A clinical trial of 125 young adults shows that those who limited screen time for 48 hours immediately after a concussion had a significantly shorter duration of symptoms than those who were permitted screen time.
These findings, published in JAMA Pediatrics, offer the first clinical evidence that restricting time spent at a computer, television or phone screen in the acute period after a concussion can reduce the duration of symptoms. The study supports preliminary clinical recommendations to limit screen time.
An estimated 2.5 million people go to the emergency department annually because of concussions. Many are children aged 10 to 19 years old. In 2017, 15% of high-schoolers had reported being diagnosed at least once with a concussion.
The US Centers for Disease Control and the International Concussion in Sports Group recommend a period of complete cognitive and physical rest for 24 to 48 hours after a concussion diagnosis. Yet there are no clear guidelines regarding what constitutes cognitive rest during this period.
“It's one thing parents and children always ask in the emergency department,” said lead author Dr Theodore E. Macnow, assistant professor of paediatrics at the University of Massachusetts Medical School. "Is screen time allowed?" The average American teen can spend seven hours a day in front of a screen, not including time spent doing schoolwork, and many clinicians caution against screen time after a concussion, he said.
Other clinicians, however, believe limited screen time, so long as it doesn't induce symptoms, is permittable as one of the few forms of safe distraction during this time.
“We're still learning how to treat concussions and there are no clear recommendations regarding screen time,” said Macnow. “Nobody has yet looked at this question in a rigorous way. We wanted to get a better handle on this question, so we conducted a randomised clinical trial.” From June 2018 to February 2020, Macnow and colleagues assessed 125 patients age 12 to 25 who presented with a concussion to the Emergency Department at UMass Memorial Medical Center, the clinical partner of UMass Chan Medical School in Worcester.
Patients were assessed and randomly placed in one of two cohorts. The first cohort was instructed to abstain from any electronic screens for 48 hours, while the second group was allowed any form of screen so long as it didn't induce symptoms. Both groups were advised to avoid work and schoolwork for the first 48 hours.
Patients completed a Post-Concussion Symptom Scale (PCSS) at the time of diagnosis and every day for the 10-day study. The PCSS is a 22- symptom scale, which grades each symptom from 0 (not present) to 6 (severe) and reliably detects change over time in concussed patients. In the absence of a head injury, a baseline score of less than 3 on the PCSS survey is considered normal.
Additionally, patients completed a screen time survey on days one to three and an activity survey from days four to 10. An analysis of the data showed that the group permitted screen time during the initial 48 hours after a concussion experienced a significantly longer time to recover, measured by a PCSS score of less than three. On average, this group experienced a median time of eight days until symptom resolution compared with 3.5 days for the group that abstained from screen time.
During this time, the cohort permitted screen time logged a median of 630 minutes over the 48-hour period while the cohort abstaining from screen time logged a median of 130 minutes.
“These findings support the conclusion that brief screen time abstinence after a concussion is associated with a faster recovery,” said Macnow. “Given these data, preliminary clinical recommendations should be to limit screen time. It's not clear why screen time exacerbated concussion symptoms but there are a lot of reasons to suspect it's not good.”
It's possible that electronic photons, known to triggers migraines, could play a role. Or that screen use may detract from sleep and resumption of normal activities, both of which are felt to be beneficial to concussion recovery. “These findings suggest that a larger, more diverse, multicentre study is warranted to see if the results are consistent,” said Macnow.
“We only looked at the first 48 hours after diagnosis. It would be worthwhile to see if abstaining from screen time longer had more of an impact or if specific screen time activities, like video games versus television, have a more pronounced effect on recovery time.”
Study details
Effect of Screen Time on Recovery From Concussion
Theodore Macnow, Tess Curran, Courtney Tolliday, Kirsti Martin, Madeline McCarthy, Didem Ayturk, Kavita M. Babu, Rebekah Mannix.
Published in JAMA Pediatrics on 7 September 2021
Abstract
Importance
There are limited data to guide screen time recommendations after concussion.
Objective
To determine whether screen time in the first 48 hours after concussion has an effect on the duration of concussive symptoms.
Design, Setting, and Participants
This randomised clinical trial was conducted in the paediatric and adult emergency departments of a tertiary medical center between June 2018 and February 2020. Participants included a convenience sample of patients aged 12 to 25 years presenting to the emergency department within 24 hours of sustaining a concussion. A total of 162 patients were approached, 22 patients met exclusion criteria, and 15 patients declined participation; 125 participants were enrolled and randomised.
Interventions
Patients were either permitted to engage in screen time (screen time permitted group) or asked to abstain from screen time (screen time abstinent group) for 48 hours after injury.
Main Outcomes and Measures
The primary outcome was days to resolution of symptoms, defined as a total Post-Concussive Symptom Scale (PCSS) score of 3 points or lower. Patients completed the PCSS, a 22-symptom scale that grades each symptom from 0 (not present) to 6 (severe), each day for 10 days. Kaplan-Meier curves and Cox regression modeling were used to compare the 2 groups. A Wilcoxon rank sum test was also performed among participants who completed the PCSS each day through recovery or conclusion of the study period.
Results
Among 125 patients with concussion, the mean (SD) age was 17.0 (3.4) years; 64 participants (51.2%) were male. A total of 66 patients were randomised to the screen time permitted group, and 59 patients were randomized to the screen time abstinent group. The Cox regression model including the intervention group and the patient’s self-identified sex demonstrated a significant effect of screen time (hazard ratio [HR], 0.51; 95% CI, 0.29-0.90), indicating that participants who engaged in screen time were less likely to recover during the study period. In total, 91 patients were included in the Wilcoxon rank sum test (47 patients from the screen time permitted group, and 44 patients from the screen time abstinent group).
The screen time permitted group had a significantly longer median recovery time of 8.0 days (interquartile range [IQR], 3.0 to >10.0 days) compared with 3.5 days (IQR, 2.0 to >10.0 days; P = .03) in the screen time abstinent group. The screen time permitted group reported a median screen time of 630 minutes (IQR, 415-995 minutes) during the intervention period compared with 130 minutes (IQR, 61-275 minutes) in the screen time abstinent group.
Conclusions and Relevance
The findings of this study indicated that avoiding screen time during acute concussion recovery may shorten the duration of symptoms. A multicentre study would help to further assess the effect of screen time exposure.
JAMA article – Effect of Screen Time on Recovery From Concussion (Open access)
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