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Concussions in sports: Rest vs Active Recovery

Apr 17, 2017

Samantha Gentile, PT, DPT

Imagine you’re a junior high school student applying to college. Your social calendar is at an all time high and you finally made the varsity football team. It’s the first game of the season and your team is winning 21 to 7. The coach puts you in and the ball is passed to you…“WHAM” you get tackled. The back of your helmet hits the turf. You lay there for a second thinking, “What happened?” As the medical team runs to your side you notice that the stadium lights seem to be too bright and your head is throbbing. After some time the athletic trainer helps you to your feet and walks you to the sideline for further evaluation. They suspect that you suffered a concussion. You are given a list of instructions and urged to rest until you are seen by your doctor. So what just happened? Why do they want you to rest? What do they mean by rest? How long should you rest?

If you Google ‘concussion’ you will come across multiple vague definitions. The 2012 Zurich guidelines for concussions in sports defines a concussion as “…a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by bio-mechanical forces.” Following a concussion a complex process occurs which increases the brains demand for glucose. In a healthy individual the rise in demand will result in increased blood supply to the brain. In a concussed athlete, this process becomes impaired and blood supply to the brain actually decreases.

This is the reason your head is throbbing and the lights seem brighter and bothersome. Symptoms vary from person to person and may consist of cognitive, physical, emotional deficits and/or sleep disorders. During this time your brain is more susceptible to injury and permanent damage. It is thought to take approximately ten days for the brain to recover, but some sources state longer recovery periods. Within this time period 80-90% of athletes diagnosed with a concussion will become symptom free and cleared by a medical professional to begin return-to-learn and return-to-play protocols.

What about the other 10-20% of concussed athletes? Physical and cognitive activity initiated too soon following a concussion can exacerbate symptoms and delay recovery. Rest ensures that the brain will be protected from excessive stress or additional insult while the brain restores homeostasis.

So yes, you want to rest, but what is rest? Rest refers to refraining from both physical and cognitive tasks. is a great resource for parents and coaches and helps to define rest:

Physical Rest Cognitive Rest
  • No sports
  • No weight training
  • No cardiovascular training
  • No gym classes
  • No sexual activity
  • No leisure activities that risk additional head injury or make symptoms worse (biking, playing
  • sports)
  • No exercise, athletic chores that result in increased heart rate
  • Increased sleep
  • Time off from school or work
  • No or reduced homework
  • No or limited reading
  • No or limited visually stimulating activities, such as computers, video games, texting or use of cell phones, and limited or no TV
  • No trips, social visits in or out of the home

Okay, so now you’re resting and it’s post concussion day 5. You have been sitting in your house trying to ‘rest’ because your symptoms aren’t improving. You are told to limit your cell phone use and TV watching, and you haven’t spoken to your friends in days, not to mention missing the party last weekend! How much longer do you have to ‘rest’?

It is becoming more evident that too much rest can contribute to increased symptoms, depression, and decreased academic performance. This can also delay recovery and increase the potential for permanent deficits. If resting allows the brain to recover then why doesn’t every athlete recover with rest? It is because symptoms after a head injury are not specific to the brain. For instance many non-concussed individuals will report symptoms seen on a concussion symptom checklist such as headaches or anxiety. This is because our cervical, vestibular, and vision systems can produce concussion-like symptoms. Furthermore cognitive and mood disorders are also known to produce or exacerbate concussion symptoms. Addressing these systems as early as 72 hours following injury may in fact facilitate recovery. Rehabilitation to these systems should not alter heart rate or blood pressure, and can therefore be a safe option if monitored and performed appropriately. Recent studies suggest it is safe and effective to begin moderate sub-symptom threshold exercise as early as 14 days post-injury in order to help restore normal blood supply to the brain. The current recommendation from 2012 is to have children rest until asymptomatic. Adolescent and adult athletes who remain symptomatic after 3 weeks should begin sub-symptom threshold aerobic activity.

Following a suspected concussion it is important to have a thorough evaluation of all systems which may be contributing to symptoms. This may require a multi-disciplinary approach. 1-2 days of rest is still considered best practice following a sports related concussion. Following an initial period of rest early rehabilitation can hasten recovery and decrease the adverse consequences of prolonged rest. A physical therapist (PT) who specializes in concussion rehabilitation can play a unique and crucial role in the recovery process. A PT can help to distinguish and treat various systems contributing to symptoms, assist in setting guidelines for return-to-learn, and evaluate and set cardiovascular guidelines to decrease symptoms and return-to-play.