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 until now 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.
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," 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, 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 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 visually stimulating activities, such as
|No trips, social visits in or out of the home|
| Increased rest and sleep
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.
Rest: deceivingly simple concussion treatment
"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."
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.
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.
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.
Posted June 19, 2012. Most recently revised March 20, 2013