Abstract
Background
Understanding of the significance and treatment of concussion/mild traumatic brain injury (mTBI) has changed in recent years. Because the majority of students with concussion/mTBI typically do not exhibit obvious cognitive deficits and do not achieve low scores on many standardized cognitive and language tests, the social and academic impact of mTBI is often not recognized. Recommendations are that all students who have an mTBI have a neurodevelopmental assessment, yet less than a third of young children who have experienced an mTBI receive comprehensive evaluations. Two recent issues of Seminars in Speech and Language Disorders (Lundine, 2020; Salvatore, 2019) describe the current research on concussion/mTBI and the critical role of speech-language pathologists (SLPs) in multidisciplinary teams for these students. Recommendations for treatment and for returning to life activities after mTBI have changed considerably. O’Brien (2020) expresses concern that SLPs must be familiar with the most current research on this topic.
In this article by Banks and Salvatore (2019), the authors describe the current recommendations for return to activities after mTBI. Several years ago, the consensus was that for any TBI, more rest meant faster recovery and better outcomes, regardless of the severity of head injury. This rest included no exposure to light, little to no exposure to sound, and avoiding any sort of activity that required cognitive effort. These activities could only be resumed after a sufficient amount of physical and cognitive rest. Recently, rest recommendations have begun to change. Researchers now indicate that rest recommendations should differ for each circumstance (McCrory et al., 2017). There is a lack of global consensus regarding the ideal length of time that both cognitive and physical activities should be avoided. Much of what SLPs do clinically with students with mTBI can be both cognitively and physically demanding. Therefore, it is important for SLPs to know and understand the needs of individuals who have sustained a concussion/mTBI as it relates to rest.
Research on Concussion/mTBI Recommendations
Physical Activities
Concussion researchers have investigated rest recommendations related to both physical and cognitive activity. In a study of teenage student athletes, Majerske and colleagues (2008) found that individuals with concussions were able to tolerate significantly less graded physical activity (jogging and running) than controls. Results of this study suggested potential danger associated with high levels of physical activity after sustaining a concussion. However, Majerske et al. (2008) noted that although none of the concussed participants in their study were able to tolerate the highest levels of activity (due to exacerbating symptoms), they were able to tolerate low and intermediate activity levels. Those athletes who performed intermediate physical activity reported the most improved cognitive and overall symptom severity scores at follow-up compared with those who performed low and high amounts of physical activity. The same study also found that 1 week of cognitive rest improved test scores and decreased concussion symptoms.
Avoidance
Often, individuals who have sustained a concussion report pain after sustaining their physical injury, and they will attempt to avoid that pain. Several studies concerning chronic pain have examined the effect of avoidance behaviors on the presence, amount, and duration of pain (e.g., Asmundson et al., 1999; Philips, 1987). Avoidance behaviors (comparable to rest from physical activity after concussion) may contribute to both longer duration of pain and perhaps higher intensity and frequency of pain. It may be that longer durations and higher amounts of pain associated with rest from most physical activity are related to the general deconditioning of the body over time without use. Psychological factors may also lead to the increased perception of pain and that the brain may be anticipating pain that is not present. Current research shows that the most effective way to avoid psychological and physical effects after injury is to increase activity (Schnabel et al., 2004; Teasell et al., 2010).
The presence of fatigue is very common after concussion (Partridge, 2014; Schatz et al., 2011). Fatigue may lead to the avoidance of physical activity, which, in turn, leads to physical deconditioning. This deconditioning may contribute to increased fatigue. Researchers suggest that the most effective means to combat symptoms of chronic fatigue syndrome is to begin a tailored, graded exercise program, especially for those who are otherwise healthy. Also, problems with balance are common following concussion.
Cognitive Exertion
Persons with mTBI are at risk of cognitive overexertion, which can result when a person should engage in several cognitive activities simultaneously, for example, orienting and attending to a task, retrieving information from short-term and long-term memory, and employing executive functions to work through the activity. Due to increased cognitive load, cognitive overexertion worsens concussion symptoms. Yet current research indicates that cognitive activities should not be completely avoided following an mTBI. In a recent study (Gibson et al., 2013), researchers found that 63% of the participants who participated in strict cognitive rest (complete avoidance of works, school, screens, etc.) did not show significantly different symptom duration times than the group that did not participate in cognitive rest. Thus, recovery times were not influenced by cognitive rest. Other researchers have shown evidence that returning too soon to high-demand cognitive activities (school work, socialization, use of technology such as phones, television, and computers, etc.) may increase the amount of time it takes to recover from a concussion. Cognitive rest may be more important than physical rest. Gioia and colleagues (2010) found that during the first few days after sustaining a concussion, more than 80% of individuals reported an increase in their symptoms as they increased cognitive exertion. Alternatively, just below 40% of individuals who had sustained a concussion reported an increase in their symptoms with physical exertion. In another recent study, researchers examined the medical records and patient reports of more than 300 athletes who were 8 to 21 years old and had sustained a concussion (Brown et al., 2014). They found that those athletes who had sustained a concussion and reported engaging in more days of cognitively exerting activity after injury took the longest to recover from concussion-associated symptoms. There may be a type combination for physical and cognitive rest, which is most conducive to recovery after a concussion is sustained.
Many physicians and sports medicine professionals follow recommendations of the Consensus Statement on Concussion in Sport, recommending both physical and cognitive rest in the initial stages after sustaining a concussion. There is, however, evidence that those who follow doctor-prescribed rest recommendations after a concussion may experience longer symptom durations (Moor et al., 2015). Researchers have investigated whether physical rest after a concussion affects the time it takes for individuals with concussion to return to asymptomatic living. A study of student athletes diagnosed with a concussion discovered that sleep and activity restriction were not significant predictors of symptom duration or students’ return to classroom and playing sports, that is, physical and cognitive rest did not impact recovery (Buckley et al., 2017).
Current Recommendations
Because speech-language therapy for persons with concussion/mTBI relies heavily on physical and cognitive activity integration, it is important that SLPs know the current recommendations for physical and cognitive activity after injury. The most current Consensus Statement on Concussion in Sports states that both cognitive and physical rest are important for recovery from concussion, but there is no sufficient evidence for recommending several days of physical and cognitive rest. A brief period of rest (24–48 hrs) is suggested. After this period, individuals who have sustained a concussion should be allowed to gradually return to physical and cognitive activity. Tolerance for both physical and cognitive activity should increase over time. If symptoms worsen, however, a return to activity should be discontinued. There is no research on the effects of cognitive rest alone. It may be that persons with concussion require longer cognitive rest than physical rest.
The implementation of these guidelines may influence concussion diagnosis, treatment, and adherence to rehabilitation protocols including physical and cognitive rest. Coaches, players, and management may have different agendas regarding return to athletics and academics. Each injury is unique, and symptoms present themselves differently. Also important is the need to educate professionals that not every diagnosis carries with it a specific prescribed intervention. Because each case of concussion is different, each recommendation for rest after concussion may be different. Clinicians and rehabilitation specialists in the field of brain injury need to assist people in finding balance between physical activity and cognitive exertion. These efforts should maximize patient gains, make recovery efficient, and assist concussed individuals back to full participation safely and with minimal risk. Based on the literature reviewed in this article, recommendations following concussion/mTBI provide an argument for physical rest for at least 24 hrs with a graded return to full activity. Cognitive rest may need to be longer, perhaps 1 to 3 days.