Pillar Four: Conservative Treatment (Physical/Cognitive Rest)

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Along with teachers, coaches, school nurses, school psychologists, neuropsychologists, and administrators, parents play a crucial role in a child’s treatment and recovery from diagnosed concussion.  No matter how ‘mild’ a concussion may seem, concussion is a form of traumatic brain injury (TBI), which needs to be treated seriously.

Immediately after a concussion, engaging in even the most basic physical or mental tasks can make symptoms worse and slow recovery. In the first few days after concussion (what one leading sports neurologist calls the “acute rest” phase) parents therefore need to make sure their child get lots of rest and limits physical exertion and activities of daily living.

Because a concussion impacts the brain’s cognitive functions (e.g. those that involve thinking, concentrating, learning, memory, and reasoning), limiting an athlete’s scholastic and other cognitive activities, at least in the first few days after injury, is believed to give the brain time to heal and is thought to speed recovery.

The optimal amount and timing of physical and cognitive rest, however, is not yet known, and expert thinking on cognitive rest, in particular, has been evolving rapidly over the last several years.  Some clinicians suggest that concussed athletes avoid “screen time,” such as television, computers/tablets, gaming, even texting, but, as neurologist Jeffrey Kutcher points out in his recent book, Back in the Game, there is “no hard scientific basis for this recommendation, commenting that it is “hard to imagine, from a neuroscience perspective, that the injury itself gets worse as a result” of activities that make a headache worse or produce an increased sense of mental “fogginess.” Kutcher’s advice, is to avoid those things that make a patient feel significantly worse, but if the patient isn’t otherwise overly troubled while texting, or surfing the web, “then go ahead.” 

There is a growing expert consensus that taking cognitive rest to extremes and significantly isolating a concussed student-athlete by keeping them home from school cut off from the social interactions of being around their friends or teammates may accentuate the feeling of depression that they often feel in the first few days after injury as a direct effect of the injury itself.  In other words, as Dr. Kutcher observes, “Rest is the very thing we tell patients to do when they are diagnosed with concussion … and yet rest is something that can also eventually produce symptoms that look a lot like the concussion itself.”

Experts therefore recommend taking a common sense approach, keeping a concussed student-athlete home from school for a few days, and then easing back into school gradually before returning to a full school day (what is now increasingly dubbed “return to learn”), social activities, and to get a concussed student-athlete moving and active again.  The key is to reintroduce physical and mental activities during what Dr. Kutcher calls the “relative rest” phase in a way which does not make symptoms worse, and to discontinue any activity if it provokes symptoms or makes them worse.

Dr. Kutcher emphasizes the need for parents to be supportive and encouraging, “to let the child go back to school – if they feel like it – but also be prepared with a backup plan of options to employ if things do not go well” when they do, such as leaving a particular class early, or even the school day early.  “Don’t let them work out in any significant way, or dive into tough academic work at home,” he advises, but “also don’t turn the patient into a mushroom … unless it is all they can handle.”

In the event concussion symptoms/cognitive impairment persist (e.g. post-concussion syndrome), management by a multi-disciplinary team of concussion specialists, more formal academic accommodations (e.g. “IEP” or “504 plan”) and consideration of alternative therapies, may need to be considered.

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