TBI: What Does 'Brain Rest' Really Mean?

Flaura K. Winston, MD, PhD


August 13, 2012

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Hello. I'm Dr. Flaura Winston. I am a pediatrician and a doctorally trained bioengineer at the Children's Hospital of Philadelphia (CHOP), and I co-direct the Center for Injury Research and Prevention.

Today, I want to talk about best practices for general physicians and nurses in treating a child who may have suffered a concussion. Concussion, also known as "mild traumatic brain injury," has become a major concern for many parents and healthcare providers. Increased news coverage about injured professional athletes has highlighted the harmful long-term effects of these injuries.

As pediatric healthcare providers, we know that although all people of all ages can suffer concussions, adolescents are most at risk for the negative consequences. We also know that we need to look beyond sports to find concussion. In fact, motor vehicle crashes are the leading cause of concussion for our youth.

Primary care providers and nurses play vital roles in counseling children and families about what they should do following a concussion. Taking the time to talk about the injury and its effects goes far in helping families cope and reduce anxiety.

We know that concussion is a functional rather than a structural injury, which is why diagnosis requires careful medical examination looking for specific symptoms rather than the use of radiographs or MRI. Unfortunately, the subtle signs of concussion and its complications can often go overlooked by the untrained eye.

Prompt recognition of the concussion within the first 48 hours of a head jolt or blow and treatment with immediate cognitive, or brain, and physical rest are crucial to preventing prolonged symptoms of concussion. I want to zero in on why brain and physical rest are so important in the hours, days, and weeks following a concussion.

Cognitive, or brain, and physical rest address a metabolic mismatch that occurs once a child has a concussion. The brain needs an influx of glucose energy in order to heal, but cerebral blood flow fuel energy is actually decreased in the event of a concussion. Any physical or mental activity that diverts this limited brain energy supply from the recovery site will aggravate or prolong symptoms. Cognitive and physical rest protect the brain during the crucial and highly vulnerable initial phase of recovery. The brain just needs to rest.

What do cognitive and physical rest entail? They mean completely withdrawing from any metabolically demanding activities that aggravate symptoms of a concussion. This means many everyday activities are off limits until the child has your okay to return to them. This includes no school, no physical exercise, no computer use or social media, no video games, no text messages, and no reading for school or homework. Short periods of watching TV or reading for pleasure may be permitted if they don't elicit symptoms, such as headaches.

Although bed rest isn't necessary, only light walking should be permitted, and nothing that breaks a sweat or causes symptoms to appear should be allowed. Follow up with the patient every week for 2-4 weeks after the initial visit to make sure the symptoms are responding to rest, and give the patient and parents a schedule for slowly resuming regular activities each week.

Most concussions can be handled in a primary care setting. However, there are a few red flags that signal the need for a concussion specialist:

  • The patient's symptoms remain after 3 weeks of cognitive, or brain, rest;

  • The patient has a history of repeated concussions;

  • The patient has a seizure or migraine disorder or other neurologic comorbidity;

  • The patient has preexisting attention-deficit/hyperactivity disorder (ADHD), a learning disability, or other psychological issues;

  • The patient undergoes an initial neuropsychological evaluation that reveals persistent problems; and

  • The patient has difficulty with returning to school and their symptoms reappear.

It's important to acknowledge that asking children and adolescents to stick to cognitive and physical rest can be asking a lot of today's busy kids. They don't want to slow down or be cut off from their friends and activities and actually might feel stressed about falling behind with schoolwork. These are all very legitimate concerns.

However, it's important for you to discuss with the whole family the limited window of opportunity to let the brain heal and avoid a prolonged and frustrating recovery. This requires rest. Explain that the more immediate and complete their commitment is to brain and physical rest, that the concussion symptoms will resolve within a few weeks rather than taking several months or longer.

Families and clinicians should adhere to "return to learn" and "return to play" protocols, which provide sequential steps of increased activity as concussion symptoms resolve. Protocols should be supported proactively with a note to parents to share with school staff. These protocols and fact sheets can be found at Concussion Care for Kids: Minds Matter, along with additional information and research on concussion management for children and young adults. Following any injury, I encourage parents to visit After the Injury to learn about recovery.

Thanks for watching.


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