Cognitive Rest: The Often Neglected Aspect of Concussion Management

mArch 2010  1 © 2010 Human Kinetics ATT 15(2), pp. 1-3 T IS DIFFICULT these days to get through a week without seeing an article or hearing a news report on the topic of sport-related concussion. The National Football League has been under extensive scrutiny in both the media and in Congress. Interestingly, and justifiably, many of the reports admit that concussions are not only a problem for the NFL, but also for the thousands of high school and youth student-athletes who look up to professional athletes. Unlike their NFL counterparts, however, these young athletes face many unique challenges, including the cognitive demands of school, which should be accounted for in concussion management protocols. Recent advances in concussionrelated research have provided clinicians with numerous guidelines for recognition, assessment, and return to play. It is now widely recognized that neurometabolic impairment is the foundation of a concussive injury, which involves a cascade of neurochemical abnormalities that follow a force application to the brain.1 In the wake of these impairments, both physical activity and cognitive activity become sources of additional neurometabolic demand on the brain. A basic treatment assumption in concussion is that symptom exacerbation, or reemergence of a symptom in the wake of physical or cognitive activity, is a signal that the brain’s dysfunctional neurometabolism is being pushed beyond its tolerable limits. Therefore, the clinician must carefully manage the neurometabolic demands of the brain during recovery from a concussion to avoid exceeding a threshold that produces worsening of symptoms. Knowledge of neurometabolic dysfunction has greatly improved management of concussive injuries; however, traditional concussion management often neglects the student-athlete’s role as a student. It is now well-accepted that excessive neurometabolic activity can interfere with recovery from a concussion and that physical rest is needed. Athletes are typically withheld from physical activities until they become asymptomatic and then are progressed through a graded physical exertion return-to-play protocol. Although physical rest is an important facilitator of symptom resolution, physical rest alone fails to address another key aspect of brain function in youth—mental exertion associated with school activities. A substantial body of literature has documented the neurocognitive deficits that are associated with concussion. Recent work has demonstrated that a significant degree of symptom exacerbation follows cognitive activity. This form of exacerbation is known as a cognitive exertion effect. In one study, 88.5% of girls and 55.4% of boys reported such adverse effects after concussive injury (Gioia et al., Unpublished data). Therefore, we believe that cognitive rest should be incorporated into a concussion management protocol. Although cognitive rest has been advocated in the last two international consensus statements4,5 John Parsons, PhD, AT/L, Report Editor