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