Advertisement

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population

Published:March 28, 2020DOI:https://doi.org/10.1016/j.apmr.2020.02.015

      Abstract

      Objectives

      To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education.

      Design

      Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit.

      Setting

      Three military treatment facilities.

      Participants

      Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded.

      Intervention

      Not applicable.

      Main Outcome Measures

      Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury.

      Results

      Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time.

      Conclusions

      Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider’s use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

      Keywords

      List of abbreviations:

      CI (confidence interval), MLM (multilevel modeling)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • McCrory P.
        • Meeuwisse W.H.
        • Aubry M.
        • et al.
        Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.
        Br J Sports Med. 2013; 47: 250-258
      1. Commitee on Sports-related Concusions in Youth, Board on Children Youth and Families, Institute of Medicine, National Research Council. Concussion recognition, diagnosis, and acute management.
        in: Graham R. Rivara F.P. Ford M.A. Spicer C.M. Committee on Sports-related Concussion in Youth: Improving the Science, Changing the Culture. National Academies Press, Washington (DC)2014
        • Halstead M.E.
        • Walter K.D.
        • The Council on Sports Medicine and Fitness
        American Academy of Pediatrics. Clinical report--sport-related concussion in children and adolescents.
        Pediatrics. 2010; 126: 597-615
        • Herring S.A.
        • Cantu R.C.
        • Guskiewicz K.M.
        • et al.
        Concussion (mild traumatic brain injury) and the team physician: a consensus statement--2011 update.
        Med Sci Sports Exerc. 2011; 43: 2412-2422
        • Canadian Academy of Sport Medicine Concussion Committee
        Guidelines for assessment and management of sport-related concussion. Canadian Academy of Sport Medicine Concussion Committee.
        Clin J Sport. 2000; 10: 209-211
        • Gouvier W.D.
        • Presthholdt P.H.
        • Warner M.S.
        A survey of common misconceptions about head injury and recovery.
        Arch Clin Neuropsychol. 1988; 3: 331-343
        • Guilmette T.J.
        • Paglia M.F.
        The public's misconception about traumatic brain injury: a follow up survey.
        Arch Clin Neuropsychol. 2004; 19: 183-189
        • Swift T.L.
        • Wilson S.L.
        Misconceptions about brain injury among the general public and non-expert health professionals: an exploratory study.
        Brain Inj. 2001; 15: 149-165
        • Springer J.A.
        • Parmer J.E.
        • Bouman D.E.
        Common misconceptions about traumatic brain injury among family members of rehabilitation patients.
        J Head Trauma Rehabil. 1997; 12: 41-50
        • Bloodgood B.
        • Inokuchi D.
        • Shawver W.
        • et al.
        Exploration of awareness, knowledge, and perceptions of traumatic brain injury among American youth athletes and their parents.
        J Adolesc Health. 2013; 53: 34-39
        • King D.
        • Brughelli M.
        • Hume P.
        • Gissane C.
        Assessment, management and knowledge of sport-related concussion: systematic review.
        Sports Med. 2014; 44: 449-471
        • Kurowski B.G.
        • Pomerantz W.J.
        • Schaiper C.
        • Ho M.
        • Gittelman M.A.
        Impact of preseason concussion education on knowledge, attitudes, and behaviors of high school athletes.
        J Trauma Acute Care Surg. 2015; 79: S21-S28
        • Defense and Veterans Brain Injury Center
        DoD Worldwide Numbers for TBI.
        (Available at:) (Accessed April 15, 2019)
        • Allen C.
        • Glasziou P.
        • Del Mar C.
        Bed rest: a potentially harmful treatment needing more careful evaluation.
        Lancet. 1999; 354: 1229-1233
        • Fortney S.M.
        • Schneider V.S.
        • Greenleaf J.E.
        The physiology of bed rest. Comprehensive physiology: supplement 14. Handbook of physiology.
        environmental physiology, John Wiley & Sons, Inc: Germany2011: 889-939
        • de Krujik J.R.
        • Leffers P.
        • Meerhoff S.
        • Rutten J.
        • Twijnstra A.
        Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest.
        J Neurol Neurosurg Psychiatry. 2002; 73: 167-172
        • Moser R.S.
        • Glatts C.
        • Schatz P.
        Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion.
        J Pediatr. 2012; 161: 922-926
        • Schneider K.J.
        • Iverson G.L.
        • Emery C.A.
        • McCrory P.
        • Herring S.A.
        • Meeuwisse W.H.
        The effects of rest and treatment following sport-related concussion: a systematic review of the literature.
        Br J Sports Med. 2013; 47: 304-307
        • Silverberg N.D.
        • Iverson G.L.
        Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members.
        J Head Trauma Rehabil. 2013; 28: 250-259
        • DiFazio M.
        • Silverberg N.D.
        • Kirkwood M.W.
        • Bernier R.
        • Iverson G.L.
        Prolonged activity restriction after concussion: are we worsening outcomes?.
        Clin Pediatr (Phila). 2016; 55: 443-451
        • Gaetz M.B.
        • Iverson G.L.
        Sex differences in self-reported symptoms after aerobic exercise in non-injured athletes: implications for concussion management programmes.
        Br J Sports Med. 2009; 43: 508-513
        • Johnston K.M.
        • Bloom G.A.
        • Ramsay J.
        • et al.
        Current concepts in concussion rehabilitation.
        Curr Sports Med Rep. 2004; 3: 316-323
        • Lovell M.
        • Collins M.
        • Bradley J.
        Return to play following sports-related concussion.
        Clin Sports Med. 2004; 23: 421-441
        • Lutz R.H.
        • Kane S.
        • Lay J.
        Evidence-based diagnosis and managment of mTBI in forward deployed settings: the genesis of the USASOC neurocognitive testing and post-injury evaluation and treatment program.
        J Spec Oper Med. 2010; 10: 23-38
        • Department of Defense, Department of Veterans Affairs
        VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury.
        J Rehabil Res Dev. 2009; 46: CP1-CP68
        • McCrory P.
        • Meeuwisse W.
        • Dvorak J.
        • et al.
        Consensus statement on concussion in sport - the 5th international conference on concussion in sport held in Berlin, October 2017.
        Br J Sports Med. 2017; 51: 838-847
        • McLeod T.C.V.
        • Gioia G.A.
        Cognitive rest: the often neglected aspect of concussion management.
        Athl Ther Today. 2010; 15: 1-3
        • Meyer J.E.
        • Arnett P.A.
        Changes in symptoms in concussed and non-concussed athletes following neuropsychological assessment.
        Dev Neuropsychol. 2015; 40: 24-28
        • Thomas D.G.
        • Apps J.N.
        • Hoffmann R.G.
        • McCrea M.
        • Hammeke T.
        Benefits of strict rest after acute concussion: a randomized controlled trial.
        Pediatrics. 2015; 135: 213-223
        • McCrea M.
        • Guskiewicz K.
        • Randolph C.
        • et al.
        Effects of a symptom-free waiting period on clinical outcome and risk of reinjury after sport-related concussion.
        Neurosurgery. 2009; 65: 876-882
        • Comper P.
        • Bisschop S.M.
        • Carnide N.
        • Tricco A.
        A systematic review of treatments for mild traumatic brain injury.
        Brain Inj. 2005; 19: 863-880
        • Minderhoud J.M.
        • Boelens M.E.
        • Huizenga J.
        • Saan R.J.
        Treatment of minor head injuries.
        Clin Neurol Neurosurg. 1980; 82: 127-140
        • Mittenburg W.
        • Tremont G.
        • Zielinski R.E.
        • Fichera S.
        • Rayls K.R.
        Cognitive-behavioral prevention of postconcussion syndrome.
        Arch Clin Neuropsychol. 1996; 11: 139-145
        • Ponsford J.
        • Willmott C.
        • Rothwell A.
        • et al.
        Impact of early intervention on outcome following mild head injury in adults.
        J Neurol Neurosurg Psychiatry. 2002; 73: 330-332
        • Bradford L.S.
        Misconceptions about traumatic brain injury among U.S. Army behavioral health professionals.
        Rehabil Psychol. 2015; 60: 344-352
        • Hooper S.R.
        Myths and misconceptions about traumatic brain injury: endorsements by school psychologists.
        Exceptionality. 2006; 14: 171-182
        • Yuhasz J.E.
        Misconceptions about traumatic brain injury among correctional health care professionals.
        J Correct Health Care. 2013; 19: 135-143
        • Itriyeva K.
        • Feinstein R.
        • Carmine L.
        Pediatric providers' attitudes and practices regarding concussion diagnosis and management.
        Int J Adolesc Med Health. 2017; 31
        • Salisbury D.
        • Kolessar M.
        • Callender L.
        • Bennett M.
        Concussion knowledge among rehabilitation staff.
        Proc (Bayl Univ Med Cent). 2017; 30: 33-37
        • Remigio-Baker R.A.
        • Bailie J.M.
        • Gregory E.
        • et al.
        Activity level during acute concussion may predict symptom recovery within an active duty military population.
        J Head Trauma Rehabil. 2020; 35: 92-103
        • Gregory E.
        • West T.A.
        • Cole W.R.
        • et al.
        Use of a multi-level mixed methods approach to study the effectiveness of a primary care progressive return to activity protocol after acute mild traumatic brain injury/concussion in the military.
        Contemp Clin Trials. 2017; 52: 95-100
        • Defense and Veterans Brain Injury Center
        The progressive return to activity following mTBI clinical recommendations.
        (Available at:) (Accessed May 27, 2018)
        • McCulloch K.L.
        • Goldman S.
        • Lowe L.
        • et al.
        Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.
        J Head Trauma Rehabil. 2015; 30: 56-67
        • Department of Defense
        Department of Defense Instruction 6490.11, DoD policy guidance for management of mild traumatic brain injury/concussion in the deployed setting.
        (Available at:) (Accessed April 15, 2018)
        • Bailie J.M.
        • Remigio-Baker R.A.
        • Cole W.R.
        • et al.
        Use of the Progressive Return to Activity Guidelines may expedite symptom resolution after concussion for active duty military.
        Am J Sports Med. 2019; 47: 3505-3513
        • Cicerone L.D.
        • Kalmar K.
        Persistent postconcussion syndrome: the structure of subjective complaints after mild traumatic brain injury.
        J Head Trauma Rehabil. 1995; 10: 1-17
        • Vanderploeg R.D.
        • Silva M.A.
        • Soble J.R.
        • et al.
        The structure of postconcussion symptoms on the Neurobehavioral Symptom Inventory: a comparison of alternative models.
        J Head Trauma Rehabil. 2015; 30: 1-11
        • Meterko M.
        • Baker E.
        • Stolzmann K.L.
        • Hendricks A.M.
        • Cicerone K.D.
        • Lew H.L.
        Psychometric assessment of the Neurobehavioral Symptom Inventory-22: the structure of persistent postconcussive symptoms following deployment-related mild traumatic brain injury among veterans.
        J Head Trauma Rehabil. 2012; 27: 55-62
        • King P.R.
        • Donnelly K.T.
        • Donnelly J.P.
        • et al.
        Psychometric study of the Neurobehavioral Symptom Inventory.
        J Rehabil Res Dev. 2012; 49: 879-888
        • Johnson A.
        • Sandford J.
        Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home: systematic review.
        Health Educ Res. 2005; 20: 423-429
        • Bo M.
        • Amprino V.
        • Dalmasso P.
        • Zotti C.M.
        Delivery of written and verbal information on healthcare-associated infections to patients: opinions and attitudes of a sample of healthcare workers.
        BMC Health Serv Res. 2017; 17: 66
        • McLeod T.C.
        • Lewis J.H.
        • Bacon C.E.
        Rest and return to activity after sport-related concussion: a systematic review of the literature.
        J Athl Train. 2017; 52: 262-287
        • Schneider K.J.
        • Leddy J.J.
        • Guskiewicz K.M.
        • et al.
        Rest and treatment/rehabilitation following sport-related concussion: a systematic review.
        Br J Sports Med. 2017; 51: 930-934
        • Iverson G.L.
        Rest and activity resumption following concussion.
        in: Echemendia R. Iverson G.L. The Oxford handbook of sports-related concussion. Oxford University Press, Oxford2015