Running head: AN INTEGRATIVE REVIEW

An Integrative Review

Joelle Nixon

Bon Secours Memorial College of Nursing

NUR 4122 Nursing Research

12 November 2017

“I pledge”
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to appraise literature analyzing physical and

cognitive rest compared with analgesic therapy effects on recovery for pediatric concussions.

Physical and cognitive rest have been the protocol for management of concussions, however,

there is research that promotes the usage of analgesic therapy as an early recovery treatment. The

search methods of this integrative review is to utilize peer reviewed articles in published

journals. This integrative review includes five qualitative studies. The results of the studies

concluded that due to the intensive research on the effect of physical and cognitive rest on

concussion treatment, it is the most conclusive and effective management therapy for pediatric

concussions. Future research on this topic can be improved by creating studies that involve

research groups comparing the concepts side by side instead of mutually exclusive studies.

Mutually exclusive studies make it hard to identify in comparison of the rest and medication,

which is better for concussion management. Effort should be made in order to establish a

protocol for pediatric concussion management that is reviewed annually and evidenced-based.
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An Integrative Review

The purpose of this integrative review is to identify the best therapy for treatment of

concussions in pediatric patients. According to the statements and expert opinion from the

International Conference on Concussion and the American Academy of Pediatrics Council on

Sports Medicine and Fitness, the golden standard to treating concussions in children and youth is

cognitive and physical rest (Corwin, Grady, Joffe, & Zonfrillo, 2017). Traumatic brain injury

occurs through a blow to the head, face, or neck or injury that causes disruption in the normal

function of the brain. Concussions, also known as mild traumatic brain injuries (mTBIs), are the

most common type of mTBI and are becoming more prevalent in the acute and primary care

settings. Concussive injuries in pediatrics have grown exponentially as a health issue. Injuries

and safety are always a concern in the pediatric population and increased presence in

hospitalization and PCP visits call for more research and evidenced based practices to be

established. Concussions can develop from falls, sports, road traffic injuries and assaults. As

concussions grow in presentation, providers must have some established protocols for care,

interventions, complications and preventative strategies that are evidenced based practices and

become standards.

Design/Search Methods

A search was conducted for studies that are related to physical and cognitive rest versus

analgesic use in recovery for pediatric concussions. The integrative review contains five articles

based on studies conducted from 2010 to 2017. The search was conducted via PubMed, OVID

and EBSCO. Overall search terms included “pediatric concussion management”, “benefit of rest

on concussion recovery”, & “benefit of analgesic therapy on concussion recovery”. The search

engines generated various amounts of articles; 338, 152 and 227 articles were generated by
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PubMed, OVID and EBSCO respectively. Peer reviewed articles were used based off of studies

conducted by qualified professionals. After applying the parameters with an advanced search, the

articles were selected to include five qualitative studies which all pertained to the PICOT

question. The PICOT question to be answered is “In children with concussions, what is the effect

of physical and cognitive rest on recovery compared with analgesic medication within the

recovery phase?”

Findings/Results

As a result of the findings of the five reviewed studies, it is indicated that there is no

support for specificity in rest or analgesic medications being more beneficial in concussion

recovery (Halstead, 2016; Kinnaman, Mannix, Comstock & Meehan III, 2013; Moser, Glatts &

Schatz, 2012; Sufrinko et. Al, 2017; Thomas, Apps, Hoffmann, McCrea & Hammeke, 2015). All

research gathered can be referenced in Table 1. There were several themes across the

comparative topics of rest and analgesic medications. The themes will be organized according to

their relationship to the comparative topics.

Physical & Cognitive Rest

The subject of concussion management of three of the studies focused on rest as a

therapy and management for pediatric children with concussions. The overarching theme

encouraged rest based off of individualized cases. Factors that influenced the benefit of rest

included presentation of signs and symptoms and duration of time between diagnosis of

concussion.

In a qualitative study by Sufrinko et al. (2017), authors evaluate the effects of prescribed

rest in patients with signs of injury compared to those with symptoms only after a concussion.

The framework of this is focused on testing the generalized theory of rest and its effect on
AN INTEGRATIVE REVIEW 5

patients with signs and patients with symptoms after concussion. Signs of injury are defined as

loss of consciousness, post-traumatic amnesia, confusion/disorientation while symptoms are

defined from the subjective experience including somatic, cognitive, affective and sleep-related

symptoms of concussion. Sampling included pediatric concussion patients aged 11-18 in a

randomized controlled trial. Data was collected after patients were randomized into groups to

rest or usually. Patients then collected activity and symptom diaries which were analyzed by 2x2

ANOVAs with grouping factors. The grouping factors are symptoms and signs and the treatment

arm, prescribed rest and standard of care were used to examine the association between the

treatment arm and symptom status. Significant findings are that patients with predominantly

symptoms were likely to remain symptomatic if prescribed rest in comparison to patients with

signs of injury who benefited more from rest after concussion. In general, treatment plans should

be individualized and should begin when patients seek medical attention.

Subsequently, according to Thomas et al. (2015), the purpose of the qualitative study was

to determine the benefit on recovery of strict rest after a concussion. This experimental

randomized controlled study included sampling of children ages 11-22, presentation to the

Emergency Department within 24 hours of injury and were diagnosed with concussion. Patients

also completed diaries recording physical and mental activity level, calculated energy exertion

and recorded daily post-concussive symptoms. Neurocognitive and balance assessments were

performed on days three and ten. Analysis of data was completed by linear mixed modeling used

to detect how the group assignment contributed to the individual’s recovery course.

Lastly, Moser et al. (2012) the qualitative study aimed to evaluate the efficacy of rest for

the treatment of concussions in high school and collegiate athletes. In an experimental study of

49 participants, who were grouped based on time elapsed since sustaining the concussion and
AN INTEGRATIVE REVIEW 6

seeking treatment and start of rest. The groups were based on 1-7 days, 8-30 days and 31+ days

before the onset of prescribed rest. Data was collected by the Concussion Symptom Scale ratings

as well as composite catalogs for Immediate Post-Concussion Assessment and Cognitive Testing

scores. These tests were completed before and after prescribed rest occurred. Analysis was

completed by mixed-factorial design ANOVA to compare dependent measure intergroup and

intragroup. A significant finding is that regardless of time between concussion and onset of rest,

participants displayed improved scores and ratings and decreased symptom reporting.

Analgesic Medication

Two of the studies focused on medication, specifically analgesic, in managing treatment

for pediatric children with concussions. The theme of the research concluded that there was no

profound support in the studies to the benefit of medication for treatment of concussions. The

studies focused on the proper management and compliance to avoid toxic levels of the

medications utilized in the recovery of concussions.

A study conducted by Halstead (2016) aimed to understand the influence on the role of

pharmacologic therapy in various types of medications. These medications include

Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants,

stimulants, sleep aids and acute management like saline and IV migraine medication. This study

collected data by chart review of participants. The study analyzed findings based on the reported

outcome of usage of the medications by the participants. A significant finding is that the

medications used helped the various symptoms experienced by a concussion but did not effect

the length of recovery. The established reasons for using pharmacologic therapy include

lessening the symptoms and possibility of prevention for future injury. However, there is not

conclusive evidence to the benefit of treatment with medication.

AN INTEGRATIVE REVIEW 7

In another study, by Kinnaman et al. (2013), the authors aim research at management

strategies for pediatric patients suffering with concussions. This was a questionnaire study of

members of the American Academy of Pediatrics which queried the use of medications,

neuropsychological testing and imaging with published guidelines for concussion management.

The sample size included two hundred and twenty respondents who had experience of ten years

or more. The survey was initially piloted with pediatricians at Boston Children’s Hospital for

readability and clarity. Simple descriptive statistics were used and compared by the Student’s t-

test. A significant finding was that a majority of the sample, 89%, use medication in treatment of

concussion in pediatric patients, mainly acetaminophen and NSAIDs. Tricyclic antidepressants

and stimulants were also reported in usage for treatment of concussions but mostly for sleep

disturbance symptoms.

Discussion/Implications

Upon review of the five articles, the centralized idea for individualized based care plans

for concussions is an overarching theme. When accounting for signs and symptoms, duration

between seeking treatment, means of reporting data and research results, concussion treatment is

best managed on a case by case basis. However, there is more conclusive results and data

supporting the protocol suggesting physical and cognitive rest. The results of these studies

implicate that the existing protocols for rest, both physical and cognitive, show a strong

correlation in improving symptoms and attaining recovery. When managing concussions,

healthcare professionals should base treatment on the individual’s experience and presenting

symptoms. However, the majority research supports physical and cognitive therapy over

medication therapy for concussion management.

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Future research on this topic can be improved by having research groups that are

comparative of just physical and cognitive rest versus medication therapy but return to

play/activity in one study. It would help to know the benefits of each category in comparison to

one another rather than exclusively. If research is not to compare rest versus medication, the

medication studies should be based on the efficacy of medications and the efficacy of rest to

understand which is the best method of treatment. The studies should review the length of time

on recovery from a concussion. It would be beneficial for researchers to determine several

themes that play a role in determining which therapy will have the greatest impact on concussion

recovery.

Limitations

In this integrative review there were several limitations. One of the biggest limitations is

the limited research on the benefits of pharmacological therapy in pediatric concussion patients.

Limited research provides limited and restricted results. This in turn provides non-conclusive

results to that lead to the necessity of more conducted research in order to draw conclusions.

Another limitation faced with this study is that there is no study directly comparing the

benefits of the two, rest and medication, in treating concussions. This limitation causes difficulty

in the comparison versus the benefits of rest and proving which therapy is most beneficial in

concussion management. If there is no comparison study done, then the results of studies are

mutually exclusive and do provide basis for deeming one therapy more beneficial than the other.

There is nothing to judge the results whether it is the time of recovery, the efficacy of recovery

or the relief of symptoms.

Finally, most research based on rest which has been the standard protocol for years,

outweighs the medication research. Treatment for concussion has been based on rest due to
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evidenced based practice so naturally there are more results. Due to the extensive research

related to rest in concussion management, there are more conclusive results and support for why

the benefit is exponential than with medication therapy. Another significant limitation is the the

author of this integrative review has no experience in writing this type of review.

Conclusion

The findings and results of this integrative review highlight the conclusive benefit of

physical and cognitive rest in managing concussions in pediatric patients. The two themes of

concussion treatment overall are physical and cognitive rest and medication therapy. Due to

limited research, it is continued understanding that rest is the most beneficial and effective

treatment in concussions. In relation to the PICOT question, research in this integrative review

support rest as the more efficacious, supported treatment in comparison to analgesic therapy

within the recovery phase of concussion management.

AN INTEGRATIVE REVIEW 10

References

Corwin, D. J., Grady, M.F., Joffe, M.D., Zonfrillo, M.R. (2017). Pediatric Mild Traumatic Brain

Injury in the Acute setting. Pediatric Emergency Care, 33(9), 643-651. doi:

10.1097/PEC.0000000000001252

Halstead, M.E. (2016). Pharmacologic Therapies for Pediatric for Pediatric Concussions. SAGE

Publications, 8(1), 50-52. doi: 10.1177/1941738115622158

Kinnaman, K.A., Mannix.R.C., Comstock, R.D., Meehan III, W.P. (2013). Management

strategies and medication use for treating paediatric patients with concussions. Acta

Paediatrica, 102(9), e424-e428. doi: 10.1111/apa.12315

Moser, R.S., Glatts, C., Schatz, P. (2012). Efficacy of Immediate and Delayed Cognitive and

Physical Rest for Treatment of Sports-Related Concussion. The Journal of Pediatrics,

161(5), 922-926. doi: 10.1016/j.peds/2012.04.012

Sufrinko, A.M., Kontos, A.P., Apps, J.N., McCrea, M., Hickey, R.W., Collins, M.W., &

Thomas, D.G. (2017). The Effectiveness of Prescribed Rest Depends on Initial

Presentation After Concussion. The Journal of Pediatrics, 185, 167-172. doi:

10.1016/j.jpeds.2017.02.072

Thomas, D.G., Apps, J.N., Hoffmann, R.G., McCrea, M., Hammeke, T. (2014). Benefits of Strict

Rest After Acute Concussion: A Randomized Controlled Trial. Official Journal of the

American Academy of Pediatrics, 135(2), 213-223. doi: 10.1542/peds.2014-0966

 APA Citation Halstead, M.E. (2016). Pharmacologic Therapies for Pediatric for Pediatric Concussions. SAGE

Publications, 8(1), 50-52. doi: 10.1177/1941738115622158

Background/Problem Pediatric mild traumatic brain injuries are becoming increasingly common and being presented in
Statement emergency departments. This increase of presentation calls for a review of protocol. The mainstay
for treatment has been rest however, there is reason to consider pharmacological therapy.
Pharmacological therapy has potential to shorten course of the injury, lessen symptoms and improve
long-term outcomes after concussion.
Conceptual/theoretical The research was conducted on the effectiveness of various types of pharmacologic therapy for
Framework concussion treatment.

Design/Method/Philosophical A clinical review of various therapies to include acetaminophen/NSAIDs, tricyclic antidepressants,

Underpinnings stimulants, sleep aides and acute management like hypertonic saline and IV migraine therapy.

Sample/ Setting/Ethical A chart review was conducted for the patients using acetaminophen and NSAIDs as well as the
Considerations acute management. Ethical consideration with reviews is to ensure there is appropriate consent to
review the charts of the adolescent patients either from the parents or gain assent from the children.

Major Variables Studied (and Major variables studied were the effects of acetaminophen/NSAIDs, tricyclic antidepressants,
their definition), if stimulants, sleep aids and acute management medications like hypertonic saline and IV migraine
appropriate therapy on aiding in the recovery of concussions.

Measurement Tool/Data
Collection Method
Data Analysis
Chart review for three types of medications, post-hospital visit for the patients. And for stimulants
and sleep aids several research studies were reviewed.
The researchers conducted chart reviews that found themes within the use of each medication class
and studies conducted and results reviewed with the Wong-Baker FACES pain scale, ImPACT test,
verbal memory, reported results.

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Findings/Discussion
Appraisal/Worth to practice
NUR 4122/4222. REV 10.9.2017
For NSAIDs and acetaminophen the results were that the adolescent patients treated were found to
develop overuse headaches in 70% of the cases. After discontinuation, the headaches were resolved
in 65% of the patients. For patients treated at the regional concussion center, 17% were treated with
amitriptyline, antidepressant, and of those 82% reported improvement of headache symptoms.
Amantadine, a stimulant, was used to conduct a study of 25 athletes who were still symptomatic
after 3 weeks. Significant, p<0.005, improvement was found in symptoms and on impact test
reaction time and verbal memory. There have not been any significant research and results in the
use of methylphenidate as well as sleep aids like melatonin and trazodone. In the acute setting, there
has been use of hypertonic saline and IV migraine therapy. In a study of 44 participants, the patients
were given 3% saline and a control group given normal saline. The outcomes were based on the
Wong-Baker FACES pain score. Two to three days post treatment, there was significant
improvement in the hypertonic group however, there was no statistically significant difference in the
final pain score.
There wasn’t extensive research conducted to prove whether the medications could confidently be
used as a treatment for concussions. More research must be conducted in order to conclude the
worth to practice.
 APA Citation
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
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Kinnaman, K.A., Mannix.R.C., Comstock, R.D., Meehan III, W.P. (2013). Management strategies
and medication use for treating paediatric patients with concussions. Acta Paediatrica, 102(9),
e424-e428. doi: 10.1111/apa.12315
The purpose of the study is to assess management strategies for pediatric patients with concussions.
Pediatricians nationwide have begun to consider and use prescription medications for concussion
treatment in addition to published protocols.
Not discussed
A questionnaire of 17 items; simple descriptive
1305 pediatricians were surveyed, with a response from 220 pediatricians. 64% have been attending
for more than 10 years. 92% of respondents managed patients with concussions and 26% treated
more than 24 concussion patients a year.
Treatment of concussions with the use of pharmacological therapy.
Pediatricians reported and responded to the questionnaire via SurveyMonkey and included multiple
choice questions along with free text questions. Questions were piloted at the home hospital first,
Boston Children’s Hospital. Simple descriptive statistics were used and data was compared using
Student’s t-test. Proportions were compared with chi-squared test.
Of the 26% that treated more than 24 cases a year, 89% treated patients with medications for
concussions. The medications used were mainly over the counter, acetaminophen, used by 62% of
the doctors, NSAIDs used by 54% and melatonin used by 20%. However, many reported using
tricyclic antidepressants (20%), amantadine (10%) and methylphenidate (8%). Those treating more
than 16 cases a year most likely prescribed NSAIDs and were less likely to use other medications.
Findings/Discussion
Appraisal/Worth to practice
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Pediatricians with more experience managing concussions were more likely to use prescription
medications over NSAIDs. There is a lack of uniformity among treatment of pediatric patients with
concussions. Most admit to following guidelines already established in addition to what they
thought each individual patient can benefit from.
Limitations of the study are clearly stated in that the results may not be able to applied to the general
population of pediatric PCPs due to the participants all being a part of the AAP. There was a low
response rate of 17% and does not accurately represent practices that did not respond. Further
studies need to be completed to test the efficacy and safety of medication use.
 APA Citation
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
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Moser, R.S., Glatts, C., Schatz, P. (2012). Efficacy of Immediate and Delayed Cognitive and
Physical Rest for Treatment of Sports-Related Concussion. The Journal of Pediatrics, 161(5), 922-
926. doi: 10.1016/j.peds/2012.04.012
To understand the efficacy of physical rest for the treatment of a concussion. There is extensive
research and protocols that suggest rest at the main treatment. However, this study is to understand
the efficacy of rest compared to when it is actually prescribed.
Immediate and delayed rest treatment for concussions in sports.
Experimental, quantitative study in which athletes underwent post-concussion evaluation.
49 athletes were evaluated and were prescribed rest both physically and cognitively. The
participants were assigned to the groups of the study based on the time lapsed between the injury
and onset of rest.
Onset of rest were in three categories; 1-7 days, 8-30 days and 31+ days
Measured based on the Concussion Symptom Scale rating and scores on composite indices of the
Immediate Post-Concussion Assessment and Cognitive Testing measure. The tests were conducted
both before and after the prescribed rest.
Mixed-factorial design ANOVA were used to compare the changed on the dependent measures
(onset of rest).
The participants in the study showed significant improvement on the Post-Concussion Assessment
and Cognitive Testing. The participants also experienced decreased symptom reporting following
prescribed physical and cognitive rest, P<.001. This improvement was reported regardless of the
onset of prescribed rest (P=.44).
Suggestive that prescribed rest will prove beneficial for treating concussion related symptoms
regardless of time prescribed after a concussion whether it be weeks to months.
 APA Citation
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and Rest efficacy in concussed patients presenting with signs versus those presenting primarily with
their definition), if symptoms.
appropriate
Measurement Tool/Data
Collection Method
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Sufrinko, A.M., Kontos, A.P., Apps, J.N., McCrea, M., Hickey, R.W., Collins, M.W., & Thomas,
D.G. (2017). The Effectiveness of Prescribed Rest Depends on Initial Presentation After
Concussion. The Journal of Pediatrics, 185, 167-172. doi: 10.1016/j.jpeds.2017.02.072
Evidenced-based treatment for concussions is limited so clinical management relies on guidelines
that are by a consensus. Rest is the consensus for managing concussions in that it may promote
neurometabolic recovery of the injured brain. It is a understanding that concussed patients may
respond differently depending on clinical presentation. The study wants to understand the efficacy
of prescribed rest on clinical outcomes based on presentation.
The response to prescribed rest in patients presenting with signs of injury (loss of consciousness,
post-traumatic amnesia or PTA and confusion/disorientation) versus those with symptoms only,
including 0-1 signs of injury (somatic, cognitive, affective and sleep-related symptoms).
Randomized controlled trial, quantitative study.
93 participants in the study with 58 in the symptom group and 35 in the signs of injury group. There
are 60 males and 33 females. The number of males in the symptoms group is 39 and 21 in signs and
there are 19 females in symptoms and 14 females in signs. Ages are between 11-22 years of age.
Approved by the Children’s hospital of Wisconsin IRB.
Patients initially reported the signs of injury which were confirmed by a healthcare professional and
on day 3 and 10 reported again. Initially and again after rest the symptom group was tested with the
Post-Concussion Symptom Scale, the Balance Error Scoring System, ImPACT test. Activities and
symptom diaries were completed for the first 10 days after and follow up appointments repeated the
neurocognitive test and balance test.
Data Analysis A series of 2x2 ANOVAS with grouping factors by patient group (signs and symptoms) and
treatment arm (rest and standard of care) which allowed the scores of the tests to be examined. A
series of univariate non-parametric tests wee used to examine the association between treatment arm
and symptoms and signs at 1-9 days after injury.
Findings/Discussion The groups did not differentiate in neurocognitive test scores: verbal memory P=.29, visual
memory P=.16, visual motor speed P=.78 or reaction time P=.78 or in balance testing. The signs
group had a higher symptom score than the symptoms group. In the signs group, 62% reported
LOC, 64.9% reported PTA and 64.9% confusion.
Appraisal/Worth to practice Patients with predominantly signs benefited from rest after a concussion. However, the patients
who were predominantly symptomatic would become more symptomatic in the first few days after
injury if prescribed rest. Return to activity may be beneficial and therapeutic to recovery for those
with symptom presentation.

NUR 4122/4222. REV 10.9.2017

 APA Citation
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
NUR 4122/4222. REV 10.9.2017
Thomas, D.G., Apps, J.N., Hoffmann, R.G., McCrea, M., Hammeke, T. (2014). Benefits of Strict
Rest After Acute Concussion: A Randomized Controlled Trial. Official Journal of the American
Academy of Pediatrics, 135(2), 213-223. doi: 10.1542/peds.2014-0966
Pediatric head trauma is a heavy burden for children and visits to the Emergency department have
increased by 60% over the past 10 years. This study is searching to understand the effectiveness of
recommending 5 days of strict rest versus the usual 24 to 48 hours.
Not discussed
Randomized control trial of patients presenting to the Wisconsin Emergency Department and
Trauma Center with mild TBI/concussion.
Participants were screened based on the chief complaint of an injury to the head, age if between 11-
22 and presented within 24 hours of injury. Total of 370 participants. Of the total participants, 178
met exclusion criteria and 93 declined to participate. 99 participants were randomized.
Strict rest of 5 days versus 24-48 hours.
Initial screening gathered demographic information, injury details, initial symptoms and risk factors
for prolonged recovery (e.g. history of previous injury or migraine). The participants also received
computerized neurocognitive testing and a standard balance test. After these tests, participants were
put into random groups of 2 groups. A research assistant met with participants at their follow up
appointments to repeat the test and balance assessments.
Post Concussive Symptoms Scale (PCSS) assessed symptoms on 4 domains (physical, cognitive,
emotional and sleep) with each being graded from none (0) to severe (6). Neurocognitive the
imPACT test administered 6 neuropsychological test modules on verbal memory, visual memory,
reaction time, processing speed and impulse control. The Balance Error Scoring System (BESS)
objectively measures balance by using 3 stances (double leg, single leg, tandem) with eyes clothes
on firm floor and foam surface. Inability to maintain balance or eye opening is an error and counted

Findings/Discussion
Appraisal/Worth to practice
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on one of the 6 trials. Linear mixed modeling analyses were used.
Both groups showed an 20% decrease in energy expenditure and physical activity in the first 5 days
post injury. In both groups more than 60% of the participants experienced symptom resolution
during the follow up period however, it took 3 more days longer for 50% of the strict rest group to
report symptom resolution than the usual care group.
Recommending strict rest did not improve symptoms, neurocognitive and balance outcomes in
youth with concussions and adolescents prescribed strict rest, more symptoms were reported
throughout the study. Compliance may have been an issue and limitation to the results.