Concussion treatment: the insidious myth about resting protocols that even doctors still believe

Neuropsychologist perspective, first trained in TBI rehab, though that's no longer my area of study:

I'm so glad that this is coming to mainstream consciousness, but I'm immensely frustrated that it has taken so long. Head injury specialists have recommended relative rest for, well, 17+ years as the article reports, but there has been so much BS perpetuated by poorly educated physicians and allied health professionals.

For example: long-lasting cognitive symptoms of mild TBI (concussion is mild traumatic brain injury) do exist but are rare. They are usually tied up in a complex health history, long-lasting affective and physical symptoms, and multiple concussions close together (like within a couple of weeks).

That does not mean they don't happen, though many docs will interpret it that way.

It also doesn't mean that long-lasting physical and affecting symptoms are rare. They are much more common than persistent cognitive symptoms.

And all of that together does not mean that concussions should be treated as life-altering in general. They just can be.

The idea of full rest was nonsense and always has been. The number of patients I've seen who have been told or allowed to believe that high cognitive load (e.g. school work or work-work) might hurt their brain after a concussion is alarming. It won't. The reason you recommend a reduction in workload is to reduce the number of people failing while in early recovery.

The reason you want total rest from contact sports or equestrian sports is that getting another concussion within a couple of weeks of a prior concussion really may result in much longer-lasting symptoms.

The idea that a few concussions spaced out results in behavioral and cognitive decline over time due to CTE (which is a pathology in the brain, seen on microscopes, not a clinical syndrome) has never been adequately established. People who have hundreds and thousands of concussions do indeed have more CTE, and people with more than a few concussions have more CTE than those without concussions. But behavioral and cognitive change over a lifetime in athletes with and without CTE seem to be similar. Some people just have terrible declines and bizarre or dangerous behavior, and on autopsy, a good number of them have CTE. Tons with CTE on autopsy never have those behavioral changes.

That said, I believe in CTE, as would any responsible scientist/practitioner, but the conclusions drawn from its existence are far too overblown relative to the science. CTE is one of many pathologic changes that can compound with others to increase risk of dementia (the clinical syndrome). Most people with a dementia, even one with a diagnosis supported on autopsy, have multiple pathologic changes. That is, most people with Alzheimer's related changes have more protein and cerebrovascular problems than just the Alzheimer protein problems, and the more you have in combination, the worse your symptoms and faster your decline.

That's why a history of brain injury is a risk factor for dementia. That includes all severities of brain injury, including moderate and severe. A mild concussion or a few over your athletics days, spaced out sufficiently, will not cause you to decline over time unless you are the rare exception.

What we do know is that poor education during recovery leads to poorer outcomes. People have longer lasting post-concussion symptoms if they are not educated that the brain will heal over time. It almost always does, and people need to be given that expectation.

They also have to be told that physical and affective symptoms may persist and need to be treated individually (headaches, dizziness, depression, anxiety, etc). They also need to know that those symptoms can cause difficulty thinking, but that doesn't mean the brain is falling apart.

We also know that putting people with typical concussions and long-lasting symptoms in rehab groups with people who have moderate or severe TBI (where long lasting symptoms are the rule, not the exception) makes them recover more poorly.

Isolation and total rest have always interfered with recovery. But if the doctors don't know that, then how will the patients know? There are neurologists that refer to me who truly believe that a concussion, years ago, with no loss of consciousness, may have set off a cascade resulting in Alzheimer's onset in the patient's mid-50s. That's not a thing. The problem is always something else.

Sorry for the rant (?). It's meant to be an info dump in support of the article and the patient who made this a personal crusade. I'm happy to answer questions.

If you're curious, there is an in-depth video on CTE and its promotion in the media and medical community that I can dig up.