Rest or withdrawal after concussion: a cautionary note

November 1, 2014

 

Dr. Pat Bass’ article on concussion (“Managing a patient after concussion,” Contemporary Pediatrics, August 2014) appropriately emphasizes the importance of brain protection and heightens recognition of the condition in children and adolescents.  However, several points must be clarified, including importantly that the clinical management of concussion is not yet evidence based. At present, most recommendations for care are based on “expert consensus” and are not supported by clear empirical data.1   

Dr. Bass indicates that pediatricians should caution against an immediate return to play. This is prudent in the immediate post-injury period, in part because many patients with concussion experience difficulties such as dizziness or coordination problems that might impair their ability to function safely. However, justifying the removal from play because of the risk of “second impact syndrome” is misleading. This so-called syndrome is hypothesized to involve brain swelling after a second injury, at some time close to an initial concussion. In reality, this condition has never been clearly demonstrated to be due to a second impact, and cases are probably related to a single impact causing diffuse neurovascular dysregulation and brain swelling, which is a rare but well-documented phenomenon in the neurosurgical literature.2

Catastrophic outcomes from sports-related concussion are much more likely to stem from acute intracranial bleeding after single head impacts rather than diffuse edema or back-to-back concussions. Regardless of the exact pathology, death from sports-related head trauma in youth is also several times less likely than death from exertion-related cardiovascular events-and even less likely than death from lightning strikes.3

Dr. Bass indicates that there is no evidence of harm in recommending rest in concussion. In fact, there is a broad literature on the pathophysiologic cascade that is produced by enforced periods of rest in humans.4,5 Physical rest is contraindicated and associated with worsened outcomes in a number of medical conditions, including brain injury.6 The psychological complications of rest and removal from regular activities are also well described, and in fact removal from validating activities has been identified as one of the most powerful predictors of illness-related depression.7 Furthermore, enforced rest can quickly result in deconditioning, potentially exacerbating or producing symptoms typically attributed to the post-concussive syndrome itself.4

Recommendations from physicians to withdraw from school, social participation (including social media), and team play could iatrogenically precipitate or worsen socioemotional difficulties for adolescents, who are so dependent on their social network for validation and support. More importantly, there is no evidence that the brain can be "put to rest" volitionally. In fact, [rapid eye movement] sleep maintains nearly the same overall metabolic rate as wakefulness (even greater in certain regions such as the cingulate cortex). Cognitive rest, although recommended, remains ill defined-a rest "dosage" for activities has never been established.

It is also hard to imagine how avoiding concentration and the like could supersede reparative mechanisms of brain recovery, evolved over millions of years.8 To date, methodologically rigorous studies with humans have not yet demonstrated that rest has a beneficial effect on concussion recovery, and a mandated symptom-free waiting period before return to activity does not appear to hasten recovery.9 Ultimately, we and others consider rest a medical “treatment” that must be subject to the same degree of study and analysis as any prescribed intervention before recommendations are made for use in concussion.10

Dr. Bass emphasizes that students not return to school or sports “until asymptomatic.”  Yet, a significant proportion of the normal population without head injury commonly reports symptoms typically seen after concussion (eg, fatigue, sleep disturbance, headache, inattention), making the goal of being asymptomatic nonsensical.11

We have reached a critical juncture. Parents are now restricting their children’s participation in sports because of concerns regarding concussion.12 Pediatricians are the vanguard who must educate parents on the known risks of concussion but also the risks of a sedentary lifestyle, and the benefits of sports and team involvement for children.   

In summary, we recommend that pediatricians exercise caution when recommending more than a short period of “rest” or withdrawal from exercise, social interaction, or school. Interestingly, psychoeducation and reassurance have been found to be effective means of treatment for concussion.13 We suggest that both can be used as powerful tools in the hands of a confident and educated clinician.

 

REFERENCES

1. Crayton N, Leslie O. Time to re-think the Zurich Guidelines?: a critique on the consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, held in Zurich, November 2012. Clin J Sport Med. 2014;24(2):93-95.

2. McCrory P, Davis G, Makdissi M. Second impact syndrome or cerebral swelling after sporting head injury. Curr Sports Med Rep. 2012;11(1):21-23.

3. Kirkwood MW, Randolph C, Yeates KO. Sport-related concussion: a call for evidence and perspective amidst the alarms. Clin J Sport Med. 2012;22(5):383-384.

4. Smorawinski J, Nazar K, Kaciuba-Uscilko H, et al. Effects of 3-day bed rest on physiological responses to graded exercise in athletes and sedentary men. J Appl Physiol. 2001;91(1):249-257.

5. Fortney SM, Schneider VS, Greenleaf JE. The physiology of bed rest. Compr Physiol. 2011:889-939.

6. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke. 2008;39(2):390-396.

7. Williamson GM, Shaffer DR, Parmelee PA, eds. Physical Illness and Depression in Older Adults: A Handbook of Theory, Research, and Practice. New York: Kluwer Academic/Plenum Publishers; 2000.

8. Phillips C, Baktir MA, Srivatsan M, Salehi A. Neuroprotective effects of physical activity on the brain: a closer look at trophic factor signaling. Front Cell Neurosci. 2014;8:170.

9. McCrea M, Guskiewicz K, Randolph C, et al. Effects of a symptom-free waiting period on clinical outcome and risk of reinjury after sport-related concussion. Neurosurgery. 2009;65(5):876-882.

10. 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(4):250-259.

11. Dean PJ, O'Neill D, Sterr A. Post-concussion syndrome: prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Inj. 2012;26(1):14-26.

12. Wallerson R. Youth participation weakens in basketball, football, baseball, soccer, Fewer children play team sports. Wall Street Journal. Available at: http://online.wsj.com/articles/SB10001424052702303519404579350892629229918. Updated January 31, 2014. Accessed October 21, 2014.

13. Mittenberg W, Canyock EM, Condit D, Patton C. Treatment of post-concussion syndrome following mild head injury. J Clin Exp Neuropsychol. 2001;23(6):829-836.

Dr. Bass responds:

I would like to thank Marc P. DiFazio, MD, and Michael W. Kirkwood, PhD, ABPP-CN, for their thoughtful response and rebuttal to parts of my concussion article.

I believe that Drs. DiFazio and Kirkwood’s comments highlight one significant problem that we have today in medicine-a large amount of what we do is not in fact based on evidence. Pediatricians in very busy office practices are often asked to make care decisions on a daily basis when a clear evidence base is lacking. As a result, expert opinion in the form of guidelines or consensus often guides the pediatrician’s thinking.

Guidelines are not the be-all and end-all for pediatric care. However, they do offer the busy pediatrician a place to start and help guide decisions in areas in which the pediatrician may not have received training and may not have referrals available. In the area of concussions, I would argue that guidelines such as those referenced in the article are essential given current shortages in specialties such as pediatric neurology.

Certainly, the guideline development process is far from perfect, and I agree that the areas mentioned by Drs. DiFazio and Kirkwood are concerning and deserving of further study and investigation. I am not familiar enough with the referenced guideline development to comment on why more of the issues raised by these physicians were not addressed. However, guidelines are not mandates and each patient needs to be treated individually. I would encourage pediatricians to explore the areas raised in these thoughtful comments.

Pat F. Bass III, MD, MS, MPH
Chief Medical Information Officer
Associate Professor, Medicine and PediatricsLouisiana State University Health Science CenterShreveport, Louisiana


 

Dr DiFazio is a child neurologist and assistant professor of neurology, Children’s National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC, and medical director, Children’s National Outpatient Center of Montgomery County, Rockville, Maryland. Dr Kirkwood is a pediatric neuropsychologist and associate clinical professor, Department of Physical Medicine and Rehabilitation, Children’s Hospital Colorado and the University of Colorado School of Medicine, Aurora. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.