Concussion? When is rest NOT the best advice.
April 5, 2018 | NEUROLOGY TODAY | 35-39
Why Total Rest Following Concussion May Not Be Best
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Author: DAN HURLEY
Broad restrictions on nearly all physical and cognitive activity following a concussion are not evidence-based and may result in iatrogenic harm to patients, according to a widely praised paper in the March 5 JAMA Neurology.
Recommendations for “total rest,” “cognitive rest” or “cocooning” became widespread as clinicians sought to avoid the risk of a second mild traumatic brain injury (mTBI) in a sports-related setting, according to the Viewpoint paper by researchers at the University of California, Los Angeles (UCLA) and the University of Queensland in Brisbane, Australia.
But, they wrote, the pendulum has swung too far, to the point where children and adults are being told to avoid routine mental activity ranging from reading or watching television to texting or checking email.
“The reality is that total restriction of brain activity is not ideal, even for an injured brain,” the paper states.
Yet such recommendations continue to be made by practitioners who do not specialize in the treatment of concussion, said one of the authors of the paper.
“The majority of our patients have been referred to us because they have ongoing symptoms lasting weeks or months,” said Meeryo C. Choe, MD, assistant clinical professor of pediatric neurology and associate director of the UCLA Steve Tisch BrainSPORT Program. “Not infrequently, the provider they previously saw had told them, ‘You can’t do anything, you should be cocooned until you are symptom-free.’ They might not have been going to school or seeing friends or doing anything for weeks.”
Amaal Starling, MD, assistant professor of neurology at the Mayo Clinic in Scottsdale, AZ, said she hoped that the paper might help to reduce the number of concussion patients referred to her clinic whose recovery has been impeded by recommendations for total rest.
“The majority of individuals I see, where it’s been three months or greater from the time of injury, I would say that 90 percent of the time those individuals had been prescribed cocoon therapy, and our multidisciplinary team is trying to undo the harm it caused and get these people back into life,” Dr. Starling told Neurology Today.
SWING OF THE PENDULUM
Noting how widespread the advice to rest following concussion has become, the JAMA Neurology paper asked: “How did we get here, what is the evidence that brought us here, and what does the evolving evidence actually tell us?”
It noted that initial evidence from clinical and epidemiological studies showed that patients who experienced a second mTBI before they had fully recovered from a prior one were at increased risk of long-term neurologic impairment. That evidence led, logically, to recommendations to avoid activities in which a second mTBI could occur.
Then came studies showing that rodents permitted or forced to exercise on a running wheel following an experimentally induced concussion had worse outcomes, followed by clinical observations that early return to strenuous activities could exacerbate acute symptoms.
“The consensus on management of mTBI, driven largely by those caring for patients recovering from sport-related concussions, moved from avoiding early activities with risk of repeat mTBI to restrictions on all physical activities, whether they held significant risk for repeat mTBI or not,” the paper stated.
The pendulum swung to a point beyond that supported by evidence, with clinicians advising what the paper called “the ill-defined entity of ‘cognitive rest.’”
Cognitive rest, the paper continued, “was defined as limited mental activity, with avoidance or reduction of ‘cognitive exertion’ such as reading, homework, job activities, studying, and playing video games.” Recommendations included “wearing sunglasses, staying in a dark room, avoiding screen time of any kind, and prohibiting the use of electronic devices for activities such as texting, checking email, and accessing social media.”
Yet with basic neuroscience showing that neural stimulation is necessary for normal brain development, clinicians began to notice that the “cocoon therapy” and “complete brain rest” being recommended by some practitioners was resulting in long school absences, anxiety, depression, deconditioning and sleep disturbances.
In the end, the paper concluded, “evidence-based removal from activities with a risk of repeated mTBI was extrapolated beyond existing data to incorporate a broad range of restrictions on physical and cognitive activity.” Cocoon therapy and complete brain rest, the paper stated, “may have contributed to prolonged recoveries.”
In an interview with Neurology Today, Dr. Choe said she and colleagues at UCLA still routinely see children who have been told to “sit in a dark room, do nothing and wear sunglasses. Those kinds of very strict restrictions can in fact make symptoms last longer.”
EVIDENCE FAVORS MODERATE ACTIVITY
Perhaps the most surprising evidence of adverse effects of strict rest came from studies that were actually designed to prove its benefits. A randomized trial published in Pediatrics in February of 2015, for instance, set out to provide firm evidence in favor of strict rest. “However,” the study found, “the intervention group reported more daily post-concussive symptoms (total symptom score over 10 days, 187.9 vs. 131.9, p<.03) and slower symptom resolution.
The first author of that trial told Neurology Today that his group designed the study thinking that emergency rooms were failing to recommend sufficiently strict rest to children following a concussion. The findings convinced him that strict rest only makes things worse on average.
“Twenty years ago, the pendulum was on the side of telling kids they were fine and that a concussion was nothing to worry about,” said Danny G. Thomas, MD, assistant professor of pediatrics at the Medical College of Wisconsin. “Then, ten years ago, the pendulum swung in favor of an abundance of caution. That’s where complete rest became the standard of care. Now it’s swinging back again.”
Another paper, published in Pediatrics in 2014, included men and women between the ages of eight and 23. In its abstract, the conclusions stated: “Increased cognitive activity is associated with longer recovery from concussion. This study supports the use of cognitive rest and adds to the current consensus opinion.”
But a closer look at the paper shows that its findings were more nuanced. In its discussion, the paper cautioned that “complete abstinence from cognitive activity may be unnecessary. This is similar to the findings by Majerske et al, who found that those engaging in moderate levels of activity had better outcomes than those engaging in the highest and low- est levels of activity.”
In an email to Neurology Today, the senior author of the 2014 Pediatrics paper said he agrees “wholeheartedly” with the views expressed in the JAMA Neurology Viewpoint.
“We usually tell patients with a concussion to engage in cognitive activities and non-contact exercise below the level at which their symptoms increase,” said William Meehan III, MD, associate professor of pediatrics at Boston Children’s Hospital. The assertion that complete rest should be avoided, he added, “is not provocative or controversial but is in complete agreement with our work and that of others.”
Bert B. Vargas, MD, FAAN, associate professor of neurology and director of the sports neuroscience and concussion program at UT Southwestern Medical Center’s O’Donnell Brain Institute, said he still routinely sees patients who were told to engage in cocoon therapy following concussions, but not as frequently as he did even two years ago.
“These people who have been completely disengaged from life begin to suffer from anxiety, depression and social isolation,” Dr. Vargas said. “Thankfully, more and more we’re seeing a shift toward rehabilitation. That’s a good thing. The mounting evidence that controlled exercise helps with concussion recovery underscores the fact that treating concussion should incorporate an interdisciplinary approach with partnerships that include physical therapists and athletic trainers who are uniquely qualified to help guide and oversee an active rehabilitation plan.
Dr. Starling said that she finds it especially worrisome when patients come to her saying that their post-concussion symptoms have only worsened after months of strict rest.
“The effects of a TBI injury might not improve in everyone as quickly as we would like, but they should not worsen,” she said. “Whenever we see patients who say their symptoms are only getting worse after months, most often they were prescribed this cocoon therapy.”
LINK UP FOR MORE INFORMATION:
- Giza CC, Choe MC, Barlow KM. Determining if rest is best after concussion. JAMA Neurol 2018; Epub 2018 Mar 5.
- Kreber LA, Griesbach GS. The interplay between neuropathology and activity-based rehabilitation after traumatic brain injury. Brain Res 2016;1640(pt A):152-163.
- Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014;133(2):e299-304.
- Thomas DG, Apps JN, Hoffman RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015;135(2):213-223.
- Majerske CW, Mihalik JP, Ren D. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train 2008;43(3):265-274.
- Grool AM, Aglipay M, Momoli F, et al. Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA 2016;316(23):2504-2514.