PHILADELPHIA – A new app may offer new insights for millions of Americans diagnosed with a concussion each year. Patients are usually advised to rest for the first several days after sustaining a concussion, based on what is known about the metabolic cascade that happens shortly after an injury. Recommendations include avoiding sports and staying home from school for at least a few days. By employing a new strategy to help physicians directly learn in real-time how active their pediatric patients are during the days after sustaining a concussion, how the patients are feeling each day, and if the two are related, the team from the Perelman School of Medicine of the University of Pennsylvania and The Children’s Hospital of Philadelphia are finding new insights that may change recommendations for treating concussion patients.

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Perelman School of Medicine at the University of Pennsylvania

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The results of a pilot study using the new app to monitor 34 patients in real-time after sustaining a concussion is published online in JAMA Pediatrics this month. The app prompted each patient, at random intervals throughout the day, to report symptoms in real-time. Each patient also reported how much time they spent on a computer, reading, watching TV, gaming, and performing other cognitive activities. Patients also wore accelerometers (a device worn at the waist to measure steps) to monitor physical activity.
After sustaining a concussion, metabolic and blood flow changes make the brain more vulnerable for further injury. The number of rest days may vary between individuals. Prolonged rest beyond this acute post-injury period does not appear to add benefit and may be detrimental, therefore, the need for determining optimal timeframes for rest following concussion to return children gradually back to life activities including school and sports in a timely and safe manner.

The research team found that symptoms generally decreased as the two-week follow-up time period progressed, while cognitive and physical exertion increased. Common symptoms included headache, dizziness, and nausea. Regardless of activity levels, more than two-thirds of study participants (68 percent) had no symptoms at the end of follow-up.

The researchers also found that patients who spent more time doing cognitive-based activities like reading or looking at a computer reported more severe symptoms on a particular day as well as the next two days, especially in patients with high initial symptom scores. On the other hand, higher physical activity on a particular day corresponded to a lower symptom score that day and the next two days, especially in subjects with low initial symptom scores.

“We are excited about the success of this measurement strategy because doctors regularly tell their patients to have an initial period of cognitive and physical rest after a concussion,” said the study’s lead author Douglas J. Wiebe, PhD, an associate professor in Penn’s department of Biostatistics and Epidemiology and the Center for Clinical Epidemiology and Biostatistics. “But without using this app during real-time monitoring, clinicians have no insight as to whether patients follow these instructions or what activities they engage in. Nor do we know whether what patients do — rest or activity — has any bearing on how quickly their concussion symptoms resolve.”

Participants between 11-19 years old and for approximately two weeks after their initial office visit each patient participated in the protocol that involved wearing the accelerometer and carrying an iPod Touch® including the app.

“Our pilot study does several things,” Wiebe said. “First, it shows that using our app with this protocol offers a feasible way of gathering objective measures of physical activity and reports of cognitive activity and post-concussion symptoms in real time in pediatric patients. Second, it presents intriguing findings of possible relationships between cognitive and physical activity and post-concussion symptoms. If replicated, this could change how physicians care for their pediatric concussion patients. Third, larger studies can now be pursued with this research approach to obtain objective measures of activity rather than simply relying on self-report.”

The authors note that their study did not include the first 48-72 hours following injury, which may be the most important time frame for physical and cognitive rest, and that further work needs to address the role of activity in the immediate post-injury period as well as the weeks following injury.

Penn co-authors are Nicole Otto, MD and Danielle Sandsmark, MD. CHOP authors are Michael L. Nance, MD, Eileen Houseknecht, RN, Matthew Grady, MD, and Christina L. Master, MD.

Funding for this study was provided through a grant from the Penn Medicine Translational Neuroscience Center.

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