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.

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 Post-Concussion 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 (±SD) age was 35.2 (±13.7) 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; ∆2.3, 95% confidence interval [CI] = 7.0 to 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; ∆2.8, 95% CI = 6.9 to 12.7) for the intervention and control groups, respectively. The number of follow-up 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.