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Few pediatricians provide written instructions for cognitive rest following concussion
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BOSTON — Most providers of pediatric care recognized the importance of cognitive rest following concussion, but many failed to document the need for a rest period for recovery, according to study findings presented here during the 2012 Pediatric Academic Societies Annual Meeting.
Christina Master, MD, attending physician and assistant director of the pediatric residency program at The Children's Hospital of Philadelphia (CHOP), reported that the majority of general pediatric providers in a single large pediatric network identified cognitive rest as important in the management of pediatric concussion. However, providers gave written cognitive rest recommendations in the electronic medical record (EMR).
“The cornerstone of managing concussions is cognitive rest,” Master told Infectious Diseases in Children.
According to Master, specific instructions for cognitive rest should be consistently included in the treatment recommendations for patients with concussion. Therefore, formal educational efforts and evidence-based clinical management tools may improve pediatric concussion care, the investigators concluded.
Master and colleagues conducted their study to assess the level of understanding and implementation of the concept of cognitive rest in the management of pediatric concussion among general pediatricians and advanced providers in a single, large pediatric care network.
“This is part of a larger undertaking at CHOP to improve standardized concussion care for all of our kids who come into our system with concussion,” Master said. “The incidence of concussion has increased exponentially in recent years, and most of these children seek care through the ED or general pediatrician’s office. However, much of the information on concussion is fairly new and these physicians aren’t aware of the current recommendations.”
To complete the analysis, the investigators included a survey of general pediatric providers’ evaluation and management of concussion patients in a care network, in addition to a retrospective EMR review of a random sample of children aged 5 to18 years who were treated in the same network for initial or ongoing care for concussion between July 1, 2010, and June 30, 2011.
A total of 202 providers were contacted to participate in the study, and 86 responded to the survey; 52 of those claimed they (60.5%, 95% CI 49.9%-70.1%) included cognitive rest in their self-described management of concussion. Of the 96 EMRs reviewed for pediatric concussion patients’ first visits following the injury, only nine (9.4%, 95% CI 5.1%-16.9%) included written cognitive rest recommendations, according to the study results.
Master also said there was variability in what the physicians considered as cognitive rest. Some recommended the patient attend school but refrain from taking tests, while others recommended half days of school. However, Master said in the sports medicine program at CHOP, strict cognitive rest is the standard of care based on available animal and pathophysiological data on concussion.
“This means no school, no homework, no reading, no texting, no computer, no video games, etc., and this must be clearly explained to the patient,” Master said. “This is because after a concussive injury, your brain is trying to recover and it requires extra energy to recover. At the same time, there is reflex decrease in cerebral blood flow. So you are sending less energy to your brain at the exact time it needs more energy. It is essentially an energy crisis.”
Additional data is constantly emerging to support this recommendation. A recent study from Cincinnati showed that only 25% of the children with concussion had normalized blood flow within 2 weeks after suffering a concussive injury and 25% still didn’t have normal blood flow at one month post injury, Master added. —by Cassandra A. Richards
For more information:
- Master CL. Abstract #1501.84. Presented at: 2012 PAS Annual Meeting; April 28-May 1, 2012; Boston.
Disclosure: Dr. Master reports no relevant financial disclosures.
Perspective
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James D. Nesmith, MD, MPH
Master and colleagues assessed two things: 1.) provider prescription of cognitive rest in the initial management of concussed youth aged 5-18 years; and 2.) documentation of this prescription in the EMR.
The first objective was evaluated via a survey of general pediatric providers by asking open-ended questions about their initial management of pediatric concussion. Most respondents (60.5%) included cognitive rest in their initial management of these patients. This is actually higher than I anticipated, but I do believe this is an accurate estimate based on the researchers’ methodology. The use of open-ended questions in the survey is less likely to overestimate the prevalence of the practice compared to, for example, multiple choice questions. I commend the authors on this methodology.
There is a striking difference between the reported practice of prescribing cognitive rest (60.5%) and the documentation of this practice in the EMR (9.4%). The authors emphasize that written documentation of the treatment recommendations is needed.
Cognitive rest is a relatively new concept in the management of concussed athletes. This concept was introduced in the Second International Conference on Concussion in Sport (2005). Cognitive rest is now considered an important part of concussion management for students who sustain concussions. In my experience as director of the Concussion Clinic at Arkansas Children’s Hospital, cognitive rest is prescribed less often than physical rest by referring practitioners. Anecdotally, those concussed students who implement comprehensive rest – physical and cognitive – recover more quickly than those who do not. Physical rest until symptoms resolve seems to be more commonly practiced than the combination of physical and cognitive rest.
I concur with the authors’ conclusions that: 1.) educational efforts regarding cognitive rest are needed for practitioners; and 2.) clinical management tools (eg, pre-printed treatment prescriptions, patient education handouts, etc.) would help in their implementation.
Cognitive and physical rest should be “prescriptions” for concussed student athletes.
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