Is physical and cognitive rest effective in improving symptoms and recovery time in patients with post-concussion syndrome?

Physical and Cognitive Rest in Post-Concussion Syndrome Management

Both physical and cognitive rest are strongly recommended during the first several days after a concussion to improve symptoms and promote recovery, followed by a gradual return to activities that doesn't exacerbate symptoms. 1

Initial Management Phase

Cognitive Rest

Cognitive rest is a cornerstone of post-concussion management and should be implemented immediately after injury. This includes:

• Temporary leave of absence from school or work 1
• Shortened school/work days when returning 1
• Reduced workloads and assignments 1
• Extended time for completing tasks and tests 1
• Avoidance of activities requiring concentration and attention:
  • Video games
  • Computer use
  • Television
  • Reading (even leisure reading)
  • Standardized testing 1

Physical Rest

Complete physical rest is required until the patient is asymptomatic at rest:

• No physical exertion during acute phase 1
• Restriction from sports and exercise activities 1
• Avoidance of activities that could risk another head injury 1
• Consider limiting driving due to slowed reaction times 1

Return to Activity Phase

After the initial rest period (first several days), a gradual, structured return to activity should begin:

1. Resume activities that do not exacerbate symptoms 1
2. Monitor symptom expression (number and severity) closely 1
3. When symptom-free at rest, begin progressive reintroduction of non-contact aerobic activity that doesn't worsen symptoms 1

Structured Return-to-Activity Protocol

Follow this stepwise approach, with each stage lasting at least 24 hours:

1. No activity: Complete physical and cognitive rest
2. Light aerobic activity: Walking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises
3. Sport-specific exercise: Specific sport-related drills but no head impact
4. Non-contact training drills: More complex drills, may start light resistance training
5. Full-contact practice: After medical clearance, participate in normal training
6. Return to play/full activity: Normal activity 1

Return to School/Work Considerations

• Gradually increase duration and intensity of academic/work activities as tolerated 1
• Customize return protocols based on symptom severity 1
• Provide educational supports and accommodations as needed 1
• Monitor symptoms and progress collaboratively between healthcare providers, school/work, and the patient 1

Important Clinical Considerations

• If symptoms return during the protocol, once the patient is asymptomatic again for 24 hours, return to the previous step 1
• Medications used to control symptoms should be stopped before considering full return to activities 1
• The patient must remain symptom-free off medication 1
• Educate teachers, counselors, and administrators about cognitive effects of concussion 1

Emerging Evidence and Controversies

While traditional management emphasizes rest, some newer research suggests that prolonged inactivity may have negative effects:

• Preliminary studies show potential benefit from subsymptom threshold exercise training for persistent symptoms 1
• Some evidence suggests early light activity may not be harmful to recovery 2
• For patients with symptoms persisting beyond 4 weeks, physical exercise below symptom exacerbation threshold may reduce symptoms 1

However, the most recent and highest quality guidelines still recommend an initial period of physical and cognitive rest followed by gradual return to activities, as this approach has the strongest evidence base for improving outcomes in post-concussion syndrome 1.