Benefits of Strict Rest AfterAcute Concussion: A RandomizedControlled TrialDanny George Thomas, MD, MPHa, Jennifer N. Apps, PhDb, Raymond G. Hoffmann, PhDa, Michael McCrea, PhDc,Thomas Hammeke, PhDb

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

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

RESULTS: Ninety-nine patients were enrolled; 88 completed all study procedures(45 intervention, 43 control). Postdischarge, both groups reported a 20% decrease in energyexertion and physical activity levels. As expected, the intervention group reported less schooland after-school attendance for days 2 to 5 postconcussion (3.8 vs 6.7 hours total, P , .05).There was no clinically significant difference in neurocognitive or balance outcomes. However,the intervention group reported more daily postconcussive symptoms (total symptom scoreover 10 days, 187.9 vs 131.9, P , .03) and slower symptom resolution.

CONCLUSIONS: Recommending strict rest for adolescents immediately after concussion offered noadded benefit over the usual care. Adolescents’ symptom reporting was influenced byrecommending strict rest.

WHAT’S KNOWN ON THIS SUBJECT: Expertconsensus recommends rest after concussionwith stepwise return to activity. Animal andretrospective human data suggest that earlymental and physical activity may worsenoutcome. There are no pediatric studies testingthe efficacy of recommending strict rest afterconcussion.

WHAT THIS STUDY ADDS: Recommending strictrest postinjury did not improve outcome andmay have contributed to increased symptomreporting. Usual care (rest for 1–2 days withstepwise return to activity) is currently the bestdischarge strategy for pediatric mild traumaticbrain injury/concussion.

Departments of aPediatrics, bPsychiatry and Behavioral Medicine, and cNeurology and Neurosurgery, MedicalCollege of Wisconsin, Milwaukee, Wisconsin

Dr Thomas developed the study concept and design, obtained funding, supervised the study,acquired data, analyzed and interpreted data, and drafted and revised the manuscript; Dr Appsassisted with study concept and design, supervised the study, provided technical support, analyzedand interpreted data, and critically revised the manuscript; Dr Hoffmann assisted with study design,analyzed data, provided statistical expertise, and critically revised the manuscript; Dr McCreaassisted with study design, analyzed and interpreted data, provided technical support, and criticallyrevised the manuscript; Dr Hammeke assisted with study concept and design, supervised the study,provided material and technical support, analyzed and interpreted data, and critically revised themanuscript; and all authors approved the final manuscript as submitted.

This trial has been registered at www.clinicaltrials.gov (identifier NCT01101724).

www.pediatrics.org/cgi/doi/10.1542/peds.2014-0966

DOI: 10.1542/peds.2014-0966

Accepted for publication Nov 5, 2014

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Pediatric head trauma representsa significant injury burden forchildren, and emergency department(ED) visits for sports-relatedtraumatic brain injury (TBI) haveincreased 60% over the previous10 years.1 Most of these patients aredischarged from the ED witha diagnosis of concussion and areinstructed to rest. Restrecommendations are motivated bya concern for reinjury duringrecovery from a concussion.2,3

Additionally, retrospective studiesand animal models demonstrate thatearly physical and mental activitycan impair recovery.4–7 Becausehuman data on postinjury exertion islimited, expert consensusrecommends 24 to 48 hours of restbefore beginning a stepwise returnto activity.8 Many cliniciansrecommend a longer period of rest,and some clinicians have advocated“cocoon therapy,” which restrictspatients to several days ina darkened room before slowlyreturning to activity.9 To date, theoptimal period of rest afterconcussion remains unknown.

We sought to investigate theeffectiveness of recommending 5 daysof strict rest compared with the usualcare of 24 to 48 hours of rest onoutcomes after discharge from the EDwith acute concussion. Wehypothesized that patients who wererecommended strict rest after injurywould have a greater decrease inphysical and mental activity andimproved mean neurocognitive,balance, and symptom outcomescompared with patients who wererecommended the usual care.

METHODS

Design and Procedures

The study was a prospectiverandomized controlled trial ofpatients presenting to the Children’sHospital of Wisconsin EmergencyDepartment and Trauma Center withmild TBI/concussion (mTBI) betweenMay 2010 and December 2012 (seestudy overview, Fig 1). mTBI wasdefined by using the AcuteConcussion Evaluation (ACE) form,a standardized tool endorsed by theCenters for Disease Control (CDC).The study was approved by theChildren’s Hospital of WisconsinInstitutional Review Board andregistered with ClinicalTrials.gov(NCT01101724).

Study Participants

Patients were screened for eligibilityif they presented with a chiefcomplaint of an injury to the head(eg, head injury, scalp laceration),including any associated mechanismwith the potential to have sustaineddirect force or transmitted force tothe head (eg, motor vehicle collision,fall).

Children were eligible if they were 11to 22 years of age and presented tothe ED within 24 hours of injury andwere diagnosed with a concussion.Patients were excluded if they werenon-English speaking or if theirguardian could not consent inEnglish, were diagnosed withintellectual disability (IQ ,70) ora previous mental defect or disease(eg, attention-deficit/hyperactivitydisorder or learning disability), werediagnosed with an intracranial injury

(eg, intracranial bleeding, cerebralcontusion), had no legal guardianpresent, were being admitted, or hadconditions that interfered with validassessment of signs and symptoms,neurocognitive, or balance testing. Inaddition, patients were excluded iftheir clinician was uncomfortablewith study procedures(eg, randomization or time needed forED assessments) or if the patient lived.1 hour from the Medical College ofWisconsin. Imaging, not necessary forstudy participation, was obtained atthe discretion of the treating clinician.Assent was obtained from patients,and informed consent was obtainedfrom caregivers.

Procedures

Adolescents underwent initialscreening to gather demographicinformation, injury details, initialsymptoms, and risk factors forprolonged recovery (eg, history ofprevious concussion or migraine).10

Participants also receivedcomputerized neurocognitive testingand a standardized balanceassessment in private rooms in theED. Attempts were made to minimizedistractions and interruptions duringtesting (eg, turning off the TV,sending younger siblings to thewaiting room, placing a sign on thedoor notifying staff that testing was inprogress). Participants were thenrandomized to 1 of 2 groups usingrandomization in blocks of 4 withsealed envelopes (a random numbergenerator to assign groups).Participants, parents, and health careproviders were notified immediatelyof the results of the randomization.

FIGURE 1Study overview.

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A trained research assistant arrangedfollow-up appointments with theparticipants for 3 and 10 days aftertheir ED visit, at which time repeatneurocognitive tests and balanceassessments were administered. Forthe majority of patients, follow-upmeasures were administered bya research assistant in the patient’shome in a quiet environment. A smallnumber of patients returned to thehospital for testing in ourTranslational Research Unit,a corporate office suite, or an EDroom. The principal investigator (DT)and coinvestigator (JA) reviewedfollow-up test results within 48 hoursof completion and consulted with thefamily by phone within 24 to48 hours to communicate anyconcerning test results or symptomscores. They remained available forquestions throughout the studyperiod. If clinically indicated, patientswere referred to the ED, their primarycare physician, or a concussionspecialist for follow-up.

Interventions

Participants were randomized eitherto the strict rest (intervention) groupor the usual care (control) group. Toaccurately represent the usual carefor mTBI, the treating attendingphysician was free to verballyrecommend activity restrictions asthey saw fit in the usual care group.A survey found that a majority of EDphysicians at our institution instructpatients to rest for 1 or 2 days andthen return to school and a stepwisereturn to physical activity only afterthe patient’s symptoms haveresolved, consistent with bestpractices outlined by the CDC.11 Thestrict rest group receivedrecommendations from the treatingphysician and discharge instructionsto maintain 5 days of strict rest athome (specifically, no school, work, orphysical activity) followed bya stepwise return to activity. Becauseno optimal time of postinjury rest hasbeen determined, this 5-day intervalwas chosen to maximize differences

between usual care and strict restgroups while minimizing the burdenplaced on the subject and family. Thestrict rest group was provided schooland work excuses for the 5 dayspostinjury. Both groups received theAce—Emergency Department (ACE-ED)Care plan, endorsed by the CDC, asdischarge instructions and wereencouraged to follow up with theirprimary medical doctor or theConcussion Clinic.12 Forms differedonly in the duration of time for whichrest was recommended. Researchassistants observed and documentedthe discharge instruction informationprovided to each patient to ensureclinician compliance with groupallocation.

Assessment and Outcome Measures

Outcome measures were selected tomeasure both compliance withdischarge instructions as well as theeffect of those instructions on short-term outcomes (first 10 days).

Compliance: Physical and MentalActivity

The Three-Day Activity Diary hasbeen validated as a measure ofactivity level and energy expenditurecompared with accelerometers anddoubly labeled watermeasurements.13,14 Participantsrecord activity levels in 15-minuteintervals over the first 3 days. Weightand gender were used to calculatebasal metabolic rate, and reportedactivity levels were used to calculatetotal energy expenditure.14 While inthe ED, participants retrospectivelycompleted the diary for the daybefore and the day of the ED visitunder the guidance of a researchassistant. Participants wereinstructed to complete the diaryseveral times a day, report the time inhours spent on specific mentalactivities, and note any effects onsymptoms. Reportable mentalactivities were taken from the list ofactivities participants were advised tolimit on the ACE-ED Care form12

(see Table 1).

A research assistant collected,reviewed, and discussed the Three-Day Activity Diary with theparticipants at the 3-day follow-upappointment. The research assistantthen instructed participants on theuse of a Seven-Day Activity Diary,which is modeled after the Three-Day Activity Diary and assessesactivity level and energy expenditurebetween days 4 and 10, withactivities recorded in 1-hourintervals. Participants wereinstructed to complete this diarybefore bed each night. At the 10-dayfollow-up appointment, the researchassistant collected, reviewed, anddiscussed the Seven-Day ActivityDiary with the participants. Datafrom both diaries was used tocalculate daily total energyexpenditure, activity-related energyexpenditure, physical activity level,and mental activity.14,15

Efficacy: Symptom Survey

A standard 19-symptom Post-Concussive Symptoms Scale (PCSS)assessing symptoms in 4 domains(physical, cognitive, emotional, andsleep) was included in the diaries.16

Each symptom was graded by thesubject from none (0) to severe (6)and was obtained daily for the first10 days. Data were analyzed for totalPCSS score, total number of individualsymptoms reported, and subtotalscores for each PCSS domain.

Efficacy: Neurocognitive Assessment

Our primary neurocognitiveassessment was the Immediate Post-Concussion Assessment and CognitiveTesting (ImPACT) computerized testbattery. ImPACT V2.0 (ImPACTApplications, Inc, Pittsburgh, PA) isa widely used commercial computer-based neurocognitive test platform.This measure has been validated foruse in the ED setting and reliablydetects neurocognitive deficits afterconcussion.17,18 ImPACT administers6 neuropsychological test modules,the composite scores of which arereported in 5 fields: Verbal Memory,

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Visual Memory, Reaction Time,Processing Speed, and ImpulseControl.19–29 Scores are assessedbased on age- and gender-matchedpercentiles for 11 to 13 years, 14 to

18 years, and .19 years usingexisting ImPACT normative data. Thistest was administered in the ED andat both follow-up visits. In addition toImPACT, during follow-up visits,

subjects completed a paper ancillaryneuropsychological test battery. Thebattery comprised testsdemonstrated to be sensitive, valid,and reliable in the assessment of mildtraumatic brain injury. The batteryincluded Hopkins Verbal LearningTest, Trail Making Test Parts A & B,Symbol Digit Modalities Test, Letter-Number Sequencing from theWechsler scales, and Controlled OralWord Association Test (verbalfluency).30–34

Efficacy: Balance Assessment

The Balance Error Scoring System(BESS) objectively assessesbalance.35,36 The test consists of 3stance conditions (double leg, singleleg, tandem); each stance isperformed with eyes closed on bothnormal firm flooring and a medium-density foam surface. Inability tomaintain stance or eye opening isdeemed an error and is recorded asa quantitative measurement ofpostural instability. Performance isscored by adding the error points foreach of 6 trials. BESS was performedin the ED and at 3 and 10 days.Because of time constraints, patients

FIGURE 2CONSORT (Consolidated Standards of Reporting Trials) diagram. ADHD, attention-deficit/hyperactivitydisorder; F/U, follow-up; ICI, intracranial injury. *Did not meet inclusion criteria because they werenot diagnosed with concussion.

TABLE 1 Physical and Mental Activity Diary Metrics

PAR Intervals Recorded

1–3 d 4–10 d

Physical activity scaleA: Sleeping (resting in bed) 0.95 15 min/d h/dB: Sitting (eating, writing, using the computer, etc) 1.5 15 min/d h/dC: Standing (washing, combing, shaving, cooking, etc) 2 15 min/d h/dD: Walking indoors (light home activities) 2.8 15 min/d h/dE: Walking outdoors (light manual work) 3.3 15 min/d h/dF: Low Intensity Activity (golf, gardening, biking [,6 mph], table tennis, etc) 4.4 15 min/d h/dG: Moderate-intensity activity (jogging, biking 7–12 mph, hiking, horseback riding, dancing, snow shoveling, loading

and unloading goods, etc)6.5 15 min/d h/d

H: High-intensity activity (running [,6 mph], bicycling [.12 mph], swimming, tennis, basketball, football, soccer, wttraining, carrying heavy load upstairs, etc)

10.0 15 min/d h/d

I: Maximum-intensity activity (very high to maximal intensity: competitive running [.6 mph], cross-country skiing, etc) 15.0 15 min/d h/dMental activity(Low) Listening to music/radio or reading n/a h/d h/d(Low) Watching TV, surfing the internet, or playing video games n/a h/d h/d(Moderate) In the classroom during school n/a h/d h/d(Moderate) After-school activities, clubs or job n/a h/d h/d(High) Working on homework or studying n/a h/d h/d(High) Taking quizzes, tests, and or giving presentations n/a h/d h/d

Calculations were as follows. Basal Metabolic Rate (BMR) calculated by using Schofield equation: Male, BMR = 0.074 3 wt (kg) + 2.754 MJ/d; female, BMR = 0.056 3 wt (kg) + 2.898 MJ/d.Total energy expenditure (TEE) calculated by summing the number of 15-min periods for each categorical value (A–I). Each result was then multiplied by its respective PAR and thesubjects predicted BMR. Totals were then added to determine 24-h exertion. Activity-related energy expenditure calculated by subtracting BMR from TEE. Physical activity level (PAL)calculated by dividing TEE by BMR. PAR, physical activity ratio.

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in the ED were only tested on firmflooring and scores assessed for only3 trials.

Statistical Analysis

To investigate whether treatment ledto improved symptom,neurocognitive, and balanceoutcomes and whether there wasa significant difference in recoverytrajectory based on treatment groupassignment, linear mixed-modelanalyses were used. Linear mixedmodeling demonstrates a mean groupresponse as well as random effectsand allows each subject to havea different recovery trajectory. It alsoaccounts for correlations over timeinduced by multiple observations onthe same subject. If data are notnormally distributed, then a generallinear mixed model is used. Inaddition to these analyses, time tosymptom resolution (defined asPCSS #7) was analyzed by usinga proportional hazards model. Thetotal number of symptoms reported,neurocognitive and balance outcomedifferences from ED (day 0) to day 3and day 10, and differences in activityand symptoms in the first 5 days andover the course of the study werecompared by using t tests orWilcoxon rank sum tests when thedata were not normal. Data analysiswas conducted by using SAS (V9.3)and Stata (V13.0). The intention-to-treat principle was used for allanalyses. Statistical significance wasP , .05. The Bonferroni multiplecomparisons adjustment forcomparison of changes at days 3 and10 was P , .025. A subgroup analysiswas planned a priori to assess howpreinjury risk factors and initialpresentation influence treatmenteffects.

Calculation of Sample Size

A priori we determined that a samplesize of 44 subjects in each group wassufficient to detect a 12-pointdifference (a moderate effect size) intotal PCSS (based on an estimated SDof 22) for a power of 0.80 and type I

error (a) of .05.28 For thecomputerized neurocognitiveassessment, we were powered todetect minimal clinically significantdifferences (a difference of 9% inVerbal Memory, 17% in VisualMemory, 15% in Reaction Time, and14% in Processing Speed).23

RESULTS

Demographics

Three-hundred and seventy patientswith mTBI met inclusion criteriaduring the study period (see Fig 2);178 met exclusion criterion, and an

additional 93 patients declined toparticipate, leaving a sample of 99participants who were randomized.The strict rest group was slightlyolder (mean 14.7 vs 13.1 years), andthis was associated with slightdifferences in weight and basalmetabolic rate (see Table 2). One-third of participants in each groupwere female. There were nosignificant differences betweentreatment groups at time of EDevaluation including mechanism ofinjury, symptoms at ED presentation,history of migraine, previous mTBI,ED evaluation, and ED treatment. The

TABLE 2 Demographic Table

Total (99) Usual Care (50) Strict Rest (49)

DemographicsAge, y, median (IQR) 13.7 (12.4–15.0) 13.1 (12.1–14.5)a 14.7 (13–15.5)a

Wt, kg, median (IQR) 57.9 (46.5–68.0) 54.8 (42.6–65.6) 63 (48.9–70.5)Basal metabolic rate, MJ/d, median (IQR) 6.67 (5.88–7.58) 6.49 (5.78–7.24) 6.98 (6.04–7.79)

Preinjury activity (day before injury)TEE, MJ/d, median (IQR) 12.2 (9.6–15.4) 12.0 (8.9–15.1) 12.2 (10.1–15.9)PAL, median (IQR) 1.8 (1.5–2.2) 1.8 (1.6–2.2) 1.8 (1.4–2.2)AEE, MJ/d, median (IQR) 3.9 (2.1–6.6) 4.1 (2.3–6.5) 3.7 (1.8–7.1)Moderate–high mental activity, median (IQR) 2 h/d (0–9) 0 h/d (0–9.3) 3.0 h/d (0–7.5)

Risk factors of prolonged recoveryFemale gender, n (%) 34 (34) 18 (36) 16 (33)Previous mTBI, n (%) 6 (6) 2 (2) 4 (4)History of migraine, n (%) 6 (6) 2 (2) 4 (4)

Mechanism of injurySports, n (%) 70 (71) 33 (66) 37 (76)Football 27 (27) 11 (22) 16 (33)Basketball 9 (18) 6 (12) 3 (6)Soccer 9 (18) 4 (8) 5 (10)Baseball 1 (1) 1 (2) 0 (0)Cheerleading 3 (3) 2 (4) 1 (2)Biking 2 (2) 1 (2) 1 (2)Other 19 (19) 8 (16) 11 (22)

MVC n (%) 7 (7) 3 (6) 4 (8)Fall, n (%) 15 (15) 9 (18) 6 (12)Assault, n (%) 5 (5) 4 (8) 1 (2)Other, n (%) 2 (2) 1 (2) 1 (2)

ED reported signs/symptomsPostconcussive symptoms, n (%) 97 (98) 48 (96) 49 (100)Immediate symptoms,b n (%) 72 (73) 34 (68) 38 (78)Loss of consciousness, n (%) 36 (36) 21 (42) 15 (31)Anterograde amnesia, n (%) 27 (27) 10 (20) 17 (35)Retrograde amnesia, n (%) 18 (18) 7 (14) 11 (22)Seizure, n (%) 1 (1) 1 (2) 0 (0)

ED evaluationHead computed tomography obtained, n (%) 26 (26) 11 (22) 15 (30)

ED treatmentAnalgesic, n (%) 73 (74) 37 (74) 36 (73)Antiemetic, n (%) 21 (42) 9 (18) 12 (24)

AEE, activity-related energy expenditure; IQR, interquartile range; MVC, motor vehicle collision; PAL, physical activity level;TEE, total energy expenditure.a P , .01.b Symptoms include dazed or stunned, confused about events, answers questions slowly, and repeats questions.

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most common mechanism of injurywas sports, specifically football.Nearly all participants reported somesymptoms in the ED andapproximately one-third reporteda loss of consciousness. Only one-third of the patients in the usual caregroup were observed verballyreceiving a specific duration torestrict activity. Of those who didreceive instructions, the medianduration of strict activity restrictionwas 2 days. In the strict rest group,94% were observed verballyreceiving a specific duration torestrict activity with a medianduration of 5 days. Follow-upprocedures were completed for 88participants (43 usual care control [C]vs 45 strict rest intervention [I]).

Compliance: Physical and MentalActivity Level

Both groups exhibited an ∼20%decrease in energy expenditure andphysical activity level in the first5 days postinjury. The usual caregroup reported more total hours inhigh and moderate mental activityon days 2 to 5 than the strict restgroup (8.33 [C] vs 4.86 [I] hours,P = .03), including more school andafter school mental activity (6.66[C] vs 3.77 [I] hours, P = .03) (seeFig 3).

Efficacy: Symptom, Neurocognitive,and Balance Outcomes

In both groups, .60% of patientsexperienced symptom resolution(defined as PCSS #7) during the

follow-up period (67% [C] vs 63%[I], P = .82). However, it took 3 dayslonger for 50% of patients in thestrict rest group to report symptomresolution compared with the usualcare group (see Time to SymptomResolution, Fig 4). Moreover, thestrict rest group reported greatertotal PCSS scores over the course ofthe 10-day follow-up period (187.9[I] vs 131.9 [C], P , .03), a highertotal number of postconcussivesymptoms reported during follow-up period (70.4 [I] vs 50.2 [C],P , .03; data not shown) and highermean daily PCSS clustered aroundday 4 (see Fig 5). We found nosignificant differences betweengroups in computer-basedneurocognitive tests and balancescores at 3 or 10 days (see Table 3).Although most paperneuropsychological assessments didnot demonstrate a significantdifference, the strict rest groupperformed better at day 3 (59.9 [C]vs 67.6 [I], P , .01) and worse atday 10 (71.5[C] vs 67.6[I], P = .04)than the usual care group on theSymbol Digit Modalities Test.

Factors Associated With Recoveryand Outcome

Linear mixed modeling did not findsignificant treatment effects overtime based on group assignment fortotal PCSS and neurocognitive testmeasures. However, when PCSS wasanalyzed by domain, assignment tothe strict rest group contributed tohigher physical symptom scores ondays 2 and 3 and a trajectory ofhigher emotional symptomsthroughout follow-up. Additionalfactors were found in both groups tobe associated with longitudinaloutcomes. We found that femalepatients reported higher PCSSscores and lower energyexpenditure. As expected during thefollow-up period, total daily energyexpenditure, physical activity level,and mental activity levelsignificantly increased over time,and PCSS, visual memory, reaction

FIGURE 3Compliance with physical and cognitive rest recommendations. A, Mean daily total energy expen-diture (TEE) with 95% confidence interval. No difference seen in total energy expenditure. B, Meanhours of moderate or high mental activity with 95% confidence interval. The usual care groupreported more total hours in high and moderate mental activity on days 2 through 5 than the strictrest group (8.33 vs 4.86 hours, P = .03).

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time, and motor processingimproved over time.

Subgroup Analysis

A subgroup analysis suggests a morenuanced relationship between restand outcomes. Patients diagnosedwith concussion based onpostconcussive symptoms alone(eg, headache, dizziness) reporteda higher postconcussive symptomscore at day 10 when randomized tostrict rest (15.2 [I] vs 7.7 [C], P, .04).Patients who presented to the ED

with immediate signs of concussion(eg, loss of consciousness.30 seconds, amnesia, or confusion)trended toward lower postconcussivesymptom scores at day 10 whenrandomized to strict rest (11.0 [I] vs14.6 [C], P = .22). Similarly, patientswith a past history of concussionreported greater symptoms at day 10when randomized to strict rest(15.1 [I] vs 5.6 [C], P , .05). However,patients who presented with theirfirst concussion showed no differencein symptoms at day 10 based on

group assignment. Additionally,although patients with a history ofmigraines reported higher symptomsat day 10, no differences could beseen based on group assignment. Wewere not powered to detectdifferences between specificmechanisms of injury. However, whencomparing sport to nonsportmechanisms, we found no differencesin outcomes based on mechanism ortreatment group assignment.

DISCUSSION

Recommending strict rest from theED did not improve symptom,neurocognitive, and balanceoutcomes in youth diagnosed withconcussion. Surprisingly, adolescentswho were recommended strict restafter injury reported more symptomsover the course of this study.Although recommending strict restultimately did not significantly alterthe amount of physical activitybetween groups, it did change theamount of mental activity (eg, schoolattendance).

This is the first randomizedcontrolled trial of rest strategies inpediatric patients after acuteconcussion. Although poorcompliance with strict physical restmay have contributed to a lack ofefficacy, previous adult studies thathave assessed strict rest afterconcussion found similar results.Relander et al (1972) randomizedadmitted adult patients with mTBI tobedrest or active therapy and foundthat subjects in the active group wereable to return to work 14 days earlierthan the bedrest group.37 de Kruijket al (2002) randomized adultsdischarged with acute mTBI to usualcare or strict bedrest and found thatboth treatments resulted in nosignificant differences in actualamounts of outpatient bedrest and nodifferences in outcomes at 2 weeks,3 months, and 6 months.38 Given thatthese previous studies of morestringent rest in concussed adultssimilarly failed to demonstrate

FIGURE 4Proportion of patients reporting symptom resolution (PCSS #7) over time. It took longer for 50%the intervention group to report symptom resolution. However, the difference in overall proportionof patient reporting symptom resolution did not meet statistical significance (P = .08).

FIGURE 5Mean PCSS with 95% confidence interval over time. Patients in the intervention group experiencedhigher total symptoms over the course of follow-up with the greatest difference in mean symptomson day 4 (13.95 [C] vs 21.51 [I], P , .03).

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a benefit, strict physical rest mayinherently lack efficacy over ourcurrent modest restrecommendations.

Previous pediatric studies havedemonstrated an association withrest and outcome after concussion inthe clinic setting. In a retrospectivestudy of adolescents treated ata concussion clinic, Majerske et al(2008) found that patients with highlevels and low levels of postinjuryphysical and mental activity hadnegative outcomes, whereas patientswho reported moderate activity hadthe best neurocognitive andsymptoms scores at follow-up.7

Moser et al (2012) found decreasedconcussion symptoms and improvedscores on ImPACT after 1 week ofcognitive and physical rest, evenwhen implemented weeks to monthsafter concussion.39 Gibson et al(2013) assessed the influence ofrecommending cognitive rest topatients presenting to a concussionclinic on symptom duration andfound no association with time tosymptom resolution.40 Brown et al(2014) found a correlation betweenreporting high cognitive activity afterinjury and longer symptom duration

in patients seen in a concussionclinic.41 They did not demonstrate thesame association between moderateand low levels of cognitive exertionand symptom duration. These studiesrecruited patients from the clinicsetting days after injury, and thusmay not generalize to the acute caresetting. This current study found thatpatients in an acute care settingrandomized to 5 days of strict restfrom cognitive and physical activityexperienced symptoms longer thanthe usual care group. However, boththe strict rest and usual care groupsreported lower levels of cognitiveactivity in the first 5 days aftera concussion. Taken together, thesestudies show that our current usualcare endorsing modest physical andcognitive rest after injury is aneffective strategy for recovery.

Patients in our strict rest groupreported more symptoms over thecourse of the study. Modelingrevealed that group assignment wasassociated with high physicalsymptoms early and emotionalsymptoms throughout the study.Given that there were not significantdifferences in physical activity leveland small differences in cognitive

activity level, it is possible some othereffect of group allocation contributedto these symptom differences.Furthermore, these data do notdetermine whether these highsymptoms represented a greaterseverity of illness or were simplya reporting bias. There are manypotential explanations for thedifference in symptom reporting. It ispossible that discharge instructionsinfluenced the perception of illness,augmenting symptom reporting. Thestrict rest group may have beenbetter able to articulate theirsymptoms because they were slightlyolder. Lishman et al (1988) suggestedthat physiologic and psychologicalfactors both contribute to thedevelopment of postconcussivesyndrome, with psychological factorscontributing more to symptoms overtime.42 The deleterious effects ofstrict rest may have more to do withemotional distress caused by schooland activity restriction. Missing socialinteractions and falling behindacademically may contribute tosituational depression increasingphysical and emotional symptoms.Similarly, activity restrictions and lackof exercise may contribute to sleep

TABLE 3 Neurocognitive and Balance Assessments

ED 3 Days 10 Days

Usual (n = 49) Strict (n = 48) Usual (n = 45) Strict (n = 48) Usual (n = 43) Strict (n = 45)

ImPACT scores (percentile)Verbal Memory 30.5 (21.8–39.2) 30.1 (21.7–38.6) 25.6 (17.3–33.8) 35.6 (27.0–44.2) 34.0 (25.6–42.5) 34.3 (25.1–43.4)Visual Memory 26.1 (18.6–33.6) 28.3 (20.4–36.2) 36.4 (26.9–45.8) 32.1 (24.2–40.0) 42.6 (32.4–52.8) 33.5 (24.9–42.0)Processing Speed 29.5 (21.1–37.8) 27.6 (19.6–36.0) 37.1 (28.2–46.0) 39.5 (30.4–48.5) 47.5 (37.7–57.4) 41.3 (32.2–50.4)Reaction Time 24.2 (16.2–32.1) 17.4 (10.3–24.5) 32.9 (24.2–41.7) 39.2 (29.9–48.5) 39.1 (29.5–48.6) 43.0 (33.0–53.0)Impulse Control 14.8 (10.5–19.1) 17.4 (12.2–22.6) 9.8 (8.0–11.6) 10.8 (6.9–14.6) 12.2 (9.8–14.5) 11.8 (8.9–14.6)

BESS Total Error scoreBESS Firm total 8.4 (6.6–10.2) 10.8 (8.2–13.4) 7.6 (6.0–9.3) 7.9 (6.5–9.2) 6.1 (4.6–7.5) 6.8 (5.4–8.2)BESS Foam total — — 14.7 (12.5–17.0) 15.7 (14.0–17.4) 12.9 (10.9–14.9) 14.2 (12.6–15.8)BESS total — — 22.4 (18.8–25.9) 23.6 (21.0–26.1) 19 (15.9–22.1) 21 (18.4–23.6)

Ancillary neuropsychological testsHVLT Total Recall — — 24.0 (22.6–25.5) 24.8 (23.2–26.4) 24.2(23.6–26.3) 25.8 (24.4–27.1)HVLT Delayed Recall — — 8.4 (7.6–9.1) 8.9 (8.3–9.5) 8.0 (7.3–8.7) 8.3 (7.6–8.9)TMT A time — — 39.8 (34.6–45.1) 38.1 (34.5–41.6) 30.4 (27.7–33.1) 30.8 (27.7–33.9)TMT B time — — 82.7 (72.0–93.3) 77.0 (70.8–83.3) 66.9 (59.6–74.3) 63.2 (57.7–68.7)SDMT Total Correct — — 59.9 (54.8–64.9)a 67.6 (63.6–71.6)a 71.5 (66.4–76.7)a 67.6 (63.6–71.6)a

LNS Total Score — — 18.5 (17.5–19.4) 19.0 (18.1–19.9) 19.7 (18.7–20.4) 20.0 (19.2–20.7)COWAT Total Correct — — 30.5 (27.8–33.2) 31.2 (28.9–33.6) 33.4 (30.4–36.5) 35.1 (32.3–37.9)

Data are mean (95% confidence intervals); percentile score means “percentile score” were specified, all other data are raw scores. COWAT, Controlled Oral Word Association Test; HVLT,Hopkins Verbal Learning Test; LNS, Letter-Number Sequencing; SDMT, Symbol Digit Modalities Test; TMT, Trail Making Test Parts; —, test was not done in the ED.a P , .05.

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abnormalities and adversely affectmood. Alternatively, attending lessschool may have resulted in moretime and fewer distractions tothoughtfully complete symptomdiaries or perseverate on symptoms.

Limitations

This study had several limitations. Thestudy focused on patients who weredischarged. Because admitted patientsare more likely to have significantimmediate signs, they likely representa group of interest that may havebenefited from a strict rest protocol.Despite randomization, the strict restgroup was older, which may haveaffected results. As a conveniencesample of patients, our study may havefavored athletes and other motivatedsubjects. We used diaries to recordactivity levels and symptom scales,which has been well validated but issubject to recall bias. Findings focusonly on short-term outcomes becausethe majority of concussions improvewithin the first 7 to 10 days; however,as a result, we were unable to detectdifferences in subjects that recoveredafter the follow-up period and couldnot evaluate long-term outcomes.

Future Directions

More information is needed todetermine the optimal dischargeinstructions for mTBI from the ED.Research has shown that activerehabilitation (eg, low-level physicalactivity) can improve outcomes inlater phases of mTBI.43,44 Furtherresearch is needed to test the safetyand efficacy of active rehabilitation inthe acute postinjury period. Given theheterogeneity of mTBI, this questioncan only be answered with a largerandomized controlled trial poweredto detect effects on subgroups(eg, athletes, patients with previousconcussions or migraines, mechanismof injury) using patient-centeredoutcome measures and objectiveneurocognitive assessments.

CONCLUSIONS

This is the first study to testrecommending strict rest as anintervention to improve acuteconcussion outcomes in pediatricpatients. In the acute care setting, wefound that strict rest immediatelyafter mTBI offers no benefit overcurrent usual care. We also found that

adolescents’ symptom reporting maybe influenced by restricting activity.Further research is needed todetermine the optimal ED dischargerecommendations for adolescentsafter mTBI.

ACKNOWLEDGMENTS

We acknowledge the following peoplewho made this project possible: theInjury Research Center at the MedicalCollege of Wisconsin provided crucialfunding. Derek Jirovec, ClinicalResearch Coordinator in theDepartment of Pediatrics, wasinstrumental in data acquisition andstudy supervision as our researchcoordinator. Haydee Zimmerman,database analyst in the Department ofPediatrics, provided administrativesupport in developing our researchdatabase. Mark Nimmer, ClinicalResearch Coordinator in theDepartment of Pediatrics, providedadministrative support maintainingthe database and assisting with dataanalysis and interpretation. DavidBrousseau MD, MS, and Amy Drendel,DO, provided critical review of themanuscript.

Address correspondence to Danny G. Thomas, MD, MPH, Department of Pediatrics, Emergency Medicine, Children’s Hospital of Wisconsin Corporate Center, 999 N.

92nd St, Suite C550, Milwaukee, WI 53226. E-mail: dthomas@mcw.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Injury Research Center of the Medical College of Wisconsin

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: A companion to this article can be found on page 362, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2014-3665.

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NEW LIFE FOR AN OLD BOX: I first visited London many, many years ago. At thattimenobodyownedacellphone, textinghadnotbeen invented,andpublic telephoneboothswere incredibly important. I canstill remembermakingsure Ihadapocketofcoins before calling my family back in the States. Today, in London as elsewhere,there is little use for the public telephone. Iconic red telephone booths (or ‘boxes’ asthey are called in London) have been decommissioned and either scrapped orconverted into all sorts of things– including small libraries, aquariums, and storagefor emergency defibrillators. I have a friend in Vermont who has two phone boxesand uses them for a unique garden. Now a pair of English entrepreneurs has founda new use for the phone boxes: as charging stations for mobile devices.As reported in The New York Times (World: October 4, 2014), the pair won a LowCarbon Entrepreneur competition to help finance the project. The first chargingstation was unveiled in October 2014. The boxes were repainted green and havea solar panel on the roof. The solar panel produces enough energy to charge up to100 phones or other mobile devices a day. There is no fee for the charging service;revenue comes from advertising displayed on a screen inside.Knowing how stressed my children become when their phones are low on power,I suspect the charging stationswill beawelcome site in London.Given that therearethousands of unused telephone booths in London, the future looks bright for thoseshort on power for their phones.

Noted by WVR, MD

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