Objectives: Recent expert agreement statements and evidenced-based practice guidelines for the management of mild traumatic brain injury (mTBI) no longer support advising patients to “rest until asymptomatic,” and now recommend gradual return to activity after 1-2 days of rest. The present study aimed to: (i) document the current state of de-implementation of prolonged rest advice, (ii) identify patient characteristics associated with receiving prolonged rest advice, and (iii) examine the relationship between exposure to prolonged rest advice and clinical outcomes.

Methods: In a case-control design, participants were prospectively recruited from two concussion clinics in Canada’s public health care system. At clinic intake, participants (i) provided their demographic characteristics, injury details, and current work/school status, (ii) responded yes or no to the question “Were you advised by at least one health professional to rest for more than 2 days after your injury?”, and (iii) completed standardized questionnaires, including the Rivermead Postconcussion Symptom Questionnaire, Personal Health Questionnaire-9, and Generalized Anxiety Disorder-7,

Results: Eligible participants (N=146) were assessed at an average of 41.2 days post-injury (SD=26.7). The majority were women (67.1%) and Caucasian (60.7%), with a mean age of 40.6 years (SD=12.2). 82.9% of participants reported being advised to rest for more than 2 days (exposure group). Advice to rest was not associated with patient characteristics; that is, participants were no more or less likely to have been told rest if they were women (95% confidence interval for odds ratio = 0.48 to 2.91), Caucasian (0.87 to 6.28), older (0.93 to 1.01), had a history of prior concussion(s) (0.21 to 1.20) or psychiatric problems (0.40 to 2.30), if their index mTBI involved a loss of consciousness (0.23 to 2.10), or if they had access to financial compensation for their injury (0.50 to 2.92). In generalized linear modeling, exposure to prolonged rest advice predicted return to productivity status at clinic intake (B=-1.06, chi-squared(1) = 5.28, p= 0.02; 64.5% in the exposure group vs. 40.0% in the control were on leave from work/school, 19.8% vs. 24.0% partially returned, and 11.6% vs. 24.0% fully returned). The exposure group also had marginally (non-significantly) higher post-concussion, depression, and anxiety symptoms. 

Conclusions: Many patients who sustain an mTBI continue to be advised to rest for longer than expert agreement statements and practice guidelines recommend. Knowledge of who is more likely to be told to rest could inform strategic de-implementation of this clinical practice. We could not identify patient characteristics associated with getting prolonged rest advice. However, the present study adds to the body of evidence that advice to rest for more than 2 days after an mTBI is generally unhelpful. Patients exposed to prolonged rest advice were less likely to have resumed work/school at 1-2 months post-injury.

Advice to rest for more than two days after mild traumatic brain injury is associated with delayed return to productivity: A case-control study