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Study First To Prove Benefit Of Cognitive and Physical Rest In Concussion Recovery

1 week of prescribed rest helps both early in recovery and weeks or months after injury

Because a concussion impacts the brain's cognitive functions (those that involve thinking, concentrating, learning and reasoning), many concussion experts [1,2] believe that limiting an athlete's scholastic and other cognitive activities to allow the brain time to heal helps in recovery.  But, while physical and cognitve rest are considered the "cornerstone" of concussion management,  [1] there has been no empirical evidence to support such treatment recommendation.

Now there is.

In a study of concussed high school students published in the Journal of Pediatrics, [3] researchers - led by MomsTeam concussion expert neuropsychologist Rosemarie Scolaro Moser, PhD - found that, after one week of strict cognitive and physical rest (see box below), concussed athletes scored significantly better on the ImPACT neurocognitive test and reported statistically significant decreases in the number and severity of post-concussion symptoms.  

Significantly, the beneficial effects of the week of rest were seen whether the rest came soon after a concussion or weeks to months later. Indeed, more than a quarter of the sample which continued to experience concussion symptoms past the 31-day mark (defined by some as the point at which post-concussion syndrome is diagnosed) still demonstrated improvements with prescribed rest which were comparable to those experienced by concussed athletes in the study who were still in the early stages of concussion recovery.

"Our results represent the first data documenting the efficacy of prescribed rest for the treatment of post-concussion symptoms and cognitive dysfunction, whether the rest is applied in the early or prolonged stages of recovery," Dr. Moser notes.  The idea that cognitive and physical rest may help improve the condition of patients with post-concussion syndrome is [also] noteworthy," she writes, because "there may be a perception among clinicians that once the 7- to 10-day time period in which the neurometabolic "cascade" [4] has passed, and a patient continues to experience concussive symptoms, cognitive and physical rest is of limited use." 

Recent research [5] 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, which, 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.

"Without evidence to support the case for rest, especially when weeks or months have passed since the injury, clinicians are met with resistance from athletes, parents, and school and athletic officials who do not see the therapeutic value of missing school or sports when many weeks have already passed," the study notes. "Athletes, parents, and coaches may balk at the need for, or effectiveness of, rest and inactivity.  Without supportive empirical data, patient compliance is threatened and clinician judgments are often challenged and threatened," says Dr. Moser.

Commenting on the finding that even delayed cognitive rest may be beneficial, William P. Meehan, III, MD, MomsTEAM expert and Director of the Sports Concussion Clinic, and Director of the Micheli Center for Sports Injury Prevention in the Division of Sports Medicine
at Children's Hospital, Boston, says that the practice in his clinic has been  "always to initiate [cognitive rest], even late in the course [of treatment], if it had not been attempted already."   He thus found Dr. Moser's conclusions "reassuring."

"Our research now provides clinicians with solid evidence to show athletes, parents, schools and teams that rest really helps and should not be underestimated, no matter how long the time from injury," says Moser. "I hope it helps us debunk the mistaken philosophy that it is better to push through the pain, than to take the time to heal."

 

 Cognitive Rest
Time off from school
No homework
No reading

No visually stimulating activities, such as

  • computers
  • video games
  • texting or use of cell phones
  • limited or no television

 No:

  • Exercise
  • Athletics
  • Chores that result in perspiration/exertion
 No trips, social visits in or out of the home
 Increased rest and sleep

Study limitations

Dr. Moser was careful to note that her study comes with "significant limitations":

  • It was retrospective in nature, and thus lacks blinding, randomization, and comparison with a control group, thus making it difficult to definitively show that observed improvement in neurocognitive test scores and decreased symptoms was actually the result of prescribed rest;
  • Prescribed rest, as a construct, needs to be more accurately defined for future studies to consider and control for such factors as:
    • type (physical versus cognitive)
    • length of rest period; and
    • degree or nature of prescribed rest (for example, no school versus partial school days or school attendance but no note-taking, homework, tests, computers, etc.);
  • Other variables need to be considered to help determine just how effective prescribed rest is as a concussion treatment, such as time since concussion (e.g. before the rest is prescribed) and severity of concussion symptoms at injury;
  • Compliance with prescribed rest was not specifically monitored or documented on a daily, prospective, systematic basis, and, given the age of the athletes in the study (14 to 23, mean age of 15), it is challenge to achieve 100% compliance; 
  •  The study involved a small, selective,"convenience" sample of 49 high school to college-age athletes seeking treatment from Dr. Moser's Sports Concussion Center of New Jersey; as a result, more detailed consideration of and control for such variables as age, sex, ADD/LD, intellectual ability, and years in sports and type of sport was not possible;
  • No baseline neurocognitive (e.g. ImPACT) testing was analyzed as few patients had such data available, so it was not known to what extent considering change from baseline would affect the interpretation of the study's results; and
  • Data was not recorded or coded documenting on-field signs and/or symptoms at the actual time of injury. 
The need for further research to evaluate the long-term outcome of rest, and the optimal amount and type of rest, was emphasized in the most recent international consensus statement on concussion in sport. [1]

"Although interpretation of the present study must be tempered by the fact that the group sizes are small, these data are compelling and the first to be presented that give credence to the importance of prescribed rest as a concussion treatment," Dr. Moser says. "With so little currently known about rest from a research perspective, it is hoped that the present study will stir interest in this deceivingly simple, yet complex, construct and important treatment for concussion."

Minority view

A few in the concussion field, most notably Christopher Randolph, PhD, of the Department of Neurology at Loyola University Medical Center in Maywood, Illinois, continue 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 point to the lack of empirical data to show that physical or cognitive rest after sport-related concussion exacerbates concussive injury, and cite 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. 

2014 study [7] by researchers from Boston Children's Hospital, Children's Hospital of Philadelphia and the University of Pittsburgh Medical Center, lends support to Dr. Randolph's position as well as to Dr. Moser's, finding 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 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 (see table below) - 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.

"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 those in a 2008 study [12] which found 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. 

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 August 27, 2014 

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