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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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Tamara C. Valovich McLeod and Gerard A. Gioia

Edited by John Parsons

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Tamara C. Valovich McLeod, Megan N. Houston and Cailee E. Welch

Concussions resulting from sports and recreational activities are a significant concern in the pediatric population. The number of children and adolescents sustaining sport-related concussions is increasing and, as a result, legislation has been passed in all 50 states to ensure appropriate recognition and referral of pediatric athletes following concussion. The developing brain may make the diagnosis, assessment, and management of concussion more challenging for health care providers and requires the use of specific age-appropriate assessment tools. Concussion management must also include considerations for cognitive and physical rest, a collaborative concussion management team that includes medical and school personnel, and more conservative stepwise progressions for returning to school and to physical activity.

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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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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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15 15 2 2 First Words: Commentary on the Practice and Professions of Athletic Health Care Cognitive Rest: The Often Neglected Aspect of Concussion Management John Parsons PhD, AT/L Tamara C. Valovich McLeod * PhD, ATC Gerard A. Gioia * PhD 3 2010 15 15 2 2 1 1 3 3 10.1123/att.15.2.1 Clinical

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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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Gluteus Medius Jay R. Ebert * Peter K. Edwards * Daniel P. Fick * Gregory C. Janes * 9 2017 26 5 418 436 10.1123/jsr.2016-0088 CRITICALLY APPRAISED TOPIC The Effect of Cognitive Rest as Part of Postconcussion Management for Adolescent Athletes: A Critically Appraised Topic Rachel S. Johnson

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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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Kyle M. Petit and Tracey Covassin

, respectively. These results suggest some inconsistencies between ATs’ reported clinical practice and current best practices for the management of athletes with an SRC. 1 Similar to physical rest, cognitive rest is recommended during the first 24 to 48 hours after an SRC. 1 , 20 This may include limiting