Steven P. Broglio, PhD, ATC1,2; Michael W. Collins, PhD3; Richelle M. Williams, MS, ATC1; Anne Mucha, DPT3,4; and Anthony Kontos, PhD3
1School of Kinesiology, University of Michigan, Ann Arbor, MI
2University of Michigan Injury Center
3Department of Orthopaedic Surgery/UPMC Concussion Program-University of Pittsburgh, Pittsburgh, PA
4UPMC Centers for Rehab Services-UPMC, Pittsburgh, PA
Concussion is one of the most hotly debated topics in sports medicine today. Research surrounding concussions has experienced significant growth recently especially in the areas of incidence, assessment, and recovery. However, there is limited research on the most effective rehabilitation approaches for this injury. This review evaluates the current literature for evidence for and against physical and cognitive rest and the emerging areas targeting vestibular, oculomotor, and pharamocological interventions for the rehabilitation of sport-related concussion.
The clinical signs and symptoms of sport concussions have long been recognized as (1, 2), brought about by an extrinsic force applied directly or indirectly to the head or body (3). Much of the scientific literature surrounding this injury has focused on injury incidence(4), assessment tools (5, 6), and recovery patterns among athletes (7). Absent from the literature are reviews of empirical studies assessing the effectiveness of different rehabilitation approaches for concussed patients. Therefore, this paper will review and evaluate the evidence supporting consensus-based standard of care (e.g., physical and cognitive rest) and emerging, targeted (e.g., vestibular, oculomotor, exertional, pharamocological) rehabilitation approaches for concussion based on an evolving model of clinical concussion care (8).
The concept of physical and cognitive rest as the cornerstone of concussion management was developed and by the International Concussion in Sport Group, and currently states “The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and return to play (3).” The rationale for rest asserts that during the acute (1-7 days – possibly longer in youth) post-injury period of increased metabolic demand and limited adenosine triphosphate (ATP) reserves, non-essential activity draws oxygen and glycogen away from injured neurons. The Concussion in Sport Group recommendation has been interpreted by many clinicians to mean that all concussed athletes should be
restricted from all physical and cognitive activity until symptoms resolve. At which point, the athlete could be cleared to begin a return to play progression. This “shut down” or “dark closet” approach following concussion is wrought with potential pitfalls for patients including hyperawareness of symptoms, somatization, social isolation, and other potential co-morbid concerns. Citing the risk for prolonged and exacerbated symptoms that may not be directly related to the concussive injury, other medical organizations have recommended that athletes be permitted to engage in limited physical and cognitive activity so long as it does not worsen symptoms(9).
These two perspectives regarding strict rest versus physical and cognitive activity as tolerated are seemingly at odds with each other, in part because there is no agreed upon definition of what constitutes rest following a concussion in the literature. Such recommendations are also limited as they do not take into account the individualized nature of the injury, potential risk factors that may influence outcomes, and differential responses to recovery. Moreover, and most importantly, there are no known prospective randomized control trials evaluating rest in concussed athletes immediately following a concussion(10). In fact, the evidence for physical and cognitive rest is limited, relying on observational studies and studies of patients from sports medicine clinics during the sub-acute stage (11, 12). With a dearth of literature to support clinical guidelines, expert consensus has been used in its place.
The premise that rest is the most effective management strategy for all concussed patients assumes that all concussions are alike, yet concussion recovery is known to be influenced by several modifying factors including sex(13), concussion history(14), and age(15). Even for injuries occurring within these populations, concussions manifest in varied symptoms (e.g., headache, dizziness, fogginess), cognitive (e.g., memory, reaction time, processing speed)(16), psychological (e.g., depression, anxiety)(16), and vestibular (e.g. dizziness, imbalance, gait, vestibulo-ocular) (17) impairments. As such, this highly individualized injury results in a varied injury presentation, indicating no single rehabilitation strategy will be effective for all patients following concussion necessitating distinct treatment(8).
This content is by Dr. Spencer Baron. You should seek expert counsel in evaluating opinions, treatments, products and services. For more info see our Editorial Policies.
1. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36(3):228–35.
2. Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery. 2014;75(Suppl 4):S24–33.
3. McCrory P, Meeuwisse WH, Aubry M, Cantu RC, Dvorak J, Echemendia RJ, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine. 2013;47(5):250–8.
4. National Collegiate Athletic A NCAA Injury Surveillance Summary for 15 sports: 1988-1999 through 20032004. J Athl Train. 2007;42(2):165–320.
5. Broglio SP, Puetz TW. The effect of sport concussion on neurocognitive function, self-report symptoms, and postural control: A meta-analysis. Sports Med. 2008;38(1):53–67.
6. McCrea M, Barr WB, Guskiewicz KM, Randolph C, Marshall SW, Cantu R, et al. Standard regression-based methods for measuring recovery after sport-related concussion. J Int Neuropsychol Soc. 2005;11:58–69.
7. McCrea M, Guskiewicz KM, Marshall SW, Barr W, Randolph C, Cantu RC, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA. 2003;290(19):2556–63.
8. Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee surgery, sports traumatology, arthroscopy: official journal of the ESSKA. 2014;22(2):235–46.
9. Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher JS, Palm M, et al. National athletic trainers’ association position statement: management of sport concussion. J Athl Train. 2014;49(2):245–65.
10. Committee on Sports-Related Concussions in Y, Board on Children Y, Families, Institute of M, National Research C . The National Academies Collection: Reports funded by National Institutes of Health. In: Graham R, Rivara FP, Ford MA, Spicer CM, editors. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. National Academies Press (US); Washington (DC): Copyright 2014 by the National Academy of Sciences. All rights reserved.; 2014.
11. Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. 2012;161(5):922–6.
12. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP., 3rd Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133(2):e299–304.
13. Covassin T, Swanik CB, Sachs M, Kendrick Z, Schatz P, Zillmer E, et al. Sex differences in baseline neuropsychological function and concussion symptoms of collegiate athletes. Br J Sports Med. 2006;40(11):923–7. discussion 7.
14. Iverson GL, Gaetz M, Lovell MR, Collins MW. Cumulative effects of concussion in amateur athletes. Brain Inj. 2004;18(5):433–43.
15. Field M, Collins MW, Lovell MR, Maroon JC. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr. 2003;142(5):546–53.
16. Kontos APCM, Russo S. An introduction to sport concussion for the sport psychology consultant. Appl Sport Psyc. 2004;16(3):220–35.
17. Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. The American journal of sports medicine. 2014.
18. Belanger HG, Vanderploeg RD. The neuropsychological impact of sports-related concussion: A metaanalysis. J Int Neuropsychol Soc. 2005;11:345–57.