive injury worsened outcomes. In practical terms for parents, the study addressed the physical rest and mental rest for the child, meaning no school, homework or other cognitive effort, should be a day or a week.
Pediatric head trauma is a significant cause of emergency department visits typically for sports related injuries. Most patients are discharged from the ED with a diagnosis of concussion and a prescription for rest. For these patients, many clinicians recommended 24 to 48 hours of rest before returning in a stepwise fashion to activity as tolerated. More recently, some studies suggested that there was an enhanced risk of further injury if physical or mental activity stressed the post concussive brain. These theories rested in part on concepts such as axonal shearing and other types of injury at the cellular level. This led to an alternative approach to concussion, namely strict rest without physical or mental activity for 5 days.
This study looked at the course of recovery and found that strict physical and mental rest for 5 days after a concussion overs no benefit over the usual 1 to 2 days rest and resumption of activities as tolerated. With strict rest, symptom reporting is greater and longer than when return to stepwise activity is allowed. It may well be that strict rest serves to focus attention on symptom reporting rather than therapeutic resumption of activity. This is an important study since parents are rightly concerned about the possible permanent injuries that can result from concussions, but keeping children out of school activities unnecessarily is also another concern. One to two days rest after concussion followed by stepwise resumption of normal non-exertional activities is appropriate. However, resumption of physical exertion and sporting activities should be done only after medical clearance.