I have just heard that a 14 year old with concussion has been advised to, essentially, stop thinking. No homework. No tests. I get no contact sports, but thinking? It seems intuitively insane. I tried to google this and could find no real papers supporting this, although there does appear to be some fringe support from EEG neurofeedback practioners. Has anyone come across real, scientific studies to support this non thinking treatment?
It makes some sense… Mental concentration is a physical process, and increases blood flow to parts of the brain. It might also increase overall blood flow and blood pressure.
Perhaps related…or perhaps totally unrelated…but my doctor told me, in advance of using total anaesthesia for surgery, not to try to “fight it.” He told me to accept unconsciousness peacefully and passively, and not to try to cling to consciousness. Intense concentration of that kind really does have a physical effect on the brain.
If the recovery process *actually *required a “no thinking” restriction, they’d put the victim in an induced coma. This smells like bullshit to me.
Medical comas present significant risk, there’s a big difference between no thinking and no strenous thinking. Having said that, I’ve worked with a lot of concussion pts and I’ve never heard of this.
Well, how about the concussion Doc for the Colts (and also IU Football). The guy can be seen on the sidelines of every Colts game (even the Superbowl). I don’t think I would consider him to be a fringe supporter.
Coincidentally, my son was 14 when he got his concussion (playing soccer) and through some connections we have we got him into this guy. He didn’t quite say “no thinking” but he was told… no texting, no video games, no TV, no reading… basically sit quietly for several days. Anyone who knows or has a 14 year old boy knows this doesn’t really work completely (we’d catch him watching TV from the doorway of next room). We also got him some of the Planet Ocean DVDs or whatever they are called to help kill the boredom. He went in weekly for evaluations, and the restrictions were loosened fairly quickly, but he still had a note that if he ever got a headache in class he could go straight to the nurse without any penalty (he never used it though). It was a full six weeks before he was released for limited training again.
Anyway… he said one way to look at it is if you hurt your ankle you don’t just stop walking on it… you shouldn’t sit around wiggling it constantly. It is pretty much the same with the brain… you want to “work” it as little as possible during the initial recovery. (obviously not the scientific explanation, but it is a good analogy)
I figure if his advise is good enough for Peyton Manning it is good enough for me.
I only have this personal anecdote to share.
I love American Football. The game itself, not just the pageantry, but the ‘wargame’ aspect of it.
I played in high school as a cornerback and a wide receiver, that is to say on both defense and offense, and though I was relatively small, I was fast and pretty good with the ball.
During the summer of my 15th year, my family home was flooded and in combating that flood, I fell and injured my cranium badly enough to disallow me playing impact sports.
My job/career/avocation since then has been rather cerebral, and I am lucky that I didn’t have parents who urged me to ‘play through it’. I know people who had concussions during a game who were ‘awake’ but couldn’t remember the rest of the game. They are, without exception, somewhat diminished in their mental capacity.
I am of two minds about this, but the advice of the professionals in this seems warranted. Our brains are active organs, not just happy little boxes of thoughts. When injured, they need time to heal. This applies to many factors that occur during our (hopefully) long and complex lives.
I wish the young man health and long life.
If the goal is to reduce brain activity after the concussion, wouldn’t you want him watching TV nonstop?
I recently attended a CME on concussion and the expert strongly advised “cocooning” - resting the brain with no school, no TV or videogames, etc., until symptom free, and then progressing through graded return to full activity. She claimed that it speeded return to full function significantly but it was anecdotally based. Nevertheless it was presented as standard of care. And it does make sense.
Here’s one expert’s claim of the same:
But again no evidence offered to back up the contention.
She also discussed a role for balance therapy in speeding up recovery (including cognitve recovery) of those with prolonged symptoms but I am having a hard time finding literature that supports the claim. Still it is minimally current expert opinion. It may be data not yet published.
Right. This is what I was encountering. Many places said it, but not one had a citation I could read. I am getting the idea that one person said this years ago, it sounded right to someone and just got passed along and passed along. It does not sound right to me. Getting back to the ankle analogy. Intuitively, I think that the fuzzy thinking, confusion, and such that accompany a concussion are simply the body’s protective mechanism for the damage that occurred, like the pain of a sprained ankle. And like the ankle, the brain would best be healed by allowing it to be used up to the limits that the brain itself has imposed. Anecdotal evidence is worthless at best, and harmful at worst. “Sure give her DES. I gave it to one of my patients and she delivered a full term infant.”
Please note that my inability to find the cite does not mean that it does not exist. And to my thinking it does make a lot of sense. It is a matter of fact that concentration causes increased cerebral blood flow and increased metabolic needs. It is also a matter of fact that concussion results in a complex neurometabolic cascadein the brain, by definition diffuse axonal injury, and a poor ability to utilize the energy avaialble to it. The fuzzy thinking is not protection; it is a symptom of that neurometabolic cascade, or that abnormal function, of the the damage and o the inability to utilize energy in the brain effectively. To attempt to decrease those demands at a time that the brain cannot provide what it needs to its cells already makes intuitive sense, even without a blinded controlled study.
Unless there’s some evidence that intense thought is helpful after a concussion then it makes sense to take the approach of mental idleness for a while. It’s certainly not equivalent to taking an unnecessary medication or undergoing an unneeded procedure. Unless there is evidence to the contrary, common sense says rest the area of your body that was injured.
Here’s some of the (very preliminary) research and literature:
My NCBI - Collections
On the one hand, both Dseid and tripolar are assuming that their OPINIONS are facts. On the other hand, thank you Snowcarpet. I did not find these references, and while most are from the same people, those people have presumed credibility because of their hospital affiliations. I will see if I can get the complete papers.
And I state again, there is nothing common about common sense. My common sense tells me the exact opposite as others. Just like them, I find that I am almost always right, because just like them, I remember when I am right, and forget when I am wrong. Not that long ago concussions patients were awaken every hour or two for neuro checks. This was common sense, until studies showed it was wrong.
I didn’t see DSeid’s response before, but I think both of them were clearly opinions not declarations of fact. DSeid provided some reasonable information to base his opinion on, and I stated my case as the common sense approach in lieu of information to contradict it. Seems reasonable to me. In the cited works that I could only glance at, at least in terms of return to physical activity it was advised against.
So I have read this article: http://www.healio.com/pediatrics/journals/PedAnn/{C125FE55-4B08-4B15-94CB-CFA80FC69584}/Concussion-Pathophysiology-Rationale-for-Physical-and-Cognitive-Rest which is truly hot off the presses. I personally do not find the article extremely persuasive. I don’t think that the recommendations are particularly well documented, however the authors may be correct.
And at first glance, it seems as though the decision is a no brainer. I think that not doing school work would be very detrimental. Miss two weeks this time of year, and you will be painfully behind and trying to catch up for the entire rest of the year. Let it go for three weeks, and it seems likely that some would have to just repeat the grade. This seems like a horrible idea to me.
Do you have some means to substantiate your claim that missing 3 weeks out of the school year would result in a substantial number of students having to repeat a grade? Or that if true it makes any sense? What on earth could have happened to our kids or our schools that a 3 week lapse wastes an entire year yet children are now graduating after attending all year with record low SAT scores?
I think it would be very short sighted to risk detrimental effect on a growing brain so as not to miss out on three weeks of instruction.
I have absolutely no evidence whatsoever that missing three weeks of school would cause some (and to me some is 5% or so, and substantial is >50%) to have to repeat a year. And I absolutely do not think that what happens in those three weeks should be insurmountable. However, the child is not to even think about school work, so those three weeks are totally lost, not like a child with a non mental illness that can keep up at home. So yeah, my common sense is that some of those kids would have to repeat the grade. I will look and see if I can find some documentation for that.
Honestly what the hell are you talking about here?
I stated
a) what I had been taught with the clear caveat tat I did not know if hard data existed to back it up
b) the facts about the metabolic and neurofunctional impact of concussion on brain function (which are not opinions).
c) the fact that cognitive work increases the metabolic demands of brain tissue (again a clear fact)
d) the clearly stated opinion that it seems to make intuitive sense to attempt to decrease the metabolic demands placed upon an injured brain that is metabolically dysfunctional (and to use symptomatic concussion as a proxy for that dysfunction).
Your linked article really bases their case on the same argument with one prospective and one retrospective study to back it up.
That is sparse hard evidence but is the only evidence there is. And in my opinion it makes sense.
That said there is something to be said for adverse consequences of prolonged cognitive rest. Some kids, especially the high achievers, get anxious when they are behind. That anxiety can result headaches which can easily be confused with the headaches of concussion. That anxiety can result in decreased school performance. Balancing the possible benefit of cognitive rest beyond a few days against possible secondary problems caused by the cognitive rest is tricky given that both are impossible to quantify. In general however “complete” cognitive rest is in the range of a few days, not three weeks.
You’re seeing an assumsion of fact that’s not in their posts. There’s also a big difference between random confirmation bias, and a prudent plan based on what we think we know about anatomy and physiology.
Tell me about the studies discounting neuro checks; I thought it was because the CT scan gave us better predictive data, but I haven’t really looked at it.
For anyone’s interest this JAMA article is behind the paywall but includes the following:
So to answer the op - the quality of the evidence is fair at best (the two studies in the article you linked); it is the current recommended guideline based mostly on expert opinion and consensus. The risk of harm from following the guideline is small, the potential benefit includes possible sooner return to full cognitive and athletic function and posible decreased risk of long term impaired cognitive function. The informed physician would in that context be creating a potential malpractice liability by going against those guidelines an more importantly not doing right by the patient. IMHO of course.