Not long ago, rehabilitation professionals emphasized rest in darkened rooms for clients recovering from concussion. After recent research largely discredited that “rest cure” approach, they now emphasize a measured return to previous activities.
Flashback to 2009:
Marco, a 17-year-old high-school hockey player, sustained a concussion during a game when he crashed head-first into the perimeter boards. Four months afterward, he came to me for cognitive rehabilitation, so he could return to school activity. At the time there was little to no evidence-based research to follow, so I and others on Marco’s multidisciplinary neurotrauma team used expert opinions to guide his treatment.
I recommended limited school participation and no sports-related activity until Marco was headache-free at school. I also advised intermittent rest in a quiet darkened environment at school and at home. In addition, I provided academic and cognitive supports for Marco, such as metacognitive strategy instruction, internal and external memory strategies, and pacing education. For months. And months. Marco’s physical therapist and occupational therapist—and the physiatrist overseeing his treatment—also feared symptom exacerbation. “Don’t push him too hard” was the shared mantra. We were frustrated, however, at how little he progressed over months of care. Should we have been surprised when he bounced back just in time for hockey season?There were now murmurs of malingering among the staff. Malingering, it turns out, was not the problem. But our treatment approach was.
Around 2010, my internal evidence base started conflicting with expert opinions. The overarching philosophy for concussion rehab was that “the brain heals best at rest.” Some practitioners would go as far as to recommend cocooning the body in dark, quiet places for optimal rest. The Zurich Guidelines for 2012 advocated rest as the “cornerstone of concussion management,” as found in the Clinical Journal of Sport Medicine.
Serial acute head injury had also captured headlines in 2013. All states in the U.S. have enacted some form of concussion law meant to protect young athletes from its dangers. These are largely based on “Second Impact Syndrome”—the notion that a seemingly innocuous injury on top of a concussed brain can lead to catastrophic outcomes.
But Second Impact Syndrome has largely been dismissed as a condition, with concussion expert Paul McCrory noting in a 2012 article in Current Sports Medicine Reports, “the scientific evidence to support this concept is nonexistent”. This information may be surprising for many practitioners, as Second Impact Syndrome is routinely used as a scare tactic to prevent people with concussions from engaging in risky behaviors. However, this change in research requires practitioners across settings to revise patient education. It should be noted, though, that preventing a new traumatic brain injury on top of an existing TBI remains important in acute concussion management.
Concussion, too, has been—and remains—a hot topic in the media and minds of the American public, with increased awareness of TBIs sustained both on the battlefield and the sports field. With that increased awareness came increased scrutiny of TBI treatment, and it seemed contradictory to recommend ongoing, long-term rest in mild traumatic brain injury—while pushing patients just out of coma into increasingly intense therapy. In retrospect, it obviously didn’t make therapeutic sense. But that’s how it was until 2013, when everything changed.
The turning point
The big 2013 change came when researchers Noah Silverberg and Grant Iverson published a landmark Journal of Head Trauma Rehabilitation article questioning whether post-TBI rest really is the best medicine. They reported that too much inactivity likely creates more problems for some, and they advocated for a new model of active rehabilitation. This approach was a huge shift in rehab theory, and many in the field of concussion intervention needed time to warm up to the idea.
Since then, randomized controlled trials—such as one published this year in Pediatrics by Danny George Thomas and colleagues—have found that prolonged rest not only slows down the total recovery time but also can make symptoms more severe.
The standard protocol of care was more than not helpful. It was accidentally making some people worse.
The formal term for this situation is iatrogenesis: the inadvertent addition of complications by a medical provider. This problem was not isolated to speech-language pathologists, but was true across concussion care. Concussion management takes a team, and the field needed recalibration.
The rest trap
What exactly was the problem with prolonged rest? Here’s what we know:
The brain gets better at what it is asked to do. We are understanding more clearly the principles of neural plasticity, the brain’s capacity to grow and change throughout the lifespan. Our brains “rise to the occasion,” so to speak. Therefore, when our recommendations broadly restrict activity, we may inadvertently be encouraging increased brain laziness. After the acute period of neurotoxicity has passed, the brain must again begin functional activity to encourage recovery. Activity solely for the sake of therapy, however, likely remains unhelpful; instead, people need to re-engage in at least some of their typical life activities.
Ongoing dysfunction “steals” energy that would enable a quick bounce-back. By definition, concussion results in diffuse cortical dysfunction. However, there are predictable patterns post-injury. One of the most common set of impairments occurs within the visual-vestibular system. As many as 90 percent of people may have ocular motor changes post-concussion, as described in a 2011 Opthalmic and Physiological Optics paper, and often this presents as visual-vestibular dysfunction.
In essence, the signals from the visual and balance systems are not working in concert. Movements such as looking down at a notebook and up to a Powerpoint presentation can activate this system, often resulting in headaches and nausea. The brain’s efforts to make sense of a disrupted visual world can drain cognitive resources and slow down the total time for recovery.
Previous rehab sacrificed “fun” activities, with negative effects. We tended to limit non-academic activities. For example, students often abstained from before- and after-school activities until their full-time return to class. They were routinely told to avoid television, texting, movies and computers. Translation: We were asking students to do all of the work with none of the play, resulting in a rather depressing environment—as described in a 2015 Clinical Pediatrics article that relates treatment of mild TBI to Williamson’s Activity Restriction Model of Depression.
When we take away the activities that people enjoy, people feel worse. You are more likely to listen to your physician when she recommends both broccoli and an occasional Snickers bar, than when it is broccoli alone. As in all clinical care, quality of life must remain at the forefront of concussion care.
Tech restriction limits key social networks in the adolescent brain. For the average adolescent, reality is created by social interactions. So much of their sense of self comes from external networks related to smartphones, texting and computers. As SLPs, we well know how restricting use of such media cuts off a primary mode of communication for these students. Adolescents are social creatures and they need access to their tribe for support and healing.
Physical rest has effects similar to those of cognitive rest. Athletes are “wired” to move, and when they are removed from activity, they lose a key energy outlet. Many of us have seen athletes “at rest” going stir-crazy. Also, muscles begin to atrophy, making a post-concussion return to the field slower and less successful. Research now indicates that low-level physical activity may actually speed recovery (not that anyone is advocating an immediate return to full-contact football games).
Some students who most need academic rigor may prolong the break from it. Though the idea is controversial, there’s the possibility that some students may “create” symptoms to escape class. I haven’t seen anybody faking it, but I do have students who’d rather miss classes and whose symptom and recovery profiles don’t make sense. By keeping the rest from school brief, we can head off “convenient” concussive symptoms.
Based on the evidence to date, we now recommend two days of true cognitive and physical rest following a concussion. Most people with TBIs have no interest in activity the first two days post-injury anyway. This approach is obviously important for SLPs working with this population, as are the following considerations.
Some people are more prone to sustaining a concussion and more likely to have a slower recovery. Although the mechanisms for these risk factors are debated, the profile of risk is becoming increasingly clear.
People with a history of previous TBI, learning disability, attention-deficit hyperactivity disorder, other neurologic/psycho-emotional diagnoses, and personal or family history of headache are more likely to be concussed.
Gender also plays a role, with females showing a different risk profile from males. Although males have higher rates of concussion, largely due to the nature of sports like football, females are differently vulnerable. For example, males have greater neck circumferences, so when a male is hit, the force actually reverberates down the body. Females, however, have smaller necks, so the force stays in the head and neck. This creates a bobblehead effect, leading to more movement in the brain. The relationship between concussion and the hormonal fluctuations of the menstrual cycle is also hot topic of research, with the timing of the cycle changing vulnerability to concussion.
Knowing the risk factors is critical for SLPs, as our caseloads are filled with students already at-risk for injury. (For more on risk factors, see a 2015 ASHA Special Interest Group 2 Perspectives review by R. J. Elbin and colleagues.)
The “window for recovery” is likely longer than previously thought. The recovery window has never been clear, but previous research estimated typical adult recovery would take about a week or less, with children and adolescents taking a bit longer. The timeline for recovery appears to be increasing, with reported functional recovery frequently taking a month or more. This change is likely a result of our improved understanding of recovery.
In concussion, recovery has typically meant return to full pre-injury functioning—and most people meet that endpoint. However, as physiological research into concussion becomes more advanced, we are learning of cellular-level changes even in those showing functional recovery. The longer recovery window may be due in part to better awareness of—and communication about—TBI among patients and clients. What’s clear is that SLPs provide crucial functional support during this window.
We may have been treating the wrong conditions. Visual-vestibular dysfunction in TBI may appear to be impairments in reading and reading comprehension. This misunderstanding can lead us to mistakenly treat reading in a typical SLP way. The emerging evidence on impairments in visual-vestibular functioning is so pervasive that I now ensure every client undergoes screening for it to appropriately guide my treatment recommendations.
The mechanism of injury makes a difference. People tend to recover more slowly from TBIs sustained from trauma—falls, accidents and assaults—than those received in sports activities. Although the mechanism of this difference is not completely clear, it has been found that people with traumatic concussion have poorer memory and reaction time shortly after injury.
One theory is that the emotional reaction to a traumatic event differs, placing a greater psycho-emotional burden on the recovering system. Soon after the injury, trauma-related emotional changes could complicate recovery. This theory would help explain why, compared with sports, the concussion recovery trajectory looks different in active-duty military and car accidents. Recommending outside counseling could stave off longer-term dysfunction.
Parent and client education matters. More than a decade ago, researchers recognized the importance of early, quality education to help speed children’s TBI recovery, as described in a 2001 Pediatrics article by Jennie Ponsford and colleagues. Informing parents lessens their anxiety in a stressful situation and helps their children heal more quickly. Family members need help understanding how they can best facilitate recovery. The most well-intentioned helicopter parent may inadvertently induce a headache by asking about headache pain nonstop. It’s helpful to remind parents that quiet support may offer the most rapid recovery.
SLPs continue making inroads as active members of the multidisciplinary rehabilitation team, though in some settings we remain underutilized. In these cases, referring providers may be unaware of our expertise, pointing to a need for us to raise awareness of our offerings.
Another challenge is a need for better research for TBI intervention. The good news is that the landscape here is changing as well. Cognitive intervention research, such as the Web-based Self-Management Activity-Restriction and Relaxation Training program (described in a 2015 Journal of Head Trauma Rehabilitation article) is gaining ground. Watch for expanded best practices in concussion interventions.
Speaking of research, what would I recommend for my concussion client Marco in 2015, based on today’s evidence base?
I would begin by painting a reasonable picture of a recovery timeline. I’d let the family know Marco’s recovery may take a bit longer because of his history of learning disability—but that it’s nothing to worry about. I would educate the family on quiet support and recommend two days of rest. After that, I’d recommend he return to school with a limited schedule, allowing time for visual-vestibular assessment. Together we’d devise a tentative one- to two-week plan that incorporates one of Marco’s favorite non-school activities: watching hockey practice or working on the yearbook. I would encourage him to stay active with friends, but to choose a quiet coffee shop over the midnight run to Denny’s. And I’d authorize him to text away, provided he gets some decent sleep.