In the last 5 years, concussion in sport guidelines shifted away from rest as the “cornerstone of concussion management” (McCrory et al., 2005), and eventually replaced their recommendation of “rest until asymptomatic” in favour of recommending a maximum of 24-48 hours of rest, followed by a gradual and progressive return to cognitive and physical activity, so long as symptoms are not exacerbated. Physicians since post-World War II have exhorted the negative outcomes of bed rest (Asher, 1947), and its potential inefficacy and harm in treating concussions (Meerloo, 1949 Voris, 1950). The most current physician surveys available suggest that rest is the most commonly prescribed “treatment” for concussion (Zemek et al., 2015 Lebrun et al., 2013 Stoller et al., 2014). This advice was echoed in patient education materials (Chrisman et al., 2011). Expert consensus statements and practice guidelines continued to advise rest after concussion until at least 2013 (McCrory et al., 2005 McCrory et al., 2009 McCrory et al., 2013 Harmon et al., 2013). Cognitive rest, or restriction from mentally demanding activities, became emphasized as an important component of the rest prescription (McLeod & Gioia, 2010 Arbogast et al., 2013).
Rest gained traction as a therapeutic strategy to expedite concussion recovery despite conflictual data from randomized controlled trials (Relander et al., 1972, de Kruijk et al., 2002), and became conflated with the concept of restricting athletes from participation in contact sport to prevent repeat injury (Longhi et al., 2005).
The “rest until asymptomatic” approach to concussion management may not have become widespread until it was incorporated into the agreement statement of the First International Conference on Concussion in Sport (Aubry et al., 2002). The practice of prescribing complete rest after a concussion may have its origin in early observations that psychological stress, physical exertion, loud noise, and bright lights tended to aggravate the acute symptoms of concussion (Symonds, 1928). A complete clinical recovery within a few weeks to months is the most common outcome, but some patients develop persisting disabling symptoms (McCrea et al., 2009a Cassidy et al., 2014). The history, physical exam, and imaging should exclude more concerning etiologies, and a thorough accounting of possible confounds such as substance use, anxiety, neck injury, and other factors should be performed (Holm et al., 2005).
Clinical signs of concussion include a brief loss of consciousness and/or a period of post-traumatic amnesia or confusion. What care gaps or frequently asked questions I have noticedĬoncussion or mild traumatic brain injury (mTBI) results in acute, transient neurometabolic dysfunction (Shaw, 2002) but typically no structural brain injury detectable with clinical neuroimaging (Barkhoudarian et al., 2016 Stillman et al, 2017). Disclosures: The authors disclose no financial interest in the academic content of this article. GF Strong British Columbia Neuropsychiatry Program UBC. Andrew Howard MD FRCPC (Psychiatry) ( biography and disclosures), Tyler Schwaiger MSc ( biography and disclosures), Noah Silverberg, PhD (R Psych) ( biography and disclosures), Will Panenka MD FRCPC (Neurology and Psychiatry) ( biography and disclosures).
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