Because a concussion impacts the brain's cognitive functions (those that involve thinking, concentrating, learning and reasoning), most 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.
Physical rest
An athlete should avoid strenuous activity until the athlete has no post-concussion symptoms at rest because physical activity may make symptoms worse and has the potential to delay recovery. While strict bed rest is not necessary, and while the effect of physical activity on concussion recovery has not been extensively studied (indeed, there is some evidence to suggest that mild physical exertion may actually help concussion recovery, especially for those suffering from post-concussion syndrome), the consensus of experts recommends broad restrictions on physical activity in the first few days after a concussion, including:
- no sports
- no weight training
- no cardiovascular training
- no PE classes
- no sexual activity
- no leisure activities such as bike riding, street hockey, and skateboarding that risk additional head injury or make symptoms worse.
Cognitive rest
Just as an athlete recovering from a concussion needs to get physical rest, he needs cognitive (mental) rest as well.
Because a concussion impacts the brain's cognitive function (those that involve thinking, concentrating, learning and reasoning), not its structure, engaging in cognitive activities (in other words, doing something that requires a great deal of thinking or paying concentrated attention) may make an athlete's concussion symptoms worse, and even delay recovery (although no link has yet been definitively established to adverse long-term health effects).
As a result, most experts recommend that concussed student-athletes limit scholastic and other cognitive activities to allow the brain time to heal.
Cognitive rest means:
- Time off from school or work;
- No homework;
- No reading;
- No visually stimulating activities, such as computers, video games, texting or use of cell phones, and limited or no television;
- No exercise, athletics, chores that result in perspiration/exertion;
- No trips, social visits in or out of the home; and
- Increased rest and sleep. (1)
While cognitve rest is come to be considered the "cornerstone" of concussion management (1), it was only recently that there was any empirical evidence to support such treatment recommendation.
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, 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 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 observed. 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 Boston Children's Hospital, 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."
A parent's perspective
"While there has been a lot of emphasis in recent years on return to play guidelines for concussed athletes, because our kids are students, I like to now think of concussions as having created concussed students, as opposed to concussed athletes," says Dorothy Bedford, whose daughter, Heidi, suffered a concussion while playing hockey.
"I think from a parent's point of view, and from the point of view of the future of the student, it is more important for pay attention to the cognitive impact [of concussion]. So, not only is it important [for concussed students] to avoid play but to avoid cognitive exertion," she says, because, in her experience, it is "critical to making a successful recovery at an early point, instead of having it extended, as Heidi's was, because we made mistake after mistake" in terms of making sure she got the cognitive rest that she needed after her concussion.
Minority report
While the most recent international consensus of concussion experts (1) highlights the "concept of 'cognitive rest' ... with special reference to a child's need to limit exertion with activities of daily living that may exacerbate symptoms," including school, such recommendations are not without dissenters, most notably Christopher Randolph, PhD of the Department of Neurology at Loyola University Medical Center in Maywood, Illinois, who 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.
A 2013 systematic review of the literature on the effects of rest and treatment following sport-related concussion (7) takes a middle ground, noting that, while mental and physical rest in the initial days following a concussion have been strongly encouraged, and resting until symptom free widely recommended, there have been only three published studies evaluating the effects of rest in athletes who have suffered a sport-related concussion, and with specific reference to the Moser study, noted the absence of a control or comparison group, "so that improvements could have been attributed to a diverse range of factors."
The authors, however, identified three lines of evidence that indirectly supported the value of rest:
"First, concussions can have a large adverse effect on physical and cognitive functioning in the first few days postinjury, as the brain is in a state of metabolic crisis (4), at which time increased energy demand may hinder the restorative process, and it is believed that rest might facilitate recovery.
Second, in animal injury models, there appears to be a 'temporal window' of vulnerability in which a second overlapping injury results in greater levels of traumatic axonal injury and magnified cognitive and behavioral deficits. Thus, a rest period will reduce the likelihood of the athlete experiencing an overlapping injury.
Finally, it has been demonstrated in rodent models that exercise appears to be good for the injured brain; however, animals that are allowed to exercise too soon after injury do not show the expected exercise-induced increases in molecular markers of neuroplasticity [the ability of the brain to rewire itself after injury]. For these reasons, it is believed that rest is very likely beneficial following injury. However, this is largely based on animal research, theory and expert consensus." (7)
Common-sense approach recommended
In the absence of further studies to evaluate the effects of a resting period and the optimal duration of this period, experts recommend taking a "sensible approach involv[ing] a gradual return to school and social activities (prior to contact sports) in a manner that does not result in a significant exacerbation of symptoms." (1,7)
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.
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. Schneider K, Iverson G, Emery C, McCrory P, Herring S, Meeuwisse W. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med 2013;47:304-307.
Updated May 24, 2013
