9 responses to “Concussion management: time to give “brain rest” a rest”

  1. Useful article with sensible advice.

  2. Interesting – as an ED physician, I can’t say that anyone in my department prescribes prolonged, strict bed rest – however most of us do still recommend some variation of “rest until asymptomatic”, followed by graduated return to full activity. Are there any studies which have compared, in a prospective fashion, patients who were encouraged to resume activity while still moderately or severely symptomatic, vs those who were required to wait until resting symptoms were minimal? Many of the studies cited above (e.g. Wiebe et al. 2016) did not even enroll patients until 5 or more days post concussion so these data provides no guidance for what to do in the first few days. Others (e.g. Thomas et al. 2015) prescribed at least 1-2 days rest for all enrolled patients, during which time most if not all of them probably became asymptomatic at rest so again no help there. Furthermore, in the Thomas paper the actual amount of activity reported by the subjects was in fact quite similar, with only a couple of days during the study period having a difference which could plausibly be called clinically significant.

    Therefore, although there is a strong argument against prolonged bed rest, I don’t see any data which directly show that improved outcomes are achieved by NOT waiting until symptoms have largely abated before beginning to escalate activity intensity – unless I am missing something?

    The last question which has not been considered is that many of the citations are from eras before the widespread adoption of smartphones. The effect of screen time on young people WITHOUT traumatic head injuries is dramatically different, and more deleterious, than it was in previous decades, let alone those with traumatize brains. We simply do not have enough information to determine what adverse effect screen time may have on the concussed brain of a young person, and it doesn’t seem unreasonable to err on the side of caution and giving more restrictive advice when it comes to mental rest (particularly from electronic devices) following a head injury.

  3. Thankyou
    As a GP
    What advice should I give regarding contact sports like Ice Hockey and Rugby?

  4. Dr. Krause:
    These are most welcome points as is the opportunity for dialogue about the current epidemic of persistent post-concussive symptoms as we believe there are many reasons for this phenomenon that are not being addressed.
    One of the contributors no doubt is misinterpreted advice given acutely although with the best intentions.
    There are no studies we are aware of, as you propose, comparing individuals encouraged to resume activity with moderate-severe symptoms vs those advised to resume activity when symptoms are minimal. Many of us however have followed these individuals for months and years and have observed the negative impact of advice given to patients acutely. No harm comes from encouraging individuals with mTBI or closed head injuries to resume activity in a stepwise and gradual fashion (with an expectation that they will have to tolerate brief exacerbations in symptoms); however, we have seen individuals up to a decade after head injury who still avoid symptom exacerbation and remain symptomatic due to the initial advice of “rest until symptoms are minimal.” Perhaps the best approach as an emergency room physician, and only if the diagnosis of mTBI is conclusive, should be rest for the first 24 hours then slowly (and with the expectation of exacerbating symptoms) resume activity in a stepwise fashion (including use of screens) and keep increasing activity regardless of the temporary effect on symptoms. You can confidently assert that this approach does no harm (whereas telling individuals to rest until their symptoms are manageable may well do harm) and may rescue the subset of individuals for whom symptoms begin to dictate function and become chronic.

    Dr. O’Brien:
    Thanks for this.
    Athletes should be encouraged to follow the return to play protocol of the 4th edition of the consensus statement on concussion in sport (if they have conclusive evidence of concussion) at http://bjsm.bmj.com/content/47/5/250.full
    For individuals who remain symptomatic and for whom the protocol is having a substantially delayed impact (more than a few weeks), symptomatic exacerbations should be tolerated and increases in activity made in a stepwise fashion regardless of symptoms.

  5. Well reasoned, well laid-out and well supported by the literature cited; in fact, a breath of fresh air for treating physicians in this guideline-rich and anxiety-provoking topic. The acute pain from soft tissue or other injuries, the emotional shock of an unexpected trauma might be expected to contribute to altered sleep, anxiety and stress acutely. Headache, dizziness and other non-specific symptoms such as poor concentration and forgetfulness are common consequences of anxiety and pain. Strong analgesics and muscle relaxants can contribute to early symptoms such as nausea, dizziness and sedation. My clinical experience supports the recommendation that primary care physicians and others seeing the patient acutely should consider the differential diagnosis for such symptoms before diagnosing concussion, especially where there has been no alteration in consciousness.

    This approach represents a correction from the big swing from under-recognition of concussion, followed by excessive caution in over diagnosing and managing mild concussions, to a better-reasoned and supported approach, being a more reasoned diagnosis and evidence-supported management of the mild end of the concussion spectrum.

  6. I think the jury is certainly still out on the definitive treatment strategy for this difficult condition. Due to the difficulty of enrolling patients at the earliest onset of symptoms in various studies creating selection variation/bias, variance of definition of severity of symptomology and treatment plans, it would be years before a large enough study could give us better informed answers. If one look far and deep enough, one could also find studies that would support one strategy or another. However, the strategy proposed by Mr. Schwaiger et al could be a practical and reasonable approach.

  7. Dr. Howard: Thanks for your reply. It’s very interesting to hear your perspective on the “epidemic of persistent post-concussive symptoms”. Your comments are reminiscent of the psychological burden that a word such as “whiplash” can confer on a certain subset of patients. I now have a heightened awareness of the nihilism with which some patients may react in the wake of a concussion diagnosis.

  8. Great article. Under your 1st point of diagnosis you mention “headaches, – – – require prompt behavioural and pharmacological intervention” . As a University health physician involved with care of varsity sports teams, the management of postconcussive headache and its impact on academics is a major issue. Two questions I would appreciate your advice on:
    1) I sometimes end up using migraine prophylactics such as amitriptyline for postconcussive headache (usually with significant help), but based on dialogue with experts at concussion conferences, I have not initiated this in the 1st 2-3 months following injury. Do you have any advice on utilizing this sooner ?
    2) Any opinion on using a pain reliever such as ibuprofen in the 1st couple weeks following injury ? My concern is that in this timeframe we are monitoring symptoms (such as headache) to guide the pace of return to cognitive activity, but then masking this key symptom by using pain relievers. Thanks

  9. Dr. Hitchman:
    Thanks for your points.
    The Ontario Neurotrauma Foundation has good guidelines for treatment of post-traumatic headache.
    However, the treatment really is tailored to the individual and most athletes as you know prefer to avoid medication.
    However, one should be suggesting conventional non-narcotic analgesics with short-term benzodiazepine sedative-hypnotics for headache/sleep as reasonable measures if still symptomatic after several days. Triptans are useful for vascular/migraine-type headaches. Nortriptyline 10-25 mg is easier to tolerate than amitriptyline. If symptoms last longer than one week, screen for depression/anxiety, and if headache accompanies, consider venlafaxine + sedative-hypnotic, mirtazapine, fluvoxamine, etc.
    As for masking symptoms, the guideline is not to treat headache in order to guide the pace of return. This is actually an unreasonable expectation as most clinicians in neurosciences will appreciate. If you wanted to be strictly adherent to sports concussion guidelines (and we would recommend you tailor treatment to the individual instead) you would treat with conventional analgesics after and not before exposure to the activity.
    We will offer some suggestions on management of concussion in a separate issue.

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