Strict rest for children who have suffered concussions could do more harm than good, according to a growing body of research.
It can lead to them being ‘cocooned’ – a lack of stimulation and activity that may be bad for the developing brain.
Avoiding contact sports is still key, but a leading neurosurgeon says previously-banned activities like homework, swimming and video games could speed recovery from concussions.
Neurosurgeon Dr Christopher Giza and colleagues at the University of California, Los Angeles, recommend only a brief period of inactivity in light of their new findings.
‘Cocooning’ or keeping young people with concussions away from all mental and physical activities is not the best road to recovery, a neurologist said in a new report
After a few days rest, Dr Giza says the brain needs exercise to avoid problems like depression, poor sleep and anxiety.
Soon, recovering children should get back to some cognitive activities such as reading, homework or playing video games – and non-risky exercise like walking and swimming.
They say traumatic brain injuries (TBIs) are expected to become one of the leading causes of death and illness worldwide by 2020.
The most common form are concussions – or mild TBIs – which frequently occur among youngsters on the football or rugby field.
In recent years TBIs have been linked with an increasing risk of dementia in later life, as well as to CTE, a chronic brain-swelling disease that has been linked to the deaths of athletes, including former NFL player Aaron Hernandez.
These risks make it essential that children still stay off the field where they could be hit in the head again – most research suggests a period of about 10 days – but being utterly inactive may be harmful.
Corresponding author Dr Giza, of UCLA, said the advice ‘you’re supposed to rest after concussion’ has been given countless times to recovering patients and athletes.
It stemmed from evidence the risk of a subsequent concussion rises up to three-fold in individuals who have had a prior one.
Repeated concussions before full recovery exacerbates damage, as scientists have seen in brain scans.
Dr Giza, who has acted as an adviser for a host of sports in the US, said: ‘This body of evidence then led to clinical consensus recommendations that called for removing individuals with a concussion from risky activities such as contact sports to protect them from the increased risk.’
But, writing in JAMA Neurology, the team said this is distinct from ‘complete brain rest.’
The theory behind complete brain rest is that by avoiding any mentally taxing activities, the brain has a chance to conserve energy as normal blood flow is restored to injured areas.
Over time, the standard for caring for patients recovering from sport-related concussions moved from avoiding risky activities to restrictions on all exercise.
Dr Giza said: ‘However there remained little evidence to guide the timing and duration of restrictions – and many interpreted this as meaning there should be complete physical rest as long as the patient was symptomatic.’
Concussion symptoms can include nausea, headaches and confusion, and recovery times vary widely.
As concussion awareness increased, a series of small unreliable studies suggesting physical and cognitive rest over time was best emerged.
Dr Giza said: ‘Cognitive rest was defined as limited mental activity, with avoidance or reduction of ‘cognitive exertion’ such as reading, homework, job activities, studying and playing video games.
‘Many patients were prescribed restrictions designed to reduce neural stimulation such as wearing sunglasses, staying in a darkroom, avoiding screen time of any kind, and prohibiting the use of electronic devices for activities such as texting, checking email and accessing social media.’
But recent research on animal models has shown voluntary exercise at the appropriate boosted recovery and cognition – sometimes even very early after injury – may be safe and lead to faster healing.
Dr Giza said: ‘Even as clinical practitioners were using ‘cocoon therapy’ – a form of severe restriction of activity designed to reduce brain activity by reducing sensory, motor and cognitive stimulation – others were noting ‘complete brain rest’ could have negative consequences.
‘Prolonged absences from school, anxiety, depression, de-conditioning, sleep disturbances and other problems were increasingly seen as challenges in the recovery from concussion.’
Basic neuroscience has shown mental activity is essential for brain development – strengthening communication and connections between neurons and increasing grey matter.
Dr Giza asked, then: ‘So why would complete brain rest be good for a developing brain?’
The reality is total restriction of brain activity is likely not ideal – even for an injured brain.
‘Although it makes some sense acutely to diminish stimuli that exacerbate symptoms, this practice has led to a slippery slope of progressively limiting environmental stimuli and physical activity during recovery until the patient is ‘cocooned.”
One previous study found those who did moderate activity after a concussion did best.
Another found there was no added recovery benefit in those who did the least.
Controlled exercise is now newly-included as a consideration in recommendations for the management of sport-related concussion.
Complete Concussion Management has recently revised its guidelines to suggest between three and four days of cognitive rest, followed by a gradual reintroduction to increasingly taxing mental activities.
Research suggests a similar approach to return to physical activities as well, and Dr Giza endorses both practices.
Dr Giza said: ‘Over time, both basic and clinical science caught up with practice, informing a more refined approach of individualized management of activity after concussion – with initial brief rest followed by controlled reintroduction of cognitive activities, non-risky physical activities and, eventually, a return to normalcy.’
In the US up to 3.8 million sports-related concussions occur annually.
It’s estimated there are more than 10 million hospitalizations or deaths caused by them each year – with many times that number experiencing them.
Dr Giza has been a consultant for the National Football League, the National Hockey League Players’ Association and served on advisory panels for Major League Soccer, the National Basketball Association, the National Collegiate Athletic Association and the US Soccer Federation.