Concussion Treatment: New Recommendations for Recovery
To rest, or not to rest?

For most people who experience a concussion, symptoms are pretty mild and will improve with time without medical intervention—as long as the individual follow’s “doctor’s orders” at home.
But doctor’s orders for concussion recovery have changed over time. “When I first started doing this years and years ago, there was a feeling that rest was really important after concussion,” says Steven Flanagan, MD, chair of the Department of Rehabilitation Medicine at NYU Langone Health.
Rest is still an important component of recovery from a mild traumatic brain injury, but the recommendations are getting more nuanced. Previously, a doctor might have recommended absolute rest: staying in bed, not going to school, etc. It was all about avoiding or limiting cognitive and physical exertion.
“We're getting away from that,” says Dr. Flanagan. “There's actually good evidence that shows that aerobic exercise that's kept below a threshold that would make your symptoms worse actually helps to speed up recovery from concussion.”
Basically, the recommendation is now more of a balance: You want to avoid excessive exertion, but you don’t want to completely avoid activity, and both extremes have been shown to slow down recovery time.
Dr. Flanagan recommends a “graded” return to exercise, school, and work. That is, to move in incremental stages until you’re back to your normal level of activity. The key is to keep activity below a threshold: If you start feeling adverse effects, such as a headache, then you may have gone too far.
“If you do overdo the exercise a little bit, or if you do overdo the cognitive work a little bit, you haven't hurt your brain,” says Dr. Flanagan. “Just take it down a notch, and you can just go on then proceeding with your recovery.”
Dr. Flanagan is the chair of the Department of Rehabilitation Medicine at NYU Langone Health. He specializes in brain injury rehabilitation.
1
00:00:00.133 --> 00:00:01.232
(mellow music)
2
00:00:01.233 --> 00:00:04.466
When I see someone come to me with a concussion,
3
00:00:04.467 --> 00:00:07.799
they are anxious; they know something's wrong.
4
00:00:07.800 --> 00:00:09.999
But then I explain: this is what a concussion is,
5
00:00:10.000 --> 00:00:11.666
and this is what's gonna happen,
6
00:00:11.667 --> 00:00:15.932
and then I also tell them that the vast majority of folks
7
00:00:15.933 --> 00:00:18.166
who have a single, isolated concussion
8
00:00:18.167 --> 00:00:20.966
are going to have a full recovery.
9
00:00:20.967 --> 00:00:26.032
(hopeful music)
10
00:00:26.033 --> 00:00:30.399
The treatment of concussions is changing.
11
00:00:30.400 --> 00:00:32.932
When I first started doing this years and years ago,
12
00:00:32.933 --> 00:00:37.066
there was a feeling that rest was really important after concussion.
13
00:00:37.067 --> 00:00:40.499
Cognitive rest, don't strain your brain.
14
00:00:40.500 --> 00:00:43.766
Physical rest, don't exert yourself.
15
00:00:43.767 --> 00:00:45.266
And we're getting away from that.
16
00:00:45.267 --> 00:00:47.799
There's actually good evidence that shows
17
00:00:47.800 --> 00:00:52.699
that aerobic exercise that's kept below a threshold
18
00:00:52.700 --> 00:00:55.199
that would make your symptoms worse,
19
00:00:55.200 --> 00:00:58.766
actually helps to speed up recovery from concussion.
20
00:00:58.767 --> 00:01:01.866
They've studied predominantly adolescents and athletes,
21
00:01:01.867 --> 00:01:04.032
more than anybody else at this point,
22
00:01:04.033 --> 00:01:07.166
but what they're showing is, getting folks onto a treadmill
23
00:01:07.167 --> 00:01:09.766
or a bicycle, getting your heart rate up,
24
00:01:09.767 --> 00:01:13.366
not so high that it induces or worsens some of these symptoms,
25
00:01:13.367 --> 00:01:15.932
will actually speed up recovery.
26
00:01:15.933 --> 00:01:20.899
So we're getting away from bedrest and staying out of school
27
00:01:20.900 --> 00:01:23.266
and not doing cognitive work.
28
00:01:23.267 --> 00:01:25.166
We think that actually slows it down.
29
00:01:25.167 --> 00:01:29.466
We're doing graded return to exercise, graded return to school,
30
00:01:29.467 --> 00:01:32.266
a little bit more aggressively than we did in the past,
31
00:01:32.267 --> 00:01:34.399
but always trying to keep it below that threshold
32
00:01:34.400 --> 00:01:36.332
that makes the symptoms worse.
33
00:01:36.333 --> 00:01:39.432
And if you do overdo the exercise a little bit,
34
00:01:39.433 --> 00:01:43.599
or if you do overdo the cognitive work a little bit,
35
00:01:43.600 --> 00:01:45.132
you haven't hurt your brain.
36
00:01:45.133 --> 00:01:48.399
Maybe you slow the recovery down if you really did too much.
37
00:01:48.400 --> 00:01:50.866
You just bring it down to a different level.
38
00:01:50.867 --> 00:01:54.666
Just take it down a notch, and you can just go on then
39
00:01:54.667 --> 00:01:56.532
proceeding with your recovery afterwards.
40
00:01:56.533 --> 00:01:59.666
You didn't hurt yourself.
41
00:01:59.667 --> 00:02:08.633
(mellow music)
Management of acute moderate and severe traumatic brain injury. Waltham, MA: UpToDate, 2020. (Accessed on March 6, 2020 at https://www.uptodate.com/contents/management-of-acute-moderate-and-severe-traumatic-brain-injury.)
Traumatic brain injury: epidemiology, classification, and pathophysiology. Waltham, MA: UpToDate, 2020. (Accessed on March 6, 2020 at https://www.uptodate.com/contents/traumatic-brain-injury-epidemiology-classification-and-pathophysiology.)