The other day I received an email from a neuropsychologist at a well-known New England medical center (I'll call him "Dr. A" for short) wondering whether there was any evidence to support the recommendation made in a number of articles in our concussion center, as well as videos, that, as part of the cognitive rest a concussed student-athlete needs during concussion recovery, he or she should not play video games:
"I do not necessarily disagree," Dr. A said, "but what evidence is there that kids should do no video's etc while symptomatic? I think its good practice - if not extremely difficult to actualize - but is this just "mom's advice" or are you referring to some evidence? We are trying to validate different recovery protocols and I am looking for studies to support particular approaches (such as abstinence from activity). Am having a hard time finding anything. Please let me know if your advice is evidence based or not."
As is my practice, I immediately forwarded Dr. A's e-mail to the staff for comment, and, after collecting responses, answered his e-mail, in part, by saying, "Most of the neuropsychologists that we work with, such as Rosemarie Scolaro Moser, PhD, will tell you that a child, after suffering a concussion, should not be playing video games. There are references in any number of studies and consensus statements, including the 2008 Zurich consensus statement1 and a 2010 clinical report from the American Academy of Pediatrics2 that recommend cognitive rest, and specifically say no video games (the latter says "Other activities that require concentration and attention, including playing video games, using a computer, and viewing television, should also be discouraged, because they may exacerbate symptoms.")(emphasis supplied). But our most recent recommendations against the playing of video games is derived from a book by one of our concussion experts, William P. Meehan, III, M.D., Kids, Sports and Concussions (2011) at page 82: "Cognitive rest requires avoiding cognitive activities, such as reading, writing, doing homework, playing games such as chess or Trivial Pursuit, playing video games, text messaging, working online, and so forth." (emphasis supplied).
I went on to say, "Is that advice based on peer-reviewed studies? No. It is based on common sense. Is it 'mom's advice'? No. It is based on advice from an impeccably credentialed concussion expert, William P. Meehan, III, M.D., the head of the Sport Concussion Clinic at one of the top pediatric hospitals in the world, Children's Hospital Boston, and the author, or co-author, of numerous peer-reviewed studies."
I went on to say that, "In fact, just last week, I covered an all-day summit presented by the National Athletic Trainer's Association on "Preventing Sudden Death In Youth Athletes" on Capital Hill. Among the presenters was Kevin Guskiewicz, PhD, ATC, the Kenan Distinguished Professor at the University of North Carolina at Chapel Hill and founding director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center and the Center for the Study of Retired Athletes, who talked about the need for cognitive rest after concussion, and said, point blank, "this includes video games."
Dr. A responded, in part, as follows: "While I personally agree with most of what you say and what you are putting out there, I have some scientific and practical disagreements. First, (practically) I fear there is a serious disconnect between what professionals are saying and what is really happening. To prescribe 'do nothing' is a sure way to get noncompliance. Having parents and athletes learn how to pay attention to their symptoms seems a much more responsible approach to recovery. Difficult to do, but in some ways, no more difficult than telling a kid to "do not do video" (for example). Working with and monitoring the number of kids I do, I can tell you that even most parents don't know what their kids are doing. We risk making ourselves irrelevant by telling people to do things they cannot or will not do. And without the knowledge, we come across as moralizing. My suggestion is to just make it clear that these are "common sense" approaches to recovery and that research is ongoing."
Dr. A. continued, "Some of the problem is that there is little research to support the statements. I have reviewed the research of all the people you speak of - including Zurich and there is no evidence behind the statements about rest. The one clinical trial of bedrest got negative results. So at least that seems clear. The rest of the literature that does exist actually suggests something different - that some levels of physical activity are good for healing the brain. We even think we understand the mechanisms for this to be true (in part related to a brain chemical called BDNF). Mental exertion is much more difficult to pin down and operationalize. Again, paying attention to what makes someone feel worse is an important component. Parents need to pay attention to their kids. Not an easy task. The field is riddled with inconsistencies and poorly understood mechanisms. I think you web site is useful and primarily good. I just caution you to be less sanguine about the validity of all you offer. This whole business is a work in progress."
After again circulating Dr. A's response to the staff for comment, I responded with the following:
"I agree to some extent with what you are saying. We don't say complete bed rest by the way, and yes, you are correct that there is some suggestion, at least with respect to those diagnosed with post-concussion syndrome, that mild aerobic exertion3 may be helpful, as we point out in referencing the Buffalo protocol and other expert videos."
Based on Dr. A's input, and because MomsTeam is constantly striving to make sure that all of the information on our site is as current as possible, reflects both majority and minority positions, and to let users know where advice is based more on anecdotal evidence than peer-reviewed studies, I told him that, "We softened the black and white of the advice about cognitive and physical rest and added the caveats you suggested about using common sense, monitoring a child's symptoms and what makes them worse and cutting back where necessary, and that research is ongoing." "But," I said, "I don't agree that we are moralizing or being sanguine about the great unknowns in the concussion area. That you seem to discount the views of an international consensus of experts in the Zurich statement about the importance of cognitive rest for youth athletes is fine, but a minority view.
Taking your comments into account, we have revised and updated the following articles to present your point of view (which I continue to believe is a minority position, so it is reflected as the view of "some experts"). The first of the three articles is one of the strongest articles in our entire concussion library and provides parents a very good overview of what they should be doing, and not be doing, in the immediate aftermath of a sports concussion:
- Concussions: Parents Are Critical Participants in Recognition, Treatment, Recovery;
- Concussion Recovery Starts With Both Physical and Cognitive Rest; and
- Gradual Return to Play After Concussion Recommended.
"And, in fact, to come full circle, I believe 'mom's wisdom' or "mom advice' is also important and should always be considered. Of course, there will be clueless parents, but we find for the most part sports parents are pretty tuned in."
As proof of MomsTeam's continuing commitment to valuing the role of mothers in youth sports - the perspective, of course, from which I have always approached the subject of youth sports, here and in my book, Home Team Advantage: The Critical Role of Mothers in Youth Sports - I also alerted Dr. A. to an extraordinary series of articles and videos MomsTeam will be releasing soon which specifically taps in to the wisdom of a mother, Dorothy Bedford, and what she learned about concussions during the fourteen-month long odyssey she took with her daughter, Heidi, as she struggled to recover from her third sports-related concussion. [We have already released two videos featuring Dorothy, one cautioning parents about the impact of concusssion on a teenager's ability to drive, the other, coincidentally about the very subject of the need for cognitive and physical rest!]
Eating crow
As it turned out, my e-mail exchange with Dr. A. ended with his praising MomsTeam and eating some crow: "I did not mean you or your group! Sorry. I am referring to the universe of "experts" out there -- there is a lot of hysteria. And I wince when an expert says kids should not go to school with a concussion (maybe yes, maybe no) [Note: This may be another area where we may disagree; Dr. Meehan, for one, recommends that a child stay out of school, at least for the first couple of days]. I was involved peripherally with Zurich and there are points of disagreement. Mine are not so strong as to throw the whole thing out as overall, it was the best that could be done and still stands as a model (we modeled [our state's] consensus after it!). But there is no research to speak of - Buffalo (and our study), and some stuff from BC are the only clinical studies. Our pedi neurosurgeon and I had a tiff over a pt. whom I said should rest and she said: 'based on what?' We challenged each other to find the data - guess what? Not much and since I cited Zurich I was forced to eat some crow when I tracked it all down. There is a lot of animal research that is interesting.
"'My bad' for not being more clear about moralizing. I think your web page is about the best I have seen. Many thanks for taking my suggestions seriously. After 15 years of trying to get people to pay attention, I can't believe I am now saying this! Keep up the good work."
All in days work. All in a day's work, Dr. A!
1. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br.J. Sports Med. 20090: 43:i76-i84.
2. Halstead, M, Walter, K. "Clinical Report - Sport-Related Concussion in Children and Adolescents" Pediatrics. 2010;126(3):597-615 (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/5...).
3. Leddy J, et. al. A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion Syndrome, Clinical J of Sport Med 2010; 20(1):21-27 (doi: 10.1097/JSM.0b013e3181c6c22c).
