Presentation on theme: "Controversies in rest and exercise after concussion Part II Silverberg, N.D. AAPMR 2014 – San Diego."— Presentation transcript:
Controversies in rest and exercise after concussion Part II Silverberg, N.D. AAPMR 2014 – San Diego
Disclosures Noah Silverberg PhD Receives salary support from the Vancouver Coastal Health Research Institute. Has a forensic neuropsychology practice.
Objectives At the conclusion of this activity, the participant will be able to: 1.Summarize the best available research evidence on rest and gradual activity resumption after concussion. 2.State how they will implement this evidence in their practice.
Pre-presentation survey “Rest is the best medicine” or “Rest makes rust”
Overview 1.History of rest as a treatment for concussion 2.Clinical studies Intervention RCT Non-randomized Multifaceted interventions Observational 3.Practice recommendations
Rest has been controversial in the management of concussion for 60+ years
de Kruijk et al (2002) Sample N=107 “Mild” MTBI (e.g., PTA < 1 hr) Excluded multitrauma, hx of TBI, prior psych hx Recruitment from ED in the Netherlands
de Kruijk et al (2002) Design Parallel group RCT Outcome = severity of 16 postconcussion symptoms and SF-36 Assessed at 2 weeks, 3 months, and 6 months Fair compliance with prescriptions
de Kruijk et al (2002) Mobilization schedule NO group started on day 1 post-injury FULL group started on day 7, after 6 days of bed rest Day 1 2345 MTBI < 4 hrs bed rest < 3 hrs bed rest < 3 hrs bed rest < 1 hr bed rest Resume normal activities and work
de Kruijk et al (2002) Less severe symptoms in the REST group Better health-related QOL in the REST group
No clear effect of bed rest. Trend for bed rest to palliate symptoms during first 2 weeks, but any positive effect disappeared or even reversed in the long-term. Higher follow-up in bed rest group (87% vs. 61%) thought to underestimate long-term harms.
Sample 49 student athletes referred to a concussion clinic (age 14 to 23) Variable time post-injury o M=36 days; median=11 days
Moser 2012 Design Retrospective pre-post ImPACT 1 week of prescribed complete physical and mental rest ImPACT No other intervention during week of rest Compliance: All off school, “controlled access” to computer and cell phone use. Created time post-injury groups (1-7 days, 8- 30 days, >30 days)
Moser 2012 School or homework Trips outside the home Social visits Watching sports or “visually intense” movies Video games Computer use Texting or phone calls Reading Chores Exercise Participants instructed to do NO:
Moser 2012 Limit TV Get more sleep Participants also told to:
Moser 2012 No participation in sport ~1 week off school Compliance with other activity restrictions “less uniform” Compliance:
Moser 2012 Results Cognition and symptoms improved. Improvements did not vary with time post- injury.
Sample N=13, like Moser et al 2012 Additional eligibility criterion: IMPACT followed by no rest prior to first clinic visit
Moser 2014 Design Repeated baseline pre-post Rest prescription similar to Moser 2012, but also recommended “low exertion” activities Listening to relaxing music or audibooks Folding laundry Setting the table Slow walk in yard Meditating Taking a bath Listening to stories from a grandparent
Moser 2014 Results Overall, the group was stable between repeated baselines and improved on all measures after rest. 8 out of 13 cases had reliably improved cognition or symptoms.
Limitations of Moser 2012 & 2014 Non-representative sample (e.g., >50% with LD, ADHD, prior concussions) Retrospective No true control group Intervention likely multifaceted Lead author owns the clinic, served as a consultant for the primary outcome measure
Majerske et al. (2008) Design Retrospective cohort. 80 student athletes seen for 2+ visits at a sport concussion clinic. “Activity Intensity Scale” extracted by chart review. o 5-pt rating scale. o No school/exercise to full school and participation in sport games.
Majerske et al. (2008) Results Cognition and symptoms improved over clinic visits. Activity intensity unrelated to symptoms, but related to cognition, adjusting for time post- injury.
Brown et al. (2013) Design Prospective cohort. 335 student athletes assessed at a concussion clinic < 3 weeks post-injury. Completed Post-Concussion Symptom Scale from SCAT2 and “Cognitive Activity Scale” o Self-reported cognitive exertion since last clinic visit.