Cognitive rest

On April 5, 2011, I wrote:  Regarding postconcussive patients: "Cognitive rest is an aspect of postconcussion treatment that involves avoidance of excessive neurometabolic processes associated with cognitive activities...Cognitive rest requires the patient to refrain from all activities that involve mental exertion, such as working on a computer, watching television, using a cell phone, reading, playing video games, text messaging and listening to loud music. Any of these activities may exacerbate symptoms and could delay recovery."

Do my colleagues believe this? If so, on what is their belief based?

One response: Thank you for writing in your question about cognitive rest. When I've read that and similar quotes in the pediatric and neurology literature, and of course in the media, its struck me as bizarre. The person is supposed to lie on a bed, eyes closed, ears blocked and told to make sure not to think either? It reminds me of the article I had hanging over my desk during my fellowship. It was from The Weekly World News (an awesome tabloid filled with stories of alien invasions, Jesus citings in grilled cheese sandwiches and the like) about the death of a brilliant chess player who was thinking so hard that the electricity in his brain got out of whack and his brain exploded "like popcorn".

Another colleague wrote:  Actually, (he said a bit sheepishly) I do. I approach the concussed brain the way I would a badly sprained ankle and recommend, metaphorically speaking: 'Ace, Ice and Elevate'. Just as walking and running on a sprained ankle will prolong the pain and delay recovery, I accept the idea that cognitive activity is the equivalent of 'exercising' the brain, which should be 'rested' after an injury. I recommend gradual re-introduction of cognitive activity just as I do physical activity, even to the point of starting patients on junk novels before text books, with the recommendation that they back off if they become symptomatic with an activity. My, admittedly anecdotal, experience leads me to believe this is helpful; I've had kids with prolonged post concussive symptoms feel better after doing this (acknowledging that time, rather than 'cognitive rest' may have made the difference) and have seen kids have recurrence of symptoms with specific activities, such as math, when reading was not a problem, suggesting to me that the math was more of a 'sprint' for their brain, which wasn't ready for it.

I replied:  I would suggest, on the contrary, that I have seen invalids and chronic complainers created by traumatic brain injury interventionists who convey a message that the patient is so-so injured by their often rather trivial head bonk, with subsequent prolonged absence from school and chronic intractable headaches. I would like to know whether patients who are not seen in a traumatic brain injury program do not demonstrate prompter and better recovery than those who are.

A third colleague wrote:  worry about not being employed making money, doing schoolwork, keeping up with peers, who is dating who must not count as cognitive work!

A fourth colleague wrote:  Times, perceptions, concerns and medical practices have certainly changed. I had a little cycling accident in Princeton NJ 20 years ago, wearing a helmet properly fitted and buckled on, of course. I ran the Yellow light at a T- intersection, but as I did a pedestrian started to cross directly in my path. Next thing I knew the rescue squad was hovering over me. Over my remonstrations and objections I and my bicycle were lifted into the ambulance and taken to the hospital ER. I was x-rayed for my shoulder complaint, told I had a minor separation, and went on my way (in my wife's car), promising to see an orthopedist. I was clearly unconscious for the time it took for someone to call the squad and for them to get there, a distance of a busy town mile. Maybe 15-20 minutes. I was perfectly lucid thereafter and i don't recall a skull x-ray. Last week a saw a five year old boy (for his developmental issues) who had been knocked over by another five year-onl while standing next to the bleachers at a high-school basketball game two weeks earlier. He sustained a 3 cm gash in his scalp, right fronto-parietal area, presumably from hitting the metal frame or the edge of the bench. He was up on his feet in seconds, crying for mom, told her the whole story of who, what and where, was never drowsy, confused, disoriented, and did not vomit at any time. He was taken to the ER, where the wound was closed with metal clips after he had a skull film and a CT scan. The scan showed a "minute defect in the outer table" but nothing, nothing, nothing anywhere in his head. The child was then referred to a pediatric neurosurgeon twenty-five miles away and a difficult trip for a car-less family. This physician made a diagnosis of concussion, skull fracture and referred the child for an MRI. I (probably un-tactfully) suggested that the MRI and accompanying half-day hospitalization and sedation could be safely dispensed with. I dare say I have sown up 500 such scalp lacerations under these clinical conditions and this negative history without benefit of CT scans and never missed a neurological consequence. I think the whole medical world has gone mad but thee and me, but sometimes I fear…

Oops! I forgot    possibly as a result of my own concussion twenty years ago or my 83 years           the end of the story about the five year old with a scalp laceration. The diagnosis of skull fracture and concussion was followed by a mandate that the child stay home from school for one week and out of gym and recreation for one month and return to the neurosurgeon for followup. The office notes "report" are boiler-plate computer generated. To reiterate: The child had no clinical symptoms or signs of concussion. He was knocked over by another same size child. His head traveled forward approximately three feet before striking the bleacher. The minute defect in the outer table of the skull was not attended by any "crack" of the inner table and the CT was otherwise entirely negative. Is this not madness compounded?

A fifth colleague wrote:  There are at least two hypotheses supporting the recommendation for rest until cognitive recovery is achieved. Scientific experimentation may provide answers as to the first of these, bearing in mind that there have been some serious missteps in such work such as the well-known violations of protocol and baboon mistreatment at the U Penn head injury laboratory in the early 1980s. There is the second reason, an hypothesis for which there is already human data. Concussion may produce errors or at least slowing in execution of motor activities and to the extent that decision making, response time, memory, and alteration of performance in accordance with the timely appreciation of unexpected circumstances of play evolution are affected, second head injuries in the wake of an initial concussive event are very likely to be worse than those typical for the player. At competitive levels of play, excellent athletic performance may require an expected degree of split second sequences of activity upon which a player may rely because the speed and sequence of activities and necessary adaptation to unexpected circumstances is deeply ingrained and is not retarded in execution by very conscious reflection. That slowing is exemplified by the manner in which an average pianist (not an accomplished one) may execute a piece of music at a certain intended speed until the sequence is disrupted by an error--thinking one's way out of it slows the music down: perhaps too much cortical consciousness outweighing the cerebellorubroextrapyramidopyramidal shortcuts. An example in sports was the "tweener" passing shot from baseline to the far opponent court corner that Federer must have executed by such practice without the interference of reasoning, vision, or conscious thought--the practice effect is exemplified by the fact that he achieved this unbelievable shot in two successive US Opens--against Djikovic (2009) and Dabul (2010)(apologies if I have misspelt their names) Head injuries are not frequently encountered in tennis, but a quarterback (o for the Rugby playing world the tight-head or hooker)may greatly increase their chances of injury (neck rather than head for the Rugby front-liners) by executing actions with anticipated speed and effect at a given practiced pace, not anticipating the dangers that lurk when that speed and momentary adaptations are impaired.

The fifth colleague also wrote:  Cognitive rest cannot help but bring to everyone's mind the "rest cure" ideas of Weir Mitchell. Of course it is best known now in the setting of the chronic headaches of Philadelphia’s wealthy society matrons. He prescribed prolonged inactive bed rest, closed curtains in a darkened room, with no distractions/visitors/activities, for a set interval of time (a month in some cases I think). He said to Osler and others that he had considerable success in finding these individuals relived of headache when released from their rest. There was one temporary exception--a grand dame who when he came to release her was told him that she had no intention of leaving her comfortable bed. Mitchell's response was "If you intend to remain in bed then I have no choice but to join you." As she showed no tendency to relent he proceeded to start to unbutton his vest. The result, he related on a number of occasions, was that the old lady made haste to demonstrate her intention of getting up. Mitchell also applied this method as a last resource in erythromelalgia of Weir Mitchell and in the neuralgia of locomotor ataxia.

A sixth colleague wrote: Given that more than 90% of cerebral energy metabolism is spent in the brain's so-called default mode of maintaining brain structure and connections (listen to Marcus Raichle's musings @ http://www.youtubexomiwatch?v=ualOUAtwUA8 ), behaviorally imposed cognitive rest (an imaginary concept) in reality has trivial to no potential for actually "resting" the brain in terms of curtailing cerebral energy utilization - unless there is pharmacologically mediated suppression of trans-synaptic communications.

Bad enough for us to fool or mislead others, but far worse to fool ourselves. Cognitive rest? Humbug.

PS: Sorry for the Faulknerian run-on sentence.

A seventh colleague wrote:  A good example of colleague six’s warning about "cognitive rest" is the way the retina works. In the absence of light, there is an energy-consuming "dark current": stimulating the eye with light reduces energy expenditure. So less stimulation can mean more energy use.