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Traumatic Brain Injury

Effect of Screen Time on Recovery From ConcussionA Randomized Clinical Trial

Educational Objective
To determine whether screen time in the first 48 hours after concussion has an effect on the duration of concussive symptoms.

1 Credit CME

JAMA Pediatrics

Published Online: September 7, 2021

Original Investigation

Article Information and Disclosures

Theodore Macnow, MD^1,2;

Tess Curran, MD, MPH¹;

Courtney Tolliday, MD²;

Kirsti Martin, MD²;

Madeline McCarthy, MD, MS^1,2;

Didem Ayturk, MS¹;

Kavita M. Babu, MD^1,3;

Rebekah Mannix, MD, MPH^4,5

Author Affiliations

¹University of Massachusetts Medical School, Worcester
²Department of Pediatrics, UMass Memorial Children’s Medical Center, Worcester, Massachusetts
³Department of Emergency Medicine, UMass Memorial Medical Center, Worcester, Massachusetts
⁴Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
⁵Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts

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Key Points

Question What is the effect of screen time in the first 48 hours after concussion on the duration of concussive symptoms?

Findings In this randomized clinical trial including 125 patients with concussion aged 12 to 25 years, those who abstained from screen time during the first 48 hours of recovery had a statistically significant shorter duration of symptoms (3.5 days) than those who were permitted screen time (8 days).

Meaning This study provides preliminary evidence supporting clinical recommendations to limit screen time in the acute period after concussion.

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 randomized clinical trial was conducted in the pediatric 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 randomized.

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 randomized 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 multicenter study would help to further assess the effect of screen time exposure.

Trial Registration ClinicalTrials.gov Identifier: NCT03564210

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Article Information

Accepted for Publication: May 21, 2021.

Published Online: September 7, 2021. doi:10.1001/jamapediatrics.2021.2782

Corresponding Author: Theodore Macnow, MD, Department of Pediatrics, UMass Memorial Children’s Medical Center, 55 Lake Ave N, Worcester, MA 01655 (theodore.macnow@umassmemorial.org).

Author Contributions: Drs Macnow and Mannix had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Macnow, Martin, Babu.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Macnow, Curran, Ayturk, Babu, Mannix.

Critical revision of the manuscript for important intellectual content: Macnow, Tolliday, Martin, McCarthy, Babu, Mannix.

Statistical analysis: Macnow, Curran, Ayturk, Mannix.

Obtained funding: Babu.

Administrative, technical, or material support: Macnow, Martin, Babu.

Supervision: Macnow, McCarthy, Babu.

Conflict of Interest Disclosures: Dr Martin reported receiving grants from the Beth Israel Deaconess Department of Neonatology Foundation outside the submitted work. Dr Babu reported receiving grants from the National Institutes of Health and having contracts with the National Highway Traffic Safety Administration and the Massachusetts Department of Public Health outside the submitted work. No other disclosures were reported.

Additional Contributions: The authors thank Mariann Manno, MD, of the University of Massachusetts Medical School and Division of Emergency Medicine at the UMass Memorial Children’s Medical Center for her personal and divisional support of this project; Peter Lazar, BS, of the University of Massachusetts Medical School for assistance with crafting the REDCap surveys; and Michael Monuteaux, ScD, of the Division of Emergency Medicine at Boston Children’s Hospital for statistical support. All of these persons provided uncompensated assistance. We also thank all of the patients and their families for participating in this clinical trial. The authors received permission from the named individuals to be acknowledged in the manuscript.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.