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The Effect of Cognitive Rest as Part of Postconcussion Management for Adolescent Athletes: A Critically Appraised Topic

Rachel S. Johnson, Mia K. Provenzano, Larynn M. Shumaker, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon

Clinical Scenario:

It is hypothesized that cognitive activity following a concussion may potentially hinder patient recovery. While the recommendation of cognitive rest is often maintained and rationalized, a causal relationship between cognitive activity and symptom duration has yet to be established.

Clinical Question:

Does the implementation of cognitive rest as part of the postconcussion management plan reduce the number of days until the concussed adolescent patient is symptom free compared to a postconcussion management plan that does not incorporate cognitive rest?

Summary of Key Findings:

A thorough literature search returned 7 possible studies; 5 studies met the inclusion criteria and were included. Three studies indicated that increased cognitive activity is associated with longer recovery from a concussion, and, therefore, supported the use of cognitive rest. One study indicated that the recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution. One study indicated that strict rest, defined as 5 days of no school, work, or physical activity; might prolong symptom duration.

Clinical Bottom Line:

There is moderate evidence to support the prescription of moderate cognitive rest for concussed patients. Clinicians who intend on implementing cognitive rest in their concussion protocols should be aware of inconsistencies and be open-minded to alternative treatment progressions while taking into consideration each individual patient and maintaining adequate patient-centered care principles.

Strength of Recommendation:

Grade B evidence exists that prescription of moderate cognitive rest for concussed patients may be beneficial as a supplement to physical rest as treatment for symptom reduction in adolescents.

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Cognitive Rest: The Often Neglected Aspect of Concussion Management

Tamara C. Valovich McLeod and Gerard A. Gioia

Edited by John Parsons

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Youth Concussion Management Practices Among Athletic Trainers: A Vignette-Based Survey

Reid Skeel, Anissa Maffett, Abigail Feder, Cayla Mitzkovitz, and Sofia Lesica

with significant symptoms, (2) continued brain recovery in which symptoms abate, and finally (3) full recovery to preclinical neurological baseline. 7 The primary goals of concussion management are to prevent further injury during the vulnerable acute phase, provide physical and cognitive rest for the

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Effectiveness of Vestibular Rehabilitation Therapy for Treatment of Concussed Adolescents With Persistent Symptoms of Dizziness and Imbalance

Kyoungyoun Park, Thomas Ksiazek, and Bernadette Olson

from participation in individualized VRT. 14 – 17 For these adolescents, VRT may be more beneficial than continued physical and cognitive rest when an adolescent’s symptoms last longer than 30 days, although the exact timing for referral and treatment is not conclusive. Strength of Recommendation

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The Effects of Aerobic Exercise on Postconcussion Symptoms in Patients With Persistent Symptoms: A Critically Appraised Topic

Timothy A. Kulpa, Jamie Mansell, Anne Russ, and Ryan Tierney

Context: Patients who do not fully recover from a concussion in 7–14 days may require an impairment-based rehabilitation program. Recent evidence indicates improved outcomes with active rehabilitation compared to passive physical and cognitive rest. Clinical Question: In patients with persistent symptoms (greater than 4 weeks) following concussion, how does aerobic exercise affect postconcussion symptoms? Clinical Bottom Line: There is moderate and sufficient SORT Level B evidence to support the inclusion of subsymptom threshold (SST) exercise in the multimodal treatment plan for patients suffering from persistent symptoms after concussion. All five included studies reported moderate to very large effects ranging from d = 0.72 to d = 10.64 in reducing symptoms after the implementation of SST aerobic exercise. Additionally, two studies also identified moderate and very large effects (d = 0.77, d = 2.56) favoring aerobic exercise over stretching interventions. These results indicate that this treatment has potential clinical utility and is a viable option to reduce symptoms in patients with postconcussion syndrome and persistent symptoms following concussion.

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The Effects of Early Physical Activity Compared to Early Physical Rest on Concussion Symptoms

Landon Lempke, Abbis Jaffri, and Nicholas Erdman

is necessary to prevent a protracted recovery. 1 For the past several decades, physical rest has been prescribed as a mainstay for SRC management. 1 More recently, rest has been divided into cognitive and physical components. Cognitive rest may include restricting daily living activities, such as

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Subsymptomatic Aerobic Exercise for Patients With Postconcussion Syndrome: A Critically Appraised Topic

Katrina G. Ritter, Matthew J. Hussey, and Tamara C. Valovich McLeod

postconcussion syndrome (PCS). 3 Current recommendations for the treatment of concussions and PCS include physical and cognitive rest; however, this recommendation is vague, lacks evidence, 4 and leaves a large degree of decision making up to the individual clinician. For a long time, it was believed that

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Are Irish Athletic Therapy Students Confident in Concussion Assessment and Management? A Cross-Sectional Study of Final Year Students’ Self-Efficacy

Anna P. Postawa, Enda F. Whyte, and Siobhán O’Connor

/Ocular Motor test), 13 concussion management/rehabilitation skills (e.g., providing advice on cognitive rest and return-to-play progression), and the frequency of their use on clinical placement (Section 4). The scores of 0, 50, and 100, respectively, represented beliefs of “cannot do at all,” “moderately can

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Patient-Reported Outcomes Following Vestibular Rehabilitation on Concussion-Induced Vertigo: A Critically Appraised Paper

Stephanie P. Thompson and Tamara Valovich McLeod

finding for athletic training and sports medicine providers. Previously concussion management consisted of physical and cognitive rest, followed by a return to activity progression once the patient was asymptomatic. 7 , 8 However, more recent guidelines recommend a symptom-limited approach that includes

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Hyperbaric Oxygen Therapy to Treat Acute Sport-Related Traumatic Brain Injuries: A Case Series

Patricia R. Roby, Robert C. Lynall, Michael J. Cools, Stephen W. Marshall, Janna C. Fonseca, James R. Stevens, and Jason P. Mihalik

this case series investigation. Clinical Bottom Line The standard of care for athletes suffering from sport-related concussion had long consisted of both physical and cognitive rest until their self-reported symptoms resolved and objective clinical measures of concussion show signs of recovery. This