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Research Letter
November 2016

Ecologic Momentary Assessment to Accomplish Real-Time Capture of Symptom Progression and the Physical and Cognitive Activities of Patients Daily Following Concussion

Author Affiliations
  • 1Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Department of Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 3Pediatric Sports Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 4Student Health Services, Sports Medicine, University of Pennsylvania, Philadelphia
  • 5Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 6Pediatric Sports Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Pediatr. 2016;170(11):1108-1110. doi:10.1001/jamapediatrics.2016.1979

Physical and cognitive rest are recommended as the cornerstone of treatment for concussion, largely based on expert opinion.1-3 However, it is unclear whether physical and cognitive rest aid recovery in youths with a concussion.4 In fact, a 2015 study suggests prolonged rest may correlate with more symptoms.4 Also unknown is the extent to which pediatric patients adhere to recommendations for physical and cognitive rest.5 We aimed to (1) determine the feasibility of ecologic momentary assessment following youth concussion, (2) gather real-time reports of cognitive and physical activity, and (3) compare objective measures with real-time reported symptoms among youths during recovery after concussion.


Patients aged 11 to 19 years with a concussion were enrolled from a subspecialty concussion program and monitored with a concussion tracking app that we developed. The study was approved by the Institutional Review Board of The Children’s Hospital of Philadelphia. Patients were enrolled using an informed consent process or an assent process following written informed consent from a parent or guardian. The diagnosis of concussion was made by pediatricians trained in sports medicine and trauma based on the Zurich consensus diagnostic criteria.1 For approximately 2 weeks after their initial office visit, participants wore an accelerometer and carried an iPod Touch (Apple) loaded with the app that gave random prompts to complete a symptom (the Post Concussion Symptom Scale) and activity questionnaire several times each day. Daily cognitive rest and exertion was measured as number of text messages sent, minutes of screen time and gaming, and minutes of reading or school work. These indicators were summed using factor analysis into a composite score. Cross-correlation plots that help determine which variable may lead or lag another explored whether participants’ levels of physical activity (step count) or cognitive activity (composite score) on a given day were associated with their symptom score that day or on subsequent days, or vice versa.


Thirty-four patients were enrolled a median of 6 days after injury (interquartile range, 3-10) (Table). Most patients (n = 28; 82%) responded to more than 80% of prompts. Levels of physical and cognitive activity and symptoms during follow-up are reported in the Figure. Higher cognitive activity on a given day corresponded to a higher symptom score that day and on the following 2 days (correlation, approximately 0.35), especially in patients with high initial symptoms (≥15). Conversely, higher physical activity on a given day corresponded with lower symptom scores on that and the following 2 days, especially in patients with low symptoms initially (correlation, approximately −0.35). Overall, symptoms decreased as the 2-week follow-up period progressed. Regardless of activity levels, most patients (n = 23; 68%) were not symptomatic at the end of follow-up.

Demographics and Baseline Characteristics of 34 Concussion Patients
Demographics and Baseline Characteristics of 34 Concussion Patients
Cognitive Activity, Physical Activity, and Symptoms Measured in Real Time Using Ecologic Momentary Assessment in Youth Following Concussion
Cognitive Activity, Physical Activity, and Symptoms Measured in Real Time Using Ecologic Momentary Assessment in Youth Following Concussion

Objective and timely measures of physical and cognitive activity are needed to more precisely define the relationship between physical and cognitive rest and clinical outcomes, such as symptom status, on the days and weeks following concussion. Our study established that ecological momentary assessment provides a feasible approach to capture objective measures of physical activity and reports of cognitive activity and symptoms in real time in pediatric patients. In this pilot sample, we found that cognitive rest and physical activity on a given day corresponded with lower symptom severity on the subsequent 2 days. However, of interest, most patients were asymptomatic after 2 weeks of follow-up regardless of activity levels during that period. Larger samples are needed to produce generalizable findings and to pursue more nuanced explorations of the relationship between symptoms and activity frequency or intensity on the days immediately following concussion and to gauge whether these connections may be causal. Our study did not include the first 48 to 72 hours following injury that was studied by Thomas et al4 and that may be the most important time frame for physical and cognitive rest.5,6 Nevertheless, we have demonstrated that ecological momentary assessment following concussion can be used to pursue answers to these critical issues in youths.

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Article Information

Corresponding Author: Douglas J. Wiebe, PhD, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Room 902, Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104 (dwiebe@upenn.edu).

Published Online: September 12, 2016. doi:10.1001/jamapediatrics.2016.1979

Author Contributions: Dr Wiebe had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wiebe, Nance, Houseknecht, Grady, Otto, Master.

Acquisition, analysis, or intepretation of data: Wiebe, Nance, Housknecht, Otto, Sandsmark, Master.

Drafting of the manuscript: Wiebe, Master.

Critical revision of the manuscript for important intellectual content: Wiebe, Nance, Housknecht, Grady, Otto, Sandsmark, Master.

Statistical analysis: Wiebe, Master.

Obtaining funding: Wiebe.

Administrative, technical, or material support: Wiebe, Nance, Housknecht, Grady, Master.

Conflict of Interest Disclosures: None reported.

Funding/Support: Funding for this study was provided through a grant from the Penn Medicine Translational Neuroscience Center.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Luke Basta, BA, in the Department of Biostatistics and Epidemiology at the University of Pennsylvania, for data management. No compensation was received from the funding sponsor.

McCrory  P, Meeuwisse  WH, Aubry  M,  et al.  Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.  Br J Sports Med. 2013;47(5):250-258.PubMedGoogle ScholarCrossref
Moor  HM, Eisenhauer  RC, Killian  KD,  et al.  The relationship between adherence behaviors and recovery time in adolescents after a sports-related concussion: an observational study.  Int J Sports Phys Ther. 2015;10(2):225-233.PubMedGoogle Scholar
Meehan  WP  III, Bachur  RG.  The recommendation for rest following acute concussion.  Pediatrics. 2015;135(2):362-363.PubMedGoogle ScholarCrossref
Thomas  DG, Apps  JN, Hoffmann  RG, McCrea  M, Hammeke  T.  Benefits of strict rest after acute concussion: a randomized controlled trial.  Pediatrics. 2015;135(2):213-223.PubMedGoogle ScholarCrossref
Giza  CC, Hovda  DA.  The new neurometabolic cascade of concussion.  Neurosurgery. 2014;75(suppl 4):S24-S33.PubMedGoogle ScholarCrossref
Griesbach  GS, Gomez-Pinilla  F, Hovda  DA.  The upregulation of plasticity-related proteins following TBI is disrupted with acute voluntary exercise.  Brain Res. 2004;1016(2):154-162.PubMedGoogle ScholarCrossref