Rest is not best
Similar to number three on our list of the top five concussion breakthroughs of the last five years, is the idea that rest is no longer considered the treatment for concussion. In fact, it’s not really even recommended for any more than 24 to 48 hours maximum!
Back in the day, the treatment for concussion was considered to be “rest”. Sit in a dark room, don’t go on the computer, don’t look at any screens, don’t do any school work, and definitely don’t do anything physical until your symptoms go away.
The logic behind this made sense.
Concussion causes an energy deficit within the brain, so the treatment must be to conserve energy. The thinking then became that anything that you do that burns energy is likely to prolong your recovery. With really no evidence to support this idea, the standard of care became to tell patients to rest and do absolutely nothing until their symptoms went away. Unfortunately, many untrained healthcare professionals are still providing this poor advice.
If your healthcare provider is telling you this, you’re in the wrong place.
In 2015, Danny Thomas and colleagues performed a randomized controlled trial comparing pediatric patients (ages 11 to 22 years) undergoing either strict rest for five days, or one to two days of rest followed by a stepwise return to activity. Surprisingly, the group that rested for five days reported more daily postconcussive symptoms, and slower symptom resolution than the group that only had one to two days rest1. This study completely changed perspectives on appropriate concussion care, and as a result, people began challenging the entire concept of rest following concussion.
Another study in 20152 found that adolescents who reported being less adherent to their doctors’ advice for physical and cognitive rest, recovered faster than those who were compliant with rest recommendations.
In that same year, DiFazio et al., published a case report and review which provided some insight into some of the potential harmful effects of prolonged rest3, including:
- Anxiety, Expectations, and the Nocebo Effect: “Being told to stay home and that a text message may damage your brain must be quite alarming to patients.” The “nocebo effect” is the causation of sickness by the expectations of sickness. This means that if a patient thinks a concussion requires rest and no activity at all, this causes medicalization of the condition and in-turn can make people worse, as they believe that they “overdid it”.
- Depression and Other Psychological Complications: Substantial scientific evidence suggests that removal of normal life after injury (school, employment, team involvement, social interaction, etc.), has adverse effects on the ability to cope with illness generally, and is associated with psychological complications.
- Physical Deconditioning: One of the key causes of persistent concussion symptoms is altered blood flow due to physiologic changes to the way your brain vessels respond to various changes in circulation and activity. Evidence shows that physical inactivity alone causes many of these SAME changes!
It seems that we (healthcare providers) may have actually been causing persistent symptoms by telling people that the only treatment for concussion is rest. It now seems that prolonged rest is a sure-fire way to make your concussion worse!
According to the current guidelines from around the world4, following a concussion you should engage in “symptom-limited” activity with a low risk of subsequent concussions for the first 24 to 48 hours. Symptom-limited means that you can do ANYTHING that does not significantly provoke or increase your symptoms. You can go for walks, you can watch TV, you can do school work, you can go on your phone, as long as it doesn’t increase your symptoms too much.
A good rule of thumb is to take a break if your symptoms increase by more than three points (out of 10) during an activity.
Can you play sports immediately? Golf? Yes. Tennis? Yes. Football? No. You can engage in light exercise provided there is little to no risk of suffering another concussion. In fact, light exercise is now encouraged in the early stages after a concussion injury.
You can take a day or two off work or school but then you should be looking to get back in a gradual format (i.e., start with half-days and progress to full days).
Because these recommendations have done a virtual 180, the fact that rest is no longer considered the cornerstone of concussion treatment, places at number two on our top five concussion breakthroughs of the past five years.
To read the number one concussion breakthrough of the past five years, click here!
- Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. PEDIATRICS. 2015 Feb 2;135(2):213–23.
- Moor HM, Eisenhauer RC, Killian KD, Proudfoot N, Henriques AA, Congeni JA, et al. The relationship between adherence behaviors and recovery time in adolescents after a sports-related concussion: an observational study. Int J Sports Phys Ther. 2015 Apr;10(2):225–33.
- DiFazio M, Silverberg ND, Kirkwood MW, Bernier R, Iverson GL. Prolonged Activity Restriction After Concussion. Clinical Pediatrics. 2016 Jan 25;55(5):443–51.
- McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine. 2017 Jun;51(11):838–47.