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 concussion2. Clinical studies

Intervention• RCT• Non-randomized• Multifaceted interventions

Observational3. Practice recommendations

Rest has been controversial in the management of concussion

for 60+ years

Symonds 1928

Symonds 1928

Symonds 1928

Symonds 1928

Pilkington 1937

Watt 1938

Asher 1947

Meerloo 1949

Voris 1950

The first clinical trial

Historical cohort design, with varying durations of prescribed bed rest

Andreasson et al 1957

Historical controlled design comparing varying durations of prescribed bed rest

Andreasson et al 1957

The experimental intervention

Andreasson et al 1957

The experimental intervention

Reassurance

Andreasson et al 1957

The experimental intervention

Reassurance Early mobilization

Andreasson et al 1957

The experimental intervention

Reassurance Early mobilization

Advice to resume activities immediately

Andreasson et al 1957

Andreasson et al 1957

Conclusion

Contemporary evidence

Contemporary evidence

Systematic reviews

Schneider et al 2013

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

al., 2012)

Schneider et al 2013

Randomized controlled trials

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-injuryFULL group started on day 7, after 6 days of bed rest

Day

1 2 34 5

MTBI

< 4 hrsbed rest

< 3 hrsbed rest

< 3 hrsbed rest

< 1 hrbed 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

de Kruijk et al (2002)

de Kruijk et al (2002)

de Kruijk et al (2002)

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.

Non-randomized trials of rest

Moser 2012

Moser 2012

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.

Moser 2014

Moser 2014

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

Gibson et al 2013

Gibson et al 2013

Design Retrospective cohort. Chart reviews to determine:

if rest was explicitly mentioned in treatment plan. whether symptoms persisted < or > 30 days.

Gibson et al 2013

Results Advice to rest associated with slower symptom

resolution in univariate but not multivariate analyses.

Observational studies of rest

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.

Majerske et al. (2008)

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.

Brown et al. (2013)

Brown et al. (2013)

Results

• Univariate analysis

Brown et al. (2013)

Results

Multivariate Cox regression

Mittenberg et al 1996 Bell et al 2008 Silverberg et al 2013 Matuseviciene et al 2013

Multifaceted interventions that included gradual activity resumption

Summary

Is rest an effective intervention?

NO

YES

Is rest an effective intervention?

First 24-48 hours: Probably After that: Inconclusive

Possible harms not studied

Deconditioning Prolonged vestibular adaptation Chronic fatigue Depression Maintenance of anxiety/PTSD (supporting

avoidance)

cont…

Iatrogenesis (Craton & Leslie 2014)

Recommendations for clinical practice

Schneider et al 2013

Silverberg & Iverson (2013)

Silverberg & Iverson (2013)

Craton & Leslie 2014

Resources for implementation

Resources for implementation

Thank You

Contact:noah.silverberg@vch.ca