Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions

Abstract

Objectives: It is estimated that 15%-25% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop postconcussive syndrome. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their PostConcussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions.Methods: This was a pragmatic, randomized trial of adult (18-64 years) patients of an academic ED (annual census 60,000) diagnosed with MTBI occurring within 24 hours of ED visit. The intervention group received cognitive rest and graduated return to usual activity discharge instructions, and the control group received usual care discharge instructions that did not instruct cognitive rest or graduated return. Patients were contacted by text message or phone 2 and 4 weeks post-ED discharge and asked to complete the PCSS, a validated, 22-item questionnaire, to determine if there was a change in their symptoms. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school.Results: A total of 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). The mean (AESD) age was 35.2 (AE13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs. 12.8; Δ2.3, 95% confidence interval [CI] = 7.0 to 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; Δ2.8, 95% CI = 6.9 to 12.7) for the intervention and control groups, respectively. The number of followup physician visits and time off work/school were similar when the groups were compared. Thirty-eight (42.2%) and 23 (30.3%) of patients in this cohort had ongoing MTBI symptoms (PCSS > 20) at 2 and 4 weeks, respectively. Conclusions:Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given that patients continue to experience symptoms 2 and 4 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with postconcussive symptoms.

A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury

“…Predicting 30% of the control group would have PCS at 30 days, 30 and assuming an alpha of 0.05 and beta of 0.2, to detect a 15% absolute risk difference, we estimated that 236 participants (118 in each group) needed to be enrolled to reject the null hypothesis that the proportion of patients with PCS was not different between groups. To account for potential attrition, we increased the sample size by 25% and planned study enrollment for 296 patients, 148 in each group.…”

Rehabilitation modality and onset differentially influence whisker sensory hypersensitivity after diffuse traumatic brain injury in the rat

“…Onset of intervention may be pivotal in recovery, and at present, is not universally agreed upon in a clinical setting. Discharge papers outlining early rest with gradual return to usual activity did not significantly impact TBI symptoms at two weeks or one month following mild TBI in comparison to nondescript discharge papers in patients (Varner et al, 2017). Deprivation or active rehabilitation is typically initiated as early as possible, though experimental studies show that intervention initiated during week one following injury may have a negative impact on neuroplasticity .…”

“…For sports concussion, cognitive rest is the primary recommendation (Eastman & Chang, 2015). Cognitive rest implies limited driving of vehicles, television, video-games, use of computers, smart phones and tablets, socializing, school, homework, tests, exercising, and reading (Eastman & Chang, 2015;Varner et al, 2017), thereby limiting not only cognitive processing, but sensory processing as well. However, alternate recommendations for recovery from TBI include light active rehabilitation, including talking, reading, playing games, and short-term computer use (Eastman & Chang, 2015).…”

Use of the Progressive Return to Activity Guidelines May Expedite Symptom Resolution After Concussion for Active Duty Military

“…This is an important advantage over a previous study that failed to detect an advantage of PRA education but also did not measure patient activity. 43 This suggests that the benefit of the PRA-CR intervention may be mediated by elements of the PRA-CR beyond patient education itself. Future studies are needed to evaluate the mechanism through which the PRA-CR may contribute to improved symptom recovery among SMs.…”