Common-sense approach

If there is one thing on which clinicians and researchers alike agree it is this: that additional research is needed to determine how the effect of cognitive activity changes over time. In the absence of more data to establish the optimal level and duration of cognitive rest, most experts continue to recommend taking a "sensible approach involv[ing] a gradual return to school and social activities (prior to contact sports) in a manner that does not result in a significant exacerbation of symptoms." ^{[1,7,8,12,18,19]}

This is the approach recommended by the authors of the 2014 and 2015 studies in Pediatrics,^[12,18] whose findings taken together suggest that, while limiting cognitive activity is associated with a shorter duration of symptoms, a complete and extended abstinence from cognitive activity may be unnecessary, and possibly counter-productive.

This is also the approach recommended by the AAP in its 2013 clinical report on return to learning,^[8] in which the pediatrics group calls for an "individualized approach for the student when a pediatrician is making recommendations for cognitive rest and the student's RTL [return to learning] in the school setting."

"Determining the appropriate balance between how much cognitive exertion and rest is needed is the hallmark of the management plan during cognitive recovery," says the APP.

Reviewing the results of the pediatric studies demonstrating an association with rest and outcome after concussion, the studies, taken together, showed that the "current usual care endorsing modest physical and cognitive rest after injury is an effective strategy for recovery."^[18]

1. McCrory P, Meeuwisse W, Audry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br. J. Sports Med. 2013:47:250-258.

2. Halstead, M, Walter, K. Clinical Report - Sport-Related Concussion in Children and Adolescents. Pediatrics 2010;126(3):597-615.

3. Moser RS, Glatts C, Schatz P.  Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics 2012;161(5):922-926.

4. Giza CC, Hovda DA, The Neurometabolic Cascade of Concussion. J. Ath Train 2001;36(3):228-235.

5.  Maugans TA, Farley C, Altay M, Leach J, Cecil KM. Pediatric sports-related concussion produces cerebral blood flow alterations. Pediatrics 2011;129:28-37.

6. Kirkwood MW, Randolph C, Yeates KO.  Sport-Related Concussion: A Call for Evidence and Perspective Amidst the Alarms. Clin J Sports Med 2012;22(5):383-384.

7. Schneider K, Iverson G, Emery C, McCrory P, Herring S, Meeuwisse W.  The effects of rest and treatment following sport-related concussion: a systematic review of the literature.  Br J Sports Med 2013;47:304-307.

8.  Halstead ME, et al. Clinical Report: Returning to Learning Following a Concussion. Pediatrics doi:10.1542/peds.2013-2867 (epub October 27, 2013).

9. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47:15-26.

10. Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80(24):2250-2257 DOI:10.1212/WNL.ob013e31828d57dd.

11. Herring SA, Cantu RC, Guskiewicz KM, et al. American College of Sports Medicine Concussion (mild traumatic brain injury) and the team physician: a consensus statement-2011 update.  Med Sci Sports Exerc. 2011;43(12):2412-2422.

12. Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms.Pediatrics 2014;133(2):1-6.

13. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sport: postconcussive activity levels, symptoms, and neurcognitive performance.  J Athl Tr. 2008;43(3):265-274.

14. McCrory P, Johnston K, Meeuwise W, et al, Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004.  Br J Sports Med. 2005;39(4):196-204.

15. McCrory P, Meeuwise W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  J Athl Tr. 2009;44(4):434-448.

16. Gibson S, Nigrovic LE, O'Brien M, Meehan WP, The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27(7-8):839-842.

17. Moser R, Schatz P, Glenn M, Kollias K, Iverson G. Examining prescribed rest as treatment for adolescents who are slow to recover from concussion. Brain Inj. 2014; Early Online: 1-6 DOI: 10.3109/02699052.2014.964771 (e-published ahead of print October 1, 2014)

18.  Thomas DG, Apps JN, Hoffman RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics 2015;135(2). DOI:10.1542/peds2014-0966 (e-published ahead of print, January 5, 2015).

19. Catherine Saint-Louis. "Limiting Rest Is Found To Help Young Concussion Patients." New York Times Jan. 5, 2015. http://www.nytimes.com/2015/01/05/us/limiting-rest-is-found-to-help-youn... (most recently accessed, January 11, 2015)

20. Mike Florio. "Concussion conference suggests that rest may not be the best treatmen.t" NBC Sports Pro Football Talk. October 17, 2015 (accessed November 3, 2015 at http://profootballtalk.nbcsports.com/2015/10/17/concussion-conference-su...)