SGEM#331: Should Patients with a Concussion be told to Walk this Way!

Date: May 21st, 2021 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine and an Associate Editor for the NEJM Journal Watch Emergency Medicine. Reference: Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. AEM May 2021 Case: A 32-year-old female presents with headache after a low-speed motor vehicle collision as a restrained driver. She was ambulatory on scene. The patient is not anticoagulated, has no midline neck pain, and no evidence of other injuries. She is generally well appearing without any deficients on neurological examination, given her minor mechanism, and normal examination no imaging or further testing is required. You tell her you believe she has a concussion. Background: Concussions or mild traumatic brain injury (mTBI) are commonly diagnosed in the Emergency Department (ED). Most patients recover within the first week; however, 15-30% of patients develop persistent post-concussive symptoms. Historically, cognitive and physical rest have been recommended following the diagnosis of mTBI and patients have been advised to resume exercise only once symptoms have abated. Recent studies have challenged this dogma of “rest is best” with one multicenter study finding that early return to physical activity within a week of injury was associated with an improvement in time to symptom reduction. One of the issues that comes up with minor head injuries is do we need to get advanced imaging. We looked at the Canadian CT Head Rule (CCHR) published by Dr. Ian Stiell in the Lancet 2001 on SGEM#106. You can find this clinical decision instrument on MDCalc. The SGEM has also covered the issue of getting CT scans in pediatric patients with minor head injuries. That used the PECARN data which has a protocol for children less than two years of age and those older than two years of age. That SGEM#112 episode on pediatric concussions was covering a study that asked if there is a benefit to recommending strict rest after a child has a concussion. The bottom line from that episode was that in children with concussion, two days of rest followed by a gradual return to activity is preferred over five days of rest followed by a gradual return to activity. The longer strict rest period appears to cause more post-concussive symptoms. We have also looked at the diagnostic accuracy if the CCHR in patients 65 years of age or older in predicting clinically important brain injuries (SGEM#266). The published study opened the door for reducing the number of unnecessary head CTs in this cohort of patients, but further high-quality prospective studies are required prior to clinical application. There is limited information on the best strategy for preventing post-concussion syndrome (PCS). Clinical Question: Are patients presenting to the ED with mild concussion who are prescribed light exercise less likely to develop post-concussive syndrome at 30 days compared with those given standard discharge instructions?