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Three Part Question

Should [children who present with a sport-related concussion] observe [strict physical rest until asymptomatic] to reduce [postconcussive symptoms]?

Clinical Scenario

An 11 year old male presents to the emergency department after jumping for a rebound at basketball practice. He falls to the ground striking his head against the floor. He briefly loses consciousness and comes to emergency department with repetitive questioning, vomiting, and complaining of headache. You order a head CT which is unremarkable, symptoms improve during a brief observation period, and as you prepare for discharge the patient’s parents question about returning to physical and cognitive activities.

Search Strategy

Medline 1966-06/17 using PubMed, Cochrane Library (2017), and Embase.

[(Concussion [MeSH] or Post-Concussion Syndrome [MeSH] or mild traumatic brain injury [MeSH]) AND (Rest [MeSH] or Treatment Outcome [MeSH])]. Limit to Children (birth-18 years) and English language.

Search Outcome

170 studies were identified; two recent meta-analyses (published in 2017) addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Davis GA, Anderson V, Babl FE, Gioia GA, Giza CC, Meehan W, Moser RS, Purcell L, Schatz P, Schneider April 28, 2017 England	28 studies met inclusion criteria with 5 randomized controlled trials	Systematic Review (1a)	How long should children with concussion rest?	Physical and cognitive rest in the first few days following concussion in children may be beneficial, prolonged rest has not demonstrated any advantage and may even delay recovery.	Several studies had very small samples, and the larger studies were limited by issues with definitions, compliance, selection bias and recall bias. There were no validated data demonstrating the appropriate duration of cognitive or physical rest in children with concussion.
			When should children with concussion return to sport?	Children and adolescents should not resume sport activities until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.
Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, Feddermann-Demont N, Iver Mar 24, 2017 England	134 articles met inclusion criteria with 2 randomized controlled trials.	Systematic Review (1a)	Post-Concussion Symptom Scale ratings both before and following rest.	The individuals who were randomized to recommendation of strict rest reported higher total symptom over 10 days and had slower symptom resolution.	Studies included in this review were of low methodological quality and biased by systematic errors

Comment(s)

These two systematic reviews indicated that a brief period of cognitive and physical rest followed by a gradual increase in activity should be instituted. The exact amount and duration are not clearly defined at this time however 24-48 hours of rest should be observed. Children should not return to sports until they have returned to school. However, during this time, early symptom-limited physical activity is appropriate.

Clinical Bottom Line

Children who present with a sport-related concussion should have a brief period of cognitive and physical rest followed by a gradual increase in activity. Further studies should examine the length or the brief rest period, however at this time 24-48 hours of rest should be recommended.

References

1. Davis GA, Anderson V, Babl FE, Gioia GA, Giza CC, Meehan W, Moser RS, Purcell L, Schatz P, Schneider What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med 2017 Apr 28. pii: bjsports-2016-097415. doi: 10.1136/bjsports-2016-097415. [Epub ahead of print]
2. Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, Feddermann-Demont N, Iverson GL, Hayden A, Makdissi M. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017 Mar 24. pii: bjsports-2016-097475. doi: 10.1136/bjsports-2016-097475. [Epub ahead of print]