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Caution recommended when treating concussion with cognitive or physical rest
The paper by Halstead et al brings welcomed attention to the medical- academic needs of children with concussion. However, with respect to brain and body "rest", several recommendations for management are presented without a balanced appraisal of conflicting data or solid evidentiary support. We fear that these recommendations, presented as a standard, may contribute both to sub-optimal individual outcomes as well as to counter-productive policies. The authors recommend cognitive and physical rest after concussion. However, there is no evidence that the brain can be "put to rest" volitionally. Rest recommendations are based on conjecture from animal data demonstrating a "metabolic mismatch" in a vulnerable period occurring after brain trauma. Even if human pathophysiology matches lab-models in rodents and even if we had clinical markers of a vulnerable period, it is hard to imagine how "avoiding concentration" could supersede reparative mechanisms of brain recovery. Continuing this line of reasoning of a metabolic vulnerability, should we deprive concussed humans of sleep? REM sleep maintains nearly the same overall metabolic rate as wakefulness (even greater in certain regions such as the cingulate cortex).Cognitive rest remains ill-defined from a practical standpoint - a rest "dosage" for activities does not exist. Suddenly, students and families are now being told to avoid exercise, television, texting, and even spicy foods. When there is no evidence that using technology "stresses" the brain more than any other activity, should professionals really be advising parents that their role on a "team" is to enforce this advice? Enforced rest does not appear to improve recovery from many medical and neurologic conditions.1 And, regarding concussion, growing evidence suggests that cognitive rest does not result in hastened recovery.2 Of greater concern, there is evidence that enforced rest may result in deconditioning, and potentially exacerbate or even produce symptoms typically attributed to the post-concussive syndrome itself.3,4 We suggest that the authors are over-cautious when they assert that students should be at their "academic baseline" before a return to activity. Although judgment should be exercised before returning students to high risk physical activities, this recommendation is excessively broad. As noted, there is potential harm in enforcing rest. In practice, we have observed a self-perpetuating cycle: physicians interpret the re- occurrence of post-concussive symptoms to be an indicator of persistent and worsening brain injury and encourage more rest. We applaud the authors' cooperative approach between schools and providers who advocate for rationale accommodations during recovery. Education about concussion and early reassurance appears to reduce the chance of persistent symptoms after mild traumatic brain injury.5 Solid expert advice about the "known" and rational admission of "knowable unknowns" may ease patient and parental anxiety. Consequently, we agree that pediatric specialists should be engaged in prolonged or atypical cases. Appreciating the merits of this statement and its contribution to practice, we join the authors to stress an individualized patient-centered approach to the prescription of cognitive or physical rest.References1 McLean SA, Clauw DJ. Predicting chronic symptoms after an acute "stressor" - lessons learned from 3 medical conditions. Med Hypotheses. 2004;63:653-658.2 Gibson S, Nigrovic LE, O'Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27:839-42.3 Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28:250-9.4 Kirkwood MW, Randolph C, Yeates KO. Sport-related concussion: a call for evidence and perspective amidst the alarms. Clin J Sport Med. 2012;22:383-4.5 Ponsford J, Willmott C, Rothwell A, Cameron P, Ayton G, Nelms R, Curran C, Ng K. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108:1297-303.Conflict of Interest:
None declared
Saturday, January 04, 2014
Clinical Report: Returning to Learning Following a Concussion - School Considerations
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