Evolving Thinking
A few in the concussion field, most notably Christopher Randolph, PhD, of the Department of Neurology at Loyola University Medical Center in Maywood, Illinois, have continued 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 showing that a failure to engage in complete physical or cognitive rest after sport-related concussion exacerbates concussive injury, and cited 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 not indicated for most medical conditions.
A 2014 study (7) by researchers from Boston Children's Hospital, Children's Hospital of Philadelphia and the University of Pittsburgh Medical Center, provides empirical data showing that Dr. Randolph said in 2012 was lacking, but also lends support to Dr. Randolph's position that complete cognitive rest is needed. It found that teens who continue to engage in full cognitive activity after sport-related concussion take from two to five times longer to recover on average than those who limit such activity, but that complete cognitive rest was did not speed recovery: only those concussed athletes who engaged in the most cognitive activity experienced a significantly longer recovery - as measured by the duration of concussion-related symptoms - with those who engaged in less cognitive activity, ranging from complete cognitive rest to moderate cognitive rest, all recovering at about the same pace.
The findings, published online in the journal Pediatrics, provide important support for current concussion guidelines (1,2,4,8, 9) recommending cognitive rest during the initial stages of recovery from concussion which tend to recommend a common sense, symptom-limited period of cognitive rest after concussion.
"While vigorous cognitive exertion appears detrimental to recovery, more moderate levels of cognitive exertion do not seem to prolong recovery substantially," said William P. Meehan, III, MD, Director of the Sports Concussion Clinic at Boston Children's Hospital and one of the study's authors, similar to the findings of a 2008 study (12) which reported that those who engaged in moderate levels of activity after concussion 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," said Dr. Meehan.
Dr. Meehan and his fellow researchers suggested that cognitive activity may have more of an effect on recovery in the period immediately after injury, and said additional research would be needed to determine how the effect of cognitive activity changes over time.
Current concussion guidelines (1,2,8,9,10,11), as well as 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 three to five days after injury, followed by a gradual return to cognitive activity, so long as it does not trigger a return of symptoms.
"For the first three to five days, we tell our patients with concussions that they should really aim to be at a zero level or complete cognitive rest," said Meehan in an interview with the Boston Globe. (13) That means no reading, homework, text messaging, or video game playing; basically, it's fine to lie in bed quietly, watching TV or listening to music with the volume on low. Those experiencing severe symptoms may prefer to be resting anyway," he said, "but those with mild symptoms may think they can go back to school or resume exercise right away, which may delay their recovery."
After a few days, kids can slowly add mental activities such as doing a crossword puzzle or sending a few text messages to see how they feel. "If symptoms exacerbate, they should go back to resting," Meehan said. If they're feeling OK, they can continue to
gradually add mental challenges, resuming some school work on a lighter schedule. Throughout, they should continue to assess their symptoms and cut back if the headaches or dizziness return."
1. McCrory, P, 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. 2013:47:250-258.
2. Halstead, M, Walter, K. Clinical Report - Sport-Related Concussion in Children and Adolescents. Pediatrics 2010;126(3):597-615.
3. Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics 2012;161(5):922-926.
4. Giza CC, Hovda DA, The Neurometabolic Cascade of Concussion. J. Ath Train 2001;36(3):228-235 (accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155411/)
5. Maugans TA, Farley C, Altay M, Leach J, Cecil KM. Pediatric sports-related concussion produces cerebral blood flow alterations. Pediatrics 2011;129:28-37.
6. Kirkwood MW, Randolph C, Yeates KO. Sport-Related Concussion: A Call for Evidence and Perspective Amidst the Alarms. Clin J Sports Med 2012;22(5):383-384.
7. Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics. 2014;133(2):1-6.
8. Herring SA, Cantu RC, Guskiewicz KM, et al. American College of Sports Medicine Concussion (mild traumatic brain injury) and the team physician: a consensus statement-2011 update. Med Sci Sports Exerc. 2011;43(12):2412-2422.
9. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47:15-26.
10. Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80(24):2250-2257 DOI:10.1212/WNL.ob013e31828d57dd.
11.Broglio SP, et al. National Athletic Trainers' Association Position Statement: Management of Sport Concussion. J Athl Train. 2014;49(1):000-000. doi: 10.4085/1062-6050-49.1.07 (epub March 10, 2014).
12. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sport: postconcussive activity levels, symptoms, and neurcognitive performance. J Athl Tr. 2008;43(3):265-274.
13. Deborah Kotz. "Children's Concussions and Brain Rest." Boston Globe. January 26, 2014, http://www.bostonglobe.com/lifestyle/health-wellness/2014/01/06/brain-re..., accessed January 10, 2013.
Updated September 10, 2014
