#EMconf: Rest or early activity for post-concussive children?

Clinical Question: in the pediatric patient population, does participation in physical activity following acute concussion lead to more persistent post-concussive symptoms?

Take Home Message: Two recent articles suggesting that strict rest from physical activity after concussion does not appear to be beneficial in symptom resolution and may even be harmful in the pediatric population.

Study 1: JAMA 2016:

  • Prospective, multicenter, cohort study designed to study the association between participation in physical activity within 7 days post injury and incidence of persistent post concussive symptoms (PCCS)
  • Study participants included patients who presented to ED for acute head injury within preceding 48 hours who met concussion diagnosis according to 2012 Zurich consensus statement 
  •  Physical activity participation and postconcussive symptoms were rated using standardized questionnaires in the ED and at days 7 and 28 post-injury 
  •  On unadjusted analysis, early physical activity participants had lower risk of PPCS than those with no physical activity (24.6% with early physical activity vs 43.5% with strict rest) 
  • The authors concluded that among participants in their study, physical activity within 7 days of an acute concussion was associated with reduced risk of PPCS at 28 days when compared with no physical activity following injury

Study 2: Pediatrics 2015:

  • Randomized control trial designed to determine if strict rest improved concussion recovery and outcome after acute concussion 
  •  Study participants included patients who presented to ED for acute head injury within preceding 24 hours 
  • Participants were randomized to strict rest for 5 days versus stepwise return to activity over this time and underwent symptom/neurocognitive/balance assessment @ 3 and 10 days post injury 
  • Found no clinical significant difference in neurocognitive or balance outcomes. However, the strict rest group reported more post concussive symptoms at the 10 day follow up (total symptom score 187.9 vs 131.9, p<0.03) 
  • The authors concluded that recommending strict rest for adolescents immediately after concussion offered no added benefit over stepwise return to activity

Articles Reviewed:
1) Grool, A et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016; 316(23): 2504-2514


2) Thomas, G et al. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics. 2015(135); 213-223