When young athletes sustain concussions, they are typically told to rest until all symptoms disappear. That means no physical activity, reading, screen time, or friends, and little light exposure, for multiple days and, in severe cases, weeks.
Restricting all forms of activity after a concussion is known as “cocooning.” But now new guidelines, written by an international panel of concussion experts and published this month in the British Journal of Sports Medicine, question that practice. Instead of cocooning, the new guidelines suggest that most young athletes should be encouraged to start being physically active with a day or two after the injury.
“The brain benefits from movement and exercise, including after a concussion,” says Dr. John Leddy, a professor of orthopedics at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, and one of the co-authors of the new guidelines.
There has long been controversy, of course, about the best ways to identify and treat sports-related concussions. Twenty years ago, athletes who banged their heads during play were allowed to remain in the practice or game, even if they stumbled, seemed disoriented, or were “seeing stars.” Little was known then about any possible immediate or long-term consequences from head trauma during sports or about the best responses on the sidelines and afterward.
Since then, mounting evidence has indicated that sports-related concussions are not benign and require appropriate treatment. The question has been what these appropriate treatments should be.
In the early 2000s, dozens of the world’s premier experts on sports-related concussions started meeting to review studies about concussions, with plans to issue a consensus set of guidelines on how best to identify and deal with the condition.
The panel, called the Concussion in Sport Group, does not make formal clinical practice guidelines. But the group’s findings do represent the latest thinking about sports concussions by the world’s experts, based on the newest published science, says Dr. Leddy, who is also medical director of the Buffalo Concussion Management Clinic.
In its 2012 guidelines the Concussion in Sport Group recommended broadly that if an athlete of any age was found to have a sports-related concussion, he or she should rest as completely as possible, remaining in a darkened room with little visual or physical stimuli, until all symptoms had gone away and did not return once the athlete began easing back into normal activities, which could be a week or more.
This approach was thought to “promote recovery by minimizing brain energy demands following concussion,” the authors write in the new statement.
But since then, a number of studies in animals and people with diagnosed concussions have indicated that prolonged physical rest may actually delay the brain’s recovery.
So this month, the group published a new set of 2017 that significantly revise the recommendation for physical rest. Now the advice is that after a concussion an the athlete should remain quiet for 24 to 48 hours, but then should begin to get up and move.
Being physically active in this context “does not mean returning to the soccer field or football practice,” Dr. Leddy stresses. “This is about meeting certain low thresholds,” starting with a gentle walk around the block.
In his medical practice, he says, he has athletes time themselves as they return to exercise in the day or so after their injury. “We will ask them to walk until they begin to feel any return of symptoms” of the trauma, such as pain or dizziness, and note how long they have been moving. “If they went 15 minutes and then felt a headache, we’ll suggest they walk 10 or 12 minutes the next day and see if that feels O.K.,” Dr. Leddy says. If so, they can try again for 15 minutes the following day.
“Some symptoms,” such as a slight headache during the walk, “are not a problem,” he says. They may in fact indicate that the brain is healing.
The idea, he says, is to find each affected athlete’s “sweet spot,” of enough activity to stimulate brain recovery without exacerbating symptoms.
He adds that every athlete should be assessed and treated on an individual basis and also that the new guidelines do not recommend that young athletes return quickly to the classroom.
Cognitive issues related to the concussion can be lingering, he says, and should be closely monitored by an expert, such as a neurologist or sports medicine doctor who often treats concussions, together with the young athlete’s parents and school officials.
Interestingly, he says, there are some indications that continuing problems with memory or concentration after a concussion may be lessened if the child walks and otherwise is physically active.
“But there is still so much we do not know” about sports concussions, he says, especially in young athletes. Far more long-term studies of treatments and outcomes are needed.
For now, his advice to those who work with and love young athletes is that they make sure, first, that any head trauma during play is evaluated. The new guidelines include a free, scientifically validated checklist that can be used by parents or coaches on the sidelines to help to determine whether a young person has experienced a concussion and what actions should be taken.
Then, if your child hits his or her head, take the new consensus guidelines with you to your medical appointment, Dr. Leddy says. The recommendations should not supplant any doctor’s established clinical judgment, he says, but do represent the pooled knowledge of the world’s top experts.
“If it were me and my child,” he says, “I would bring it along.”