1. Controversies in rest and exercise after concussion Part II Silverberg, N.D. AAPMR 2014 – San Diego

2. Disclosures Noah Silverberg PhD Receives salary support from the Vancouver Coastal Health Research Institute. Has a forensic neuropsychology practice.

3. 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.

4. Pre-presentation survey  “Rest is the best medicine” or  “Rest makes rust”

5. Overview 1.History of rest as a treatment for concussion 2.Clinical studies  Intervention RCT Non-randomized Multifaceted interventions  Observational 3.Practice recommendations

6. Rest has been controversial in the management of concussion for 60+ years

7. Symonds 1928

11. Pilkington 1937

12. Watt 1938

13. Asher 1947

14. Meerloo 1949

15. Voris 1950

16. The first clinical trial

17. Historical cohort design, with varying durations of prescribed bed rest

18. Andreasson et al 1957  Historical controlled design comparing varying durations of prescribed bed rest

19. Andreasson et al 1957 The experimental intervention

20. Andreasson et al 1957 The experimental intervention Reassurance

21. Andreasson et al 1957 The experimental intervention Reassurance Early mobilization

22. Andreasson et al 1957 The experimental intervention Reassurance Early mobilization Advice to resume activities immediately

23. Andreasson et al 1957

24. Conclusion

25. Contemporary evidence

27. Systematic reviews

28. Schneider et al 2013  Focus on sport-related concussion  Search revealed 749 articles  2 eligible (Moser et al., 2012; Gibson et al., 2012)

29. Schneider et al 2013

30. Randomized controlled trials

31. 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

32. 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

33. 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

34. de Kruijk et al (2002) Less severe symptoms in the REST group Better health-related QOL in the REST group

35. de Kruijk et al (2002)

37. 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.

38. Non-randomized trials of rest

39. Moser 2012

40. Sample  49 student athletes referred to a concussion clinic (age 14 to 23)  Variable time post-injury o M=36 days; median=11 days

41. 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)

42. 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:

43. Moser 2012  Limit TV  Get more sleep Participants also told to:

44. Moser 2012  No participation in sport  ~1 week off school  Compliance with other activity restrictions “less uniform” Compliance:

45. Moser 2012 Results  Cognition and symptoms improved.  Improvements did not vary with time post- injury.

46. Moser 2014

47. Sample  N=13, like Moser et al 2012  Additional eligibility criterion: IMPACT followed by no rest prior to first clinic visit

48. 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

49. 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.

50. 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

51. Gibson et al 2013

52. Design  Retrospective cohort.  Chart reviews to determine:  if rest was explicitly mentioned in treatment plan.  whether symptoms persisted 30 days.

53. Gibson et al 2013 Results  Advice to rest associated with slower symptom resolution in univariate but not multivariate analyses.

54. Observational studies of rest

55. 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.

56. 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.

57. Majerske et al. (2008)

58. 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.

59. Brown et al. (2013)

60. Results Univariate analysis

61. Brown et al. (2013) Results  Multivariate Cox regression

62.  Mittenberg et al 1996  Bell et al 2008  Silverberg et al 2013  Matuseviciene et al 2013 Multifaceted interventions that included gradual activity resumption

63. Summary

64. Is rest an effective intervention? NO YES

65. Is rest an effective intervention?  First 24-48 hours: Probably  After that: Inconclusive

66. Possible harms not studied  Deconditioning  Prolonged vestibular adaptation  Chronic fatigue  Depression  Maintenance of anxiety/PTSD (supporting avoidance)

67. cont…  Iatrogenesis (Craton & Leslie 2014)

68. Recommendations for clinical practice

69. Schneider et al 2013

71. Silverberg & Iverson (2013)

73. Craton & Leslie 2014

74. Resources for implementation

76. Thank You Contact: noah.silverberg@vch.ca