Athletic Training and Sports Health Care

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Team Physician 

Cognitive Rest Means I Can’t Do What?!

Kelsey Logan, MD, FAAP

Abstract

Cognitive rest is important in concussion recovery. A common misconception is that student athletes exaggerate symptoms to miss class and schoolwork, but this fear is unfounded. Using principles of cognitive rest, student athletes understand how to better recover from concussion and start resuming normal activities.

Abstract

Cognitive rest is important in concussion recovery. A common misconception is that student athletes exaggerate symptoms to miss class and schoolwork, but this fear is unfounded. Using principles of cognitive rest, student athletes understand how to better recover from concussion and start resuming normal activities.

The author is from the Divisions of Internal Medicine and Sports Medicine, and the Sport Concussion Program, Ohio State University Sports Medicine Center, Columbus, Ohio.

The author has no financial or proprietary interest in the materials presented herein.

Address correspondence to Kelsey Logan, MD, FAAP, 3900 Stoneridge Lane, Dublin, OH 43017; e-mail: kelsey.logan@osumc.edu.

Concussion statement (true or false): Students lie about their symptoms to miss class and get out of doing school-work.

Is this true for you? I routinely get this comment from athletic trainers when I speak about concussions and return-to-play guidelines.1 Certainly, it seems to be a common fear. Anecdotally, I rarely see this, even in a practice busy with concussion management in patients from elementary to college age. Sure, some student athletes like to miss academic work, but I can literally count on one hand the number of patients who have tried to fool me into keeping them out of school, and I can tell you why.

I routinely shut down an athlete’s life, albeit temporarily, when he or she sustains a concussion. I limit nearly every portion of life during recovery—physical, academic, and social. Largely, my treatment recommendations focus on cognitive rest, and this involves more than school.

Getting physical rest from a recovering student athlete is usually easy. In the past, physical rest was the only thing mentioned in concussion management, and that was only in the context of grading scales (eg, “athlete may return to play in 1 month if asymptomatic at rest and exertion for 7 days”2). Obviously, the grading scale approach to concussion evaluation and management did not work well; the changes that have occurred since the 1st International Symposium on Concussion in Sport3 was held are immense, and thank goodness! We now treat each athlete on an individual basis, with more emphasis on return to life instead of just return to play.

“The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play.”1 Notice the part about cognitive rest: the Zurich consensus statement includes that as an essential part of management. We have finally realized that the brain cannot handle calculus any better than it can handle doing up-downs while recovering from injury. What took us so long?

The pathophysiology of concussion leads to obvious conclusions about concussion management.4 Energy availability does not match energy demand after a concussive injury is sustained, and we cannot pinpoint exactly when that will normalize. Anything that increases energy demand during recovery can worsen symptoms and lengthen recovery. This includes mental as well as physical work. A concussion treated without cognitive rest is incompletely treated.

We now understand and recommend that concussed athletes get physical and cognitive rest. They feel better and recover faster. However, cognitive rest is difficult, both for the patient and the individuals advising the patient. Again, physical rest is easy to define and enforce, comparatively. Student athletes have incredible demands on their time (and brains). They go to class all day, practice and compete for hours after school, and then do homework at night. They often stay up late to finish work or to wind down and get much less sleep than they actually need.5

Of course, social activities are important as well, and these are squeezed in wherever available. Let’s not forget family time…and then there is television, Facebook, Twitter, and texting, to mention a few other popular activities. You get the picture. Tell a student athlete not to do these things, and you will get a blank stare back, followed by laughter.

The importance of your advice to a concussed student athlete cannot be underestimated. We know from several studies that a large percentage of athletes do not recognize concussion symptoms or the potential consequences of concussion,6,7 so assuming they understand treatment principles is dangerous. An explanation of what cognitive rest entails is essential, and this takes time.

Athletes may assume and understand they cannot return to play until they feel better, but they think nothing of going to school the day after sustaining a concussion. Does this make sense? I discuss the school schedule and limitations immediately, even advising missing school until the concussive headache is manageable (without medications) and concentration is sufficient to warrant going to class. Sometimes this means limiting the school day with frequent rest breaks.

Cognitive rest absolutely means no test taking or doing major academic work during recovery. Testing a concussed (ie, brain injured) patient is not exactly fair. Recommendations to the school to postpone tests and decrease class and homework are helpful, and I find a phone call to the nurse or guidance counselor greatly promotes administrative cooperation.

The student athlete also has to learn his or her own triggers for postconcussion symptoms (eg, headache, fatigue, concentration problems) and be willing to stop the offending activity when these occur. Symptoms usually worsen with math, reading, and computer time, but it is important to ask about individual symptom exacerbation on follow-up. There are also nonacademic triggers such as computer time at home, texting, instant-messaging, talking on the phone, watching movies or television, staying out late with friends, and not getting enough sleep. Cognitive rest means limiting these activities as well, and the student athlete (and parents) should understand this.

Return to play is contingent on being asymptomatic at rest and with exertion, as well as having normal neurocognitive function. Exertion used to bring only the physical to mind. We would not want a student athlete back on the field with headaches and dizziness while running. Likewise, we would not want a student athlete back in sport with symptoms while in class. Make sure school performance is normal before field performance is even considered.

The question at the beginning of the column focused on whether student athletes “fake” symptoms during concussion recovery to get out of class or schoolwork. When a student athlete claims attending school and doing schoolwork brings symptoms on, I reiterate outside-of-school limitations. Try it. Fear of the malingerer will fade away.

References

  1. McCrory P, Meeuwisse 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 Sci Med Sport. 2009;12:340–351. doi:10.1016/j.jsams.2009.02.004 [CrossRef]
  2. Cantu RC. When to return to contact sports after a cerebral concussion. Sports Medicine Digest. 1988;10:1–2.
  3. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med. 2002;12:6–11. doi:10.1097/00042752-200201000-00005 [CrossRef]
  4. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36:228–235.
  5. Eliasson AH, Lettieri CJ, Eliasson AH. Early to bed, early to rise! Sleep habits and academic performance in college students [published online ahead of print July 15, 2009]. Sleep Breath. doi: 10.1007/s11325-009-0282-2.
  6. Kaut KP, DePompei R, Kerr J, Congeni J. Reports of head injury and symptom knowledge among college athletes: Implications for assessment and educational intervention. Clin J Sport Med. 2003;13:213–221. doi:10.1097/00042752-200307000-00004 [CrossRef]
  7. Sye G, Sullivan SJ, McCrory P. High school rugby players’ understanding of concussion and return to play guidelines. Br J Sports Med. 2006;40:1003–1005. doi:10.1136/bjsm.2005.020511 [CrossRef]
Authors

The author is from the Divisions of Internal Medicine and Sports Medicine, and the Sport Concussion Program, Ohio State University Sports Medicine Center, Columbus, Ohio.

The author has no financial or proprietary interest in the materials presented herein.

Address correspondence to Kelsey Logan, MD, FAAP, 3900 Stoneridge Lane, Dublin, OH 43017; e-mail: .kelsey.logan@osumc.edu

10.3928/19425864-20091019-08

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