Original Article

Challenges in Determining the Role of Rest

and Exercise in the Management of Mild
Traumatic Brain Injury

Journal of Child Neurology

2016, Vol. 31(1) 86-92
The Author(s) 2015
Reprints and permission:
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DOI: 10.1177/0883073815570152
jcn.sagepub.com

Elizabeth M. Wells, MD1, Howard P. Goodkin, MD, PhD2,

and Grace S. Griesbach, MD3

Abstract
Current consensus guidelines recommending physical and cognitive rest until a patient is asymptomatic after a sports concussion (ie,
a mild traumatic brain injury) are being called into question, particularly for patients who are slower to recover and in light of
preclinical and clinical research demonstrating that exercise aids neurorehabilitation. The pathophysiological response to mild
traumatic brain injury includes a complex neurometabolic cascade of events resulting in a neurologic energy deficit. It has been
proposed that this energy deficit leads to a period of vulnerability during which the brain is at risk for additional injury, explains why
early postconcussive symptoms are exacerbated by cognitive and physical exertion, and is used to rationalize absolute rest until all
symptoms have resolved. However, at some point, rest might no longer be beneficial and exercise might need to be introduced. At
both extremes, excessive exertion and prolonged avoidance of exercise (physical and mental) have negative consequences. Individuals who have experienced a concussion need guidance for avoidance of triggers of severe symptoms and a plan for graduated
exercise to promote recovery as well as optimal functioning (physical, educational, and social) during the postconcussion period.
Keywords
concussion, rest, subthreshold exercise
Received March 11, 2014. Received revised March 11, 2014. Accepted for publication March 21, 2014.

For the past decade, expert concussion guidelines for athletes

have recommended instituting physical and cognitive rest during
the postconcussion period until asymptomatic followed by a gradual return to play. Absolute rest has been considered an essential
process for ensuring complete recovery prior to reengaging in
high-risk sports. However, a number of concerns have been
expressed regarding interpretation and implementation of these
guidelines, such as the lack of evidence supporting prolonged
physical or cognitive rest, findings that prolonged absolute rest
can be associated with adverse sequelae, and emerging preclinical
and clinical data indicating that physical exercise aids neurorehabilitation following a mild traumatic brain injury.1 In this article,
the authors review and critique the rationale and research behind
recommendations for rest, current research on the role of exercise
during concussion recovery, and the utility of using exertional
assessments for concussion diagnosis and management. The
authors discuss knowledge gaps that must be addressed through
more systematic study, particularly for pediatric patients.

Current Guidelines
A highly respected and commonly followed concussion guideline is the Zurich Guideline,2 which was most recently

updated during the fourth International Conference on Concussion in Sport held in Zurich in November 2012. This guideline
recommends early cognitive and physical rest and asserts the
need to be symptom-free prior to beginning the process of
returning to sports. It prohibits physical exercise with the
exception that low-level exercise for those who are slow to
recover can be of benefit, although the optimal timing following injury for initiation of this treatment is currently
unknown. A strict interpretation of the guidelines does not
allow for noncontact physical exercise during recovery for
most patients with concussion.

Department of Neurology, Childrens National Medical Center, George

Washington School of Medicine, Washington, DC, USA
2
Departments of Neurology and Pediatrics, UVA Healthsystem,
Charlottesville, VA, USA
3
Department of Neurosurgery, UCLA Brain Injury Research Center, David
Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Corresponding Author:
Elizabeth M. Wells, MD, Department of Neurology, Childrens National
Medical Center, George Washington School of Medicine, 111 Michigan Ave
NW, Washington, DC 20010, USA.
Email: EWells@childrensnational.org

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It is important to recognize that recovery from concussion is

of variable duration. Some will recover in 1-2 days and the
majority of pediatric patients will be asymptomatic and ultimately cleared for return-to-play within 10-14 days.3,4 However, the mean duration of symptoms is over 3 weeks for
pediatric patients with a prior concussion, and 10% of patients
take longer than 3 weeks.5 Therefore, if the recommendation to
remain in a state of rest until asymptomatic was to be strictly
followed, a significant number of children would be home from
school for a week or longer for a single concussion, and some
could be held back from daily activities and exercise for
months. There are, therefore, public health reasons to question
extreme and prolonged rest and to review current research
about resuming exercise.

Evidence and Mechanism for Why Rest Can

Aid Recovery
Immediately following mild traumatic brain injury, there are
metabolic, hemodynamic, structural, and electrical changes
that alter normal cerebral function and produce a state in which
baseline metabolic demands might not be met. It has been
proposed that this energy deficit accounts for the somatic, cognitive, sleep, and mood symptoms that follow the concussion.6,7 The above-mentioned pathophysiology is presumed
to increase the brains vulnerability to repeat injury and longterm disability.8-10 This theory supports early rest as well as
avoidance of situations that increase risk for reinjury.
Preclinical studies have demonstrated a negative impact of
exercise soon after a mechanically produced mild traumatic
brain injury in the rat (eg, fluid percussion injury). Exposure
to a voluntary running wheel immediately following a mild
traumatic brain injury decreased molecular markers of plasticity, increased neuroinflammation, and worsened cognitive
outcome.11-13 Although the pathogenesis has not been completely elucidated, disruption of cellular function due to compromised cerebral metabolism after a minor traumatic brain
injury clearly contributed. It is possible that premature stimulation to the brain, through exercise, imposes a larger energetic
demand at a time when the brain is metabolically compromised. This increased cortical stimulation to the brain brought
on by early exercise can contribute to neuronal degeneration.14
Of particular relevance is an interaction between exercise
and stress. There are multiple studies demonstrating the ill
effects of sustained increases in glucocorticoid. Among these
effects is the inhibition of molecules that are key facilitators
of neuroplasticity.15,16 Recent findings from rodent studies
indicate that there is a hyper-responsiveness to stress following
a mild traumatic brain injury and exercise regimens associated
with a high stress response are particularly counterproductive
during the early postinjury period.17,18
There is also clinical evidence suggesting that early posttraumatic exertion can be harmful. Patients who are slow-torecover often report pushing through early symptoms and
returning to play with an undiagnosed, unrecognized concussion. It has been postulated that such activity leads to prolonged

recovery.19 Likewise, early exercise has been associated with

exacerbation of postconcussive symptomatology.20,21 However, it is important to note that clinical research proving that
rest enhances recovery or diminishes long-term sequelae is
lacking. The 2013 American Academy of Neurology
evidence-based Sports Concussion Guidelines state, On the
basis of the available evidence, no conclusions can be drawn
regarding the effect of postconcussive activity level on the
recovery from sports-related concussion or the likelihood of
developing chronic postconcussion complications.22 A clinical study on rest reported that high school and college athletes
with concussion benefited from a week of comprehensive
rest initiated weeks to months after a concussion.23 The intervention lasted only 1 week, and investigators did not examine
the impact of prolonged rest. There are no other clinical data
supporting late rest, and caution must be taken in generalizing
results from this small study or extrapolating to early rest and
younger ages. A recent study of 99 patients prospectively compared five days of prescribed strict rest versus standard care and
found that the patients prescribed strict rest had worse outcomes, including more postconcussive symptoms and more
missed school, with no improvement in balance or neurocognitive outcomes.24

Avoiding Contact Sports During Period of

Vulnerability
Preclinical models have evaluated the theory that the brain is
more vulnerable to injury following concussion. An experimental closed head injury in the rodent produced measurable
cognitive deficits in a juvenile age group in the absence of
gross pathology. The introduction of a second injury 24 hours
after the first impact resulted in axonal injury, astrocytic reactivity and increased memory impairment.25 Another study
demonstrated that a single mild traumatic brain injury caused
depressed glucose metabolism and the effect was worsened
by a subsequent minor traumatic brain injury. However introducing the second minor traumatic brain injury after metabolism had normalized, produced results similar to a single
injury.26
The theory that concussion is characterized by a neurometablic cascade of events lowering the threshold for harm from
additional head injury has been investigated in a few human
studies. Although concussion generally does not produce any
observable structural damage on conventional computed tomography or magnetic resonance imaging, there are reports of
microstructural and functional neurobiological changes including diffuse axonal injury, metabolic impairment, alterations in
neural activation, and cerebral blood flow perturbations on
advanced neuroimaging particularly in the first 7-10 days.27
These findings raise specific concerns about the impact of concussion on the developing brain in pediatric patients.28 Studies
have shown that repeat injury is most likely to occur in the first
few days following minor traumatic brain injury.29 A systematic review of published studies evaluating risk factors for concussion found that 10 of 13 studies reported an increased risk

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for subsequent concussion in athletes sustaining more than 1

prior concussion.30 Thus, clinical and preclinical data demonstrate a window of vulnerability during concussion and support
the recommendation to avoid contact or high-risk sports until
recovered. The period of vulnerability makes avoidance of contact sports necessary for safety, however this guideline has
been incorrectly used to justify extreme or prolonged rest.

Possible Adverse Sequelae From Extreme

Rest
Parents, physicians, and others concerned about pediatric
health are becoming increasingly aware of adverse sequelae
developing in concussion patients who are attempting continual rest or avoiding exertion for prolonged periods of time. Silverberg and Iverson1 recently published a critique of rest
and provided many examples from other areas of health, such
as chronic fatigue syndrome, low back pain, and stroke, where
bed rest has been shown to be detrimental to recovery. They
recommend gradually resuming regular daily activities as soon
as possible and supervised exercise for patients who are slow to
recover. Concussion often leads to mood dysregulation through
direct and indirect effects in children and adolescents.31 In concussed pediatric patients, mood dysregulation and adjustment
disorders can be further worsened by extreme rest that includes
social isolation, missed school, and childparent conflicts over
excessive regulation of behavior, although systematic research
in this population is lacking.32 In a study of return to play, 38%
of patients cleared for concussion had subsequent trouble in
school which was not predicted by the neuropsychological battery and felt to not be attributed to encephalopathy from concussion, but rather secondary effects such as missed school.33
Unjustified prescriptions for extreme rest, often called black
box therapy following concussion have significant public
health consequences, particularly if these prescriptions extend
for more than just the first 3 days. Recommendations to be
sedentary can contribute to children being overweight, either
temporarily or more permanently if they choose not to return
to their sport. In addition, avoidance of physical exercise and
cognitive exertion can be detrimental due to missed opportunities to promote brain recovery through exercise.

Preclinical and Clinical Studies Indicate

Exercise Aids Neurorehabilitation
Preclinical models have been employed to better understand the
effects of exercise on neurologic and cognitive activity at pathophysiologic, molecular, and genetic levels, and have indicated a
beneficial role in neurorehabilitation. A recent study34,35 suggested that exercise can mitigate age-related cognitive decline
through neuroinflammatory and epigenetic responses. Regular
treadmill running improves spatial learning and memory performance in young mice through increased hippocampal neurogenesis and decreased stress.36 Exercise has also been shown to be
beneficial in rodents following experimental traumatic brain
injury. After a concussive injury induced by fluid percussion,

rats that are exercised in a voluntary running wheel show

increases in molecular markers of neuroplasticity as well as protection from oxidative damage.37,38 These animals also show
cognitive improvement when compared to rats that sustained a
concussion but were not exercised.
Of import is that these neuroprotective effects of exercise
were only observed when exercise was delayed after the traumatic brain injury. The duration of the delay of exercise was
dependent on injury severity.39 In other words, for the beneficial
effects of exercise to be observed in the more severely injured
rodents, a longer nonexercise period had to be sustained. This
temporal component in rehabilitative exercise is in accordance with severity dependent alteration in cellular functioning
observed both in humans and animal model of traumatic brain
injury.40-43 Another factor that should be considered is that a history of previous concussions is likely to influence the waiting
period for return to activities and rehabilitative exercise.44
In terms of clinical studies, exercise has been shown to be beneficial for patients with chronic neurologic conditions and plays
an important role in neurorehabilitation for all levels of brain
injury, including demyelinating diseases and neuro-oncologic
treatment. For example, long-term survivors of pediatric brain
tumors have shown improvements in neuropsychological testing
and diffusion tensor imaging tractography following a brief exercise program.45 With regard to concussion, there are a growing
number of published reports about beneficial exercise during
recovery, prior to being cleared for a gradual return to play. The
benefits of exercise were first demonstrated in a study of 16
patients who had atypical recovery, taking more than 1 month
to recover. These patients had a rapid recovery, including return
to sports and a normal lifestyle, following a closely supervised
active rehabilitation program.44 A small study in a university concussion clinic showed that a protocol for individualized,
symptom-limited exercise testing and progressive subsymptom
threshold aerobic exercise is beneficial, particularly if progression is controlled in a quantitative manner.46 Another study in the
same clinic evaluated 91 adolescent and adult patients referred for
persistent symptoms and found that those patients who participated in an active recovery program were more likely to recover
from concussion than those who did not.47 Two-thirds of patients
in the study experienced exacerbation during exercise and more
of those patients had headache and fatigue at rest. However, 23
of 63 (36%) patients referred for postconcussive syndrome were
able to initially exercise to full capacity without worsening their
symptoms. Although the sample size was small, the study indicates that exercise does not worsen symptoms for all patients
diagnosed with postconcussive syndrome and that a graded exercise program can aid recovery.47 Importantly for pediatricians,
younger age was a predictor of likelihood of complete functional
recovery in this study. Six patients declined the exercise program,
and only 1 of these 6 had significant recovery during the study.

Vestibular Therapy
Many patients experience balance difficulty postconcussion
and some develop persistent vestibular dysfunction and

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vertigo.48 A structural cause must be ruled out and a neurologic

evaluation can help diagnose vertiginous migraine, benign paroxysmal positional vertigo, cerebellar disorder, or other
cause.49 Some providers recommend vestibular exercises for
postconcussive vertigo. A rehabilitation team reviewed vestibular home exercises prescribed for 104 concussion patients and
found that these most commonly included eye-head coordination exercises, standing static balance exercises, and ambulation exercises, but they did not assess association with
recovery.50 There is no published research assessing whether
participation in vestibular rehabilitation or vision therapy
speeds or prolongs recovery from vestibular symptoms or from
other postconcussion symptoms.

Cognitive Rest and Activity

Preclinical data support the practice of reducing cognitive and
emotional stress during recovery from acquired brain injury
including concussion. Significant upregulation of excitatory
N-methyl-D-aspartate receptors in the bilateral amygdala and
a trend toward decreased g-aminobutyric acidrelated inhibition in a rodent model indicate that mild traumatic brain injury
can predispose the brain toward heightened fear learning during stressful postinjury events by increasing excitatory processes in the amygdala.51 However, the issue of avoiding
stress can be more even more complicated than reducing vulnerability from physical trauma by avoiding sports. Stress
reduction and management is not necessarily accomplished
through removal from schoolwork and ordinary responsibilities. There is growing concern amongst psychologists who
treat postconcussive syndrome that removal from regular routines is itself a stressor and accumulation in missed work
increases subsequent fear and anxiety that can perpetuate concussion symptoms.52,53
Having a concussion impacts school attendance, performance and learning. Pediatric neuropsychologists have been
publishing on the need to provide sound advice for both physical and cognitive activity management in parallel. They
emphasize the need to focus on return to learn at least as much
as return to play. The Acute Concussion Evaluation Care Plan,
available on the CDC webpage, provides a list of possible modifications to be made in school and homework.54 However,
there are many unanswered research questions about optimal
strategies regarding days off from school, timing of rest breaks,
impact of homework reduction, and use of neuropsychological
testing to guide school management. As with return to play,
there is no universal timeline for days off or return to school
and learning.55-58

Exertional Effects Play a Role in Diagnosis

There is ongoing research to find an objective measure of the
physiological changes associated with concussion for purposes
of diagnosis and recovery.59 A recent study found that 30% of
concussed student-athletes who were symptom-free at rest and
returned to baseline on computer-aided neuropsychological

testing performed at rest exhibited cognitive decline following

moderate physical exertion and concluded that postexercise
neurocognitive testing is warranted for concussion clearance.60
Another study showed that when the Zurich guidelines were
implemented in combination with a standardized treadmill test
and computerized neuropsychological battery, athletes who
were asymptomatic at rest returned to play without exacerbation in symptoms.33 Current assessment of concussion requires
a multifaceted approach usually including symptom report,
neurocognitive testing, and balance assessment, and exertional
effects play a large role in decision-making about concussion
management and clearance.
The belief that increased concussion symptoms from exercise and cognitive exertion necessarily indicate ongoing brain
injury is challenged by clinical investigations comparing postexercise symptoms in concussed and nonconcussed individuals. A systematic review of self-reported responses following
acute bouts of exercise in concussed and nonconcussed individuals found that data from 5 studies demonstrated mean symptom scores increased from preexercise to postexercise levels
immediately following acute bouts of exercise in both concussed and nonconcussed individuals.61 Another study of the
effects of acute exercise on clinically measured reaction time
(how long it took nonconcussed collegiate athletes to catch a
vertically suspended rigid shaft) in college athletes found no
significant difference in exercised or nonexercised individuals.62 These studies were conducted primarily to evaluate the
appropriateness of sideline concussion testing given the concern that symptoms reported by athletes taken out of a game
can reflect exertional effects of exercise. However, this
research has ramifications for physical therapists, physicians
and athletes interpreting exertional symptoms as indicative of
ongoing concussion or the need to limit further exercise.

Conclusion
There is a growing concern amongst concussion specialists
about the recommendation that individuals with concussion
must be asymptomatic at rest before resuming exercise. Preclinical data about increased vulnerability to further injury during
a concussion supports the recommendation to avoid contact or
collision sports until recovery. Premature vigorous physical
activity or excessive cognitive strain can be detrimental to
recovery from minor traumatic brain injury. However, there
is no convincing clinical evidence supporting prolonged or
extreme rest following concussion. Furthermore, multiple clinical studies and a large body of preclinical research indicate
that exercise promotes neurorehabilitation, particularly for
patients with concussion, and to the authors knowledge, none
have shown adverse effects. Individualized, graded exercise
programs have been shown to promote return to normal functioning. Symptom assessment following cognitive and physical
exercise plays a role in assessment of concussion recovery,
however research demonstrating exertional effects in individuals without concussion means more studies and careful clinical
judgment are needed.

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It seems that both rest and exercise have an important role in

concussion management. The role of rest and exercise can be
different during different stages of injury and recovery. There
are preliminary data that an exercise program is likely appropriate for student-athletes, and possibly nonathletes, even
before students are cleared for their gradual return to play.
Similarly, recent studies describe how multidisciplinary pediatric concussion clinics advise students about attending school
and completing a gradual return to learn, and this practice must
be further studied and publicized. There are many unanswered
questions that must be pursued and addressed in future iterations of concussion guidelines, such as adequate duration and
degree of rest, underlying mechanisms, relevant diagnostic
tools or biomarkers, and interactions with medications. Further
research is needed to answer these questions and investigate the
role of both rest and exercise during specific phases of injury
and recovery (eg, acute, subacute, and postconcussive).
Lack of consensus on the role of rest and exercise can confuse pediatricians trying to manage concussion, and neurologists can experience increased referrals not only for
atypical concussion but also for typical presentations by
pediatricians. An individualized approach including moderate
amounts of both rest and exercise seems to be emerging as optimal treatment, but further research can help define parameters
and tools for such a program to be instituted outside a comprehensive concussion clinic. With over 1-3 million concussions
annually in the United States and 49 states requiring a professional evaluation for concussion clearance, emergency departments, pediatricians, and primary care providers need to be
prepared to manage the majority of concussions, and students,
parents, and schools need consistency from the medical community. Therefore, there is an urgent and important need for
open communication about what is known and unknown
regarding rest and exercise and reasonable options for care,
as well as further research into best assessment tools and practices prior to the next International Concussion meeting.

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Author Contributions
All authors contributed to the research and writing of the manuscript.

Declaration of Conflicting Interests

15.

16.

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

17.

The author(s) received no financial support for the research, authorship,

and/or publication of this article.
18.

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