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New Conclusions on Concussion 'Cocooning'


Until very recently, the widespread recommendation by the medical community to patients who had suffered a concussion was simple and straightforward: rest, rest and more rest. The trauma that the brain sustains during a concussion can be from linear forces (like when the brain is forcefully pushed up against the hard ridges and walls of the skull), or from rotational forces (like when a boxer’s neck twists violently after an opponent lands a hook to the jaw). Yet another example involves the wave of energy from an IED blast experienced by a soldier in combat. Any of these mechanisms can leave the sufferer with a wide range of side effects such as headaches, dizziness, confusion and fatigue. Typically, with appropriate treatment and rest, these symptoms subside over a period of a few days to a few weeks, and most young athletes will recover from a concussion with no residual problems.

The previous guidelines for concussion rehabilitation stated that young athletes should refrain from all physical activity until all the lingering symptoms were resolved. This type of treatment is referred to as “cocooning” – when all forms of exercise and brain stimulation are halted, including reading, watching television or using smartphones, engaging in lengthy conversations and even exposure to the visual stimulation of light. This type of all-encompassing brain rest historically made sense. Concussion was known to involve a “metabolic mismatch,” which involved a reduction in blood flow to the brain at exactly the time more energy was needed for healing. As more was learned about physiologic mechanisms, it was realized that there were other contributors to the “energy deficit.” And people generally felt lousy in the early stages after a concussion. The logical conclusion was that the brain needed rest to heal. And if some rest was good, more should be better. But new guidelines are flipping the well-known script and encouraging most young athletes to start being physically active as early as a few days after the concussion occurred.

So what gives on the guideline retool? Well, new research has shown that the brain actually likes activation and stimulation. Early evidence indicates that the brain benefits from and recovers faster with physical activity and movement post-concussion, and that prolonged rest time may even delay healing and recovery. Of course, as with any brain injury recovery plan, management must be individualized and return-to-play guidelines strictly followed. There is still no return to full play or competition until all symptoms have resolved, a step-wise and monitored return to play has been successfully achieved, and official clearance has been provided. And even the early cognitive and physical activity must be carefully monitored to ensure that it is, in fact, helping and not hurting the patient. But the current trend of early activation is based on evidence that a) activation seems to be beneficial and b) cocooning may actually be harmful.

After a concussion, the acute post-injury period (the initial 24 to 72 hours) should consist of rest and symptom monitoring in most situations. Even this recommended period of rest should not involve complete cessation of all activity. The more appropriate goal is to reduce exposure to physical or cognitive exertion and refrain from or discontinue activities that worsen symptoms. When those kinds of restrictions are relaxed, and gentle, cautious return to physical activity is allowed, it does not mean jumping right back into a football or baseball practice or engaging in any contact sports, for obvious reasons. Rather, we want to see young athletes begin with a very low-range physical activity such as taking a slow walk around the neighborhood or pedaling on a stationary bike, or any low-impact, low-risk physical movement that will encourage healthy blood flow and circulation to the brain and body.

The key with early activity is to take note when feeling any significant worsening or return of symptoms, such as visual changes, nausea, dizziness or headache. The goal is to limit activity to that which doesn’t cause symptoms and to be aware of symptom threshold. Daily exercise that provides enough movement to promote healing, but not enough stress to exacerbate symptoms, is the “sweet spot” athletes are urged to maintain for the remainder of the healing process until the concussion symptoms disappear completely. Since every patient has a unique physical anatomy and chemistry as well as unique recovery needs, the amount of time each patient should engage in daily exercise after a concussion will vary, and finding that personal threshold is imperative to healing without re-injury.

In addition to the physical benefit, returning to activity sooner was also studied to produce noticeable positive effects on emotion, mood and general well-being for the person who suffered the concussion. In retrospect, it makes perfect sense. Imagine a young athlete who is used to being out with friends, active playing sports, with the associated adrenaline and endorphin release. Then require that athlete to stay in bed with the lights out and no real activity for days on end, restricted from cell phone interaction with friends and forbidden from any form of digital entertainment requiring the use of a screen. What do you get? Much higher rates of depressed mood, fixation on symptoms, worry and anxiety. Letting the athlete return to a more “normal life” faster contributes to less emotional side effects post-concussion, which can also assist in a faster recovery from symptoms.

One aspect of healing that should not be rushed is accommodations associated with school, work, and cognitive activity. It’s important to be aware of the anxieties and difficulties often encountered when heading back to class or participating in any intense learning activities. The cognitive side effects from a concussion – such as memory loss or problems with concentration – can linger longer than the physical symptoms in some cases. Partnership with a neurologist is highly recommended to continue monitoring that avenue of healing. On the plus side, physical activity may also help to lessen the severity of those cognitive issues, too.

Rest after a traumatic brain injury such as a concussion is necessary, and “shutting down” for the first few days can be vital to recovery. But prolonged bedrest is a thing of the past. The brain likes activation. For the best recovery, rest time must be balanced with stimulation and activation. Consult with a neurologist after any head injury (no matter how mild) and together he/she can help develop the most efficient treatment plan for you or a loved one’s specific needs to get your player back to health and back into the game.