Extensive cognitive activity delays recovery

At least some of the questions about how much rest were addressed in two recent studies, first a 2014 study co-authored by Dr. Meehan and published in the journal Pediatrics ^[12] which found that teens who continue to engage in full cognitive activity in the period just after sport-related concussion take longer to recover than those who limit such activity in the first 7 to 10 days after injury.

Perhaps surprisingly, Dr. Meehan and his colleagues found that only those concussed athletes who continued to engage in full cognitive activity experienced a significantly longer recovery as measured by the duration of concussion-related symptoms, and that those who limited cognitive activity - ranging from complete cognitive rest to significant, but reduced cognitive activity (see table below) - all recovered at about the same pace.

"While vigorous cognitive exertion appears detrimental to recovery, more moderate levels of cognitive exertion do not seem to prolong recovery substantially," wrote Dr. Meehan, findings similar to those in an earlier study, ^[13] which found that those who engaged in moderate levels of activity had better outcomes than those engaging in the highest and lowest levels of activity.

"This seems to suggest that while limiting cognitive activity is associated with a shorter duration of symptoms, complete abstinence from cognitive activity may be unnecessary," says Dr. Meehan. 

Because the effect of cognitive rest may vary over time, such that cognitive activity has more of an adverse effect on recovery during the earlier phases, current concussion guidelines as well as the expert opinion of many clinicians involved in the assessment and management of sport-related concussion, including Drs. Meehan and Moser, recommend a period of near full cognitive rest in the first days after injury, followed by a gradual return to cognitive activity, so long as it does not trigger a return of symptoms.

Indeed, recent research ^[5] which suggests that blood flow to the brain is still reduced in more than a third of 11- to 15-year-olds even at 1 month or more post-concussion, Dr. Moser argues, not only "supports an even longer recovery period than typically thought, but is consistent with the notion that a period of rest may be therapeutic" in treating post-concussion syndrome.

Need for strict rest questioned 

But while a growing body of evidence, consensus guidelines, and the expert opinion of clinicians such as Drs. Moser and Meehan supports limiting extensive cognitive activity in order to reduce duration of concussion symptoms, such recommendations are not without dissenters, and, indeed, a more recent study on the effect of strict physical and cognitive rest, published in January 2015 in the journal Pediatrics, ^[18] appears to support the view, also expressed by some clinicians and other experts, ^[19] that there may be no advantage to strict rest, beyond the first 1 to 2 days after injury. 

Christopher Randolph, PhD of the Department of Neurology at Loyola University Medical Center in Maywood, Illinois, is one who continues to question the idea that the rest needs to be "complete" and last until an athlete is entirely asymptomatic.

Writing in an editorial in the September 2012 issue of the Clinical Journal of Sports Medicine, ^[6] Randolph and his co-authors pointed to the lack of empirical data to show that physical or cognitive rest after sport-related concussion exacerbated concussive injury, citing to studies of athletes suggesting that re-engaging in activities in the days after injury is likely to have no detrimental effect or even a beneficial one; findings consistent with the view that total bed rest is generally contraindicated for most medical conditions. (although it is important to note that he made his comments before the 2014 Brown study that appears to show that athletes who continue to engage in full cognitive activity after concussion take longer to recover than those who limit such activity)

A 2013 clinical report by the American Academy of Pediatrics ^[8] likewise noted a lack of research documenting the benefits or harm of strict cognitive rest in either prolonging concussion symptoms or the ultimate outcome for the student following a concussion.  The AAP even went so far as to state that, given the disruptive nature that concussion symptoms may pose for the student and his or her family, "adding additional restrictions that may not be needed has the potential to create further emotional stress during the recovery."

In the most recent study,^[18] researchers at the Medical College of Wisconsin reported that strict physical and cognitive rest in the five days immediately after concussion, in fact, did not help teens recover more quickly than taking it easy for one to two days after injury and then returning to school.

Indeed, the group advised to rest for five days actually reported more daily post-concussive symptoms during the first 10 days after their emergency department visit and slower resolution of symptoms than those who rested for 1 to 2 days and then returned to school.

The study was unable to explain the difference in symptom reporting, but noted that it was possible that the discharge instructions influenced the patient's' perception of illness, leading them to report more symptoms, and that the deleterious effects of strict rest they observed may have more to do with emotional distress caused by school activity and activity restriction, because missing social interactions and falling behind academically may cause concussed student-athletes to become depressed, increasing physical and emotional symptoms, just as the AAP predicted four years earlier in its 2010 clinical report^[8] when it suggested that, "adding additional restrictions that may not be needed" had the "potential to create further emotional stress during the recovery."   

Growing support for limiting cognitive rest after concussion 

Indeed, support appears to be growing among concussion clinicians and researchers for the view that prolonged rest may not be the best treatment for concussion. Most recently, a group of concussion experts, including Dr. Meehan, reported, ^[20] after meeting in October 2015 at a conference at the University of Pittsburgh Medical Center sponsored by the National Football League and closed to the press, that strict rest beyond the first few days after a concussion might actually delay recovery.  

"Exercise is a way of treating this," Dr. Javier Cardenas, a neurologist at the Barrow Concussion and Brain Injury Center in Arizona, told the Pittsburgh Post-Gazette. "Many times, we see patients who are completely restricted from any physical activity. As one of the major sources of this injury is sports and athletics, for those who are involved in athletics, this is actually a punishment. They become depressed. They become anxious. So allowing them to participate in physical activity - while keeping them out of harms' way, of course - is actually a rehabilitation method."

Another concussion expert who believes that complete cognitive rest may be over-prescribed is Elizabeth M. Pieroth, Pys. D., a clinical neuropsychologist with North Shore Medical Group in Chicago and a consultant to a number of Chicago professional sports teams, including the Bears, and an unpaid consultant to the National Football League.

Like Dr. Cardenas, in a recent video, Dr. Pieroth saw many of the same downsides to keeping concussed athletes out of school for more than a few days after injury, including social isolation, depression, and an unhealthy focus on symptoms instead of recovery: