Woman With InsomniaParents and providers are growing more concerned about concussion and how these injuries may affect kids and teens. What makes it even more unnerving is the realization that we are managing these injuries without an evidence-based playbook.

In 2013, the Institute of Medicine of the National Academy of Sciences recognized “… there is little empirical evidence for the optimal degree and duration of physical rest needed to promote recovery or the best timing and approach for returning to full physical activity…” following concussion in teens. In absence of evidence, fear of re-injury during recovery has motivated parents and providers to advocate prolonged strict rest after concussion. Some even recommend “cocoon therapy,” which restricts patients to several days in a darkened room before slowly returning to activity.

We recently published a randomized controlled trial of strict rest following acute concussion in adolescents. Patients who presented to the emergency department were randomly assigned to either rest for 1-2 days before a gradual return to activity (Usual Care Group) or 5 days of rest (Strict Rest Group).

Contrary to expectations, strict rest for five days immediately after concussion did not help teenagers get better compared to our current advice. We found that teenagers instructed to rest for 5 days actually reported more symptoms over the next 10 days and took longer to recover. While we don’t know why strict rest was not helpful, we do have some theories.

One theory is that making patients sit as home forced them to focus on their injuries, therefore increasing symptom reporting. When you have a toothache, it bothers you more at night when there is less distraction. Similarly, returning to activity after a concussion may serve as a distraction from symptoms.

It is also possible that keeping a teenager from school cuts them off from a vital social environment, which increases symptom reporting. Another theory is that patients in our study may have been influenced by the recommendation to rest and had negative expectations about resting. Finally, it is possible that return to normal activity (school and light physical activity) serves as a form of rehabilitation.

These results demonstrated that our current standard of care was better than prolonged strict rest after injury. We should be cautious when imposing excessive restrictions of activity following concussion and be mindful that our expectations about concussion may influence teenagers’ perception of illness.

We should balance two goals as parents and providers: prevent re-injury and encourage recovery. As long as the activities our kids pursue don’t put them at risk for a second bonk on the head and don’t make them feel worse, they are safe and may help them start to feel better again.

Once a teenager is fully recovered, a provider should evaluate him before he engages in any high-risk activities (e.g., sports). With proper management, concussions do not lead to permanent problems. In the end, concussions get better with time; how fast is based on the individual.

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From issue: 30/03-04