Concussions: Tough Love

by Nicholas Otts, MD

edited by Gal Altberg, MD

A Common Problem:

16 y F presents with headaches, nausea, cloudy mentation, and irritability a day after heading a ball during a soccer game. You diagnose a concussion. Parents want to know when she should start exercising again and when she can go back to school?                          

 Two female soccer players competing for the ball, aerial view.

A Small Dose of EBM:

Many physicians commonly advocate for both physical and mental rest following concussion, but the evidence for that practice is lacking.  Let’s break it down into two areas, PHYSICAL and MENTAL.


Evidence for physical rest post concussion is based on old small observational studies, animal models, and “expert consensus” opinions, which in the EBM world is the same thing as letting the patient’s Mother and Google decide what is best.

Evidence that does exist suggests aerobic physical activity is beneficial in the initial week post concussion.

A prospective, multicenter cohort study showed physical activity within a week (versus no physical activity) was associated with reduced risk of persistent postconcussive symptoms a month later (1). A prospective randomized control trial showed similar benefit (2). Further, another study suggested that patients that had prolonged symptoms a week after the initial event, aerobic physical activity improved symptoms and was beneficial to recovery (3).

(*Important caveat: these studies refer to aerobic physical activity that does not risk further head injury. This does not mean the patient can return to whatever exercise activity he or she wants.)

Thus, the tough love advice of getting the athlete back on the exercise bike (but off the football field) is probably the better approach than nurturing them on the couch with Netflix and pizza.


The current approach is to suggest “mental rest,” until the patient has no further symptoms, which includes a prescription for staying home from school, avoid reading or writing, and “stimulating” video games.

The evidence for this approach is based on expert consensus and observational studies, which, again, is not ideal for clinical decision making (4,5,6).

1107_gsoccer1 01 1107_gsoccer1 01

A prospective trial previously mentioned (2) actually suggested that cognitive rest lengthened duration of post concussive symptoms.

Bottom line, if you prescribe cognitive rest or cognitive activity as tolerated, the evidence so far will not back you either way.  But I think it reasonable to suggest that children attempt as much mental activity as they can tolerate without worsening symptoms. Thus, the tough love approach in this scenario may also be best.


1 Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA 2016; 316:2504.

2 Thomas DG, Apps JN, Hoffmann RG, et. al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015; 135:213.

3 Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med 2010; 20:21.

4 Brown NJ, Mannix RC, O’Brien MJ, et. al. Effect of cognitive activity level on duration of post concussive symptoms. Pediatrics 2014; 133: e299.

5 Sady MD, Vaughan CG, Gioia GA. School and concussed youth: recommendations for concussion education and management. Phys Med Rehabil Clin N Am 2011; 22:701.

6 Howell D, Osternig L, Van Donkelaar P, et. al. Effects of concussion on attention and executive function in adolescents. Med Sci Spots Exerc 2013; 45: 1030.